Anatomical considerations of the sural nerve in the distal leg: Side branch patterns and significance in nerve harvesting procedures.

BACKGROUND: The sural nerve is a somatosensory nerve that provides sensation to the posterolateral aspect of the lower leg and the lateral part of the ankle and foot. Due to its location and anatomical properties, it is often used as an autologous nerve graft. However, the nerve harvest can be complicated by the presence of side branches. The objective of this study was to investigate the anatomy of the sural nerve and to map its side branches. This information can be used to predict the localization of separate incisions during the stair-step incisions technique for nerve harvest, thereby reducing the risk of complications. METHODS: The study involved the dissection of 50 adult cadaveric legs (25 left and 25 right) obtained from 27 Central European cadavers. The focus of the dissection was to identify the sural nerve, small saphenous vein, and surrounding anatomical structures. Detailed measurements were taken on the side branches of the sural nerve, tributaries of the small saphenous vein, and their interrelationship. RESULTS: The average number of sural nerve side branches in a single leg was 4.2±1.9. These side branches were categorized into six groups based on their location and course: mediodistal, medioproximal, lateroproximal, laterodistal, medial perpendicular, and lateral perpendicular. Specific patterns of combination of these side branches were also identified and described. The branching point of the sural nerve was found to be 5.8±2.7 cm proximal to the lateral malleolus, whereas the small saphenous vein branching point was located more distally, 4.5 ± 2.8 cm proximal to the lateral malleolus. The highest density of sural nerve side branches was found 2.1-6.0 cm above the lateral malleolus. CONCLUSION: This study presents valuable data about the relationship between the sural nerve and the surrounding anatomical structures in the distal part of the leg, including the identification of its side branches and their relevance during nerve harvest procedures. On the basis of the most frequent locations of side branches, a three-incision-technique for nerve harvest is proposed.

The Anterior Saphenous Vein. Part 2. Anatomic considerations in normal and refluxing patients. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum and the International Union of Phlebology.

BACKGROUND: The term Anterior Accessory of the Great Saphenous Vein suggest this is a branch tributary vein despite this vessel's anatomic features of a truncal vein. A multisocietal group suggested to designate this the Anterior Saphenous Vein (ASV). This study was aimed to evaluate its ultrasound anatomy in normal and varicose limbs. METHODS: The clinical anatomy of the ASV was evaluated by narrative review of the literature. Additionally, the course of the ASV was evaluated in 62 limbs with no evidence of venous disease and 62 limbs with varicosities. RESULTS: The ASV length, patterns of origin and termination are reported in both normal and patients with varicose veins. Discussion of the patterns is supported by the narrative review of the literature. CONCLUSIONS: The ASV must be considered a truncal vein and its treatment modalities should be the same that for the great and small saphenous veins rather than a tributary vein.

Saphenous vein valve assessment utilizing upright CT to potentially improve graft assessment for bypass surgery.

Saphenous veins (SVs) are frequently employed as bypass grafts. The SV graft failure is predominantly seen at the valve site. Avoiding valves during vein harvest would help reduce graft failure. We endeavored to detect SV valves, tributaries, and vessel size employing upright computed tomography (CT) for the raw cadaver venous samples and in healthy volunteers. Five cadaver legs were scanned. Anatomical analysis showed 3.0 (IQR: 2.0-3.0) valves and 13.50 (IQR: 10.00-16.25) tributaries. The upright CT completely detected, compared to 2.0 (IQR: 1.5-2.5, p = 0.06) valves and 9.5 (IQR: 7.5-13.0, p = 0.13) tributaries by supine CT. From a total of 190 volunteers, 138 (men:75, women:63) were included. The number of valves from the SF junction to 35 cm were significantly higher in upright CT than in supine CT bilaterally [upright vs. supine, Right: 4 (IQR: 3-5) vs. 2 (IQR:1-2), p < 0.0001, Left: 4 (IQR: 3-5) vs. 2 (IQR: 1-2), p < 0.0001]. The number of tributaries and vessel areas per leg were also higher for upright compared with supine CT. Upright CT enables non-invasive detection of SV valves, tributaries, and vessel size. Although not tested here, it is expected that upright CT may potentially improve graft assessment for bypass surgery.

[Anatomy of foot perforator veins in surgery of varicose veins]. / Anatomiya perforantnykh ven stopy v khirurgii varikoznoi bolezni.

OBJECTIVE: To clarify the role of clinical anatomy of foot and ankle perforator veins (PV) in surgical treatment of varicose vein disease. MATERIAL AND METHODS: Anatomy of foot and ankle PV was assessed in 50 amputated lower extremities by anatomical dissection. RESULTS: There were 4-6 PVs at the medial surface of the foot. These veins connected medial marginal vein and vv. plantaris medialis (VPM). There were 2-3 PVs at the lateral surface of the foot. These veins connected lateral marginal vein and vv. plantaris lateralis (VPL). All PVs on the lateral surface of the foot constitute the neurovascular bundles. PVs flowing into vv. dorsalis pedis are localized on the medial surface of the medial marginal vein at the level of the ankle base. In most cases, we found an arterial branch nearby at the subfascial level. In anterior part of the plantar surface of the foot, we distinguished 4-5 small PVs (~1 mm) flowing into vv. digitales plantares through the commissural orifices of the aponeurosis. There were 6-9 vessels (~1 mm) along the fascial aponeurotic septa. These vessels connected superficial plantar venous network and plantar veins. Small arterial branch was found almost in all cases near these veins. Noteworthy is the area where the plantar veins lie on the quadratus plantae and are covered by a leaf of deep plantar fascia. This anatomy is similar to topography of posterior tibial veins. CONCLUSION: Foot perforator veins constitute the neurovascular bundles as a rule. Plantar vein topography and their relationship with PV confirm an existence of muscular-venous pump of the foot.

Feasibility and short-term complication rate of mechanochemical ablation for epifascial tributaries of incompetent great saphenous veins.

OBJECTIVE: The aim of the present study was to investigate the occurrence of skin complications after mechanochemical ablation with the ClariVein device (Merit Medical, South Jordan, Utah) for incompetent great saphenous veins (GSVs) and compare the results in terms of the target vein characteristics, especially in the presence of an epifascial GSV tributary. METHODS: A single-center, retrospective study was performed. We reviewed 33 limbs of 32 patients with GSV insufficiency who had undergone mechanochemical ablation with the ClariVein device from December 2017 to February 2020. The 33 limbs were divided into two groups: the epifascial group, comprising 11 limbs of 11 patients, and the nonepifascial group, comprising 22 limbs of 21 patients. The patients underwent postoperative follow-up examinations at 1 week and 1, 3, 6, and 12 months. The skin complication counts and scores on a four-point scale were recorded. RESULTS: Regarding the baseline characteristics, the epifascial group showed a significantly lower GSV depth in the distal thigh region compared with the nonepifascial group (2.64 ± 0.5 mm vs 7.05 ± 2.57 mm; P < .001). No statistically significant difference was found between the two groups in terms of the sclerosant (sodium tetradecyl sulfate) volume (5.45 ± 2.02 mL vs 6.59 ± 1.79 mL; P = .109) or ablation length (31.82 ± 3.92 cm vs 32.95 ± 4.05 cm; P = .449). All ClariVein procedures were technically successful (33 of 33 limbs; 100%), and no major complications were reported. The hyperpigmentation score was significantly greater in the epifascial group than in the nonepifascial group (score, 0.18 ± 0.4 vs 0 ± 0; P = .0401), although the hyperpigmentation count was not significantly different between the two groups (2 of 11 limbs [18.2%] vs 0 of 22 limbs [0.0%]; P = .1042). Although marginally higher counts and scores were observed in terms of phlebitis and bruising in the epifascial group, these differences were not statistically significant. CONCLUSIONS: Endovenous treatment with the ClariVein device for incompetent GSVs can be performed safely. However, caution should be exercised when the epifascial GSV tributary is treated during the ClariVein procedure because of its predilection to result in hyperpigmentation.

Hypersensitivity reaction after cyanoacrylate closure of incompetent saphenous veins in patients with chronic venous disease: A retrospective study.

PURPOSE: The objective of this study was to evaluate the incidence of, the risk factors for, the nature of the disease, and the management of hypersensitivity reaction (HSR) after cyanoacrylate closure (CAC) of incompetent saphenous veins in patients with chronic venous disease. METHODS: Data consisting of all incompetent saphenous veins, including great saphenous veins, anterior accessory saphenous veins, and small saphenous veins, treated with CAC at Siriraj Hospital (Bangkok, Thailand) from January 2017 to December 2018 were retrospectively evaluated. RESULTS: A total of 126 saphenous veins, including 106 great saphenous veins (84.1%), 7 anterior accessory saphenous veins (5.6%), and 13 small saphenous veins (10.3%) of 126 limbs from 101 patients were included. A HSR occurred in 16 of 101 patients (15.8%), in 19 of 126 limbs (15.0%), and in 19 of 126 treated saphenous veins (15.0%). HSR-related erythema, itching, swelling, and pain occurred in 100.0%, 95.0%, 68.4%, and 52.6%, of HSR patients, respectively. HSR occurred 1 week after CAC. All HSR symptoms were mild, could be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and antihistamine, and were resolved within 1 week. The risk factors for HSR were suprafascial saphenous vein with a depth <1 cm from the skin, and saphenous vein diameter of ≥8 mm. CONCLUSIONS: A HSR occurred in 15.8% of patients and in 15.0% of limbs after CAC. Risk factors for HSR were a suprafascial saphenous vein located close to the skin and a large saphenous vein. All HSR symptoms were mild in severity, occurred at 1 week after CAC, and were resolved within 1 week after treatment with nonsteroidal anti-inflammatory drugs and antihistamines. To prevent HSR, CAC should be avoided in suprafascial saphenous veins that are located close to the skin, and CAC in saphenous veins with a size of ≥8 mm should be performed with caution.

Estudo experimental comparativo da resistência tensional da safena magna no tornozelo e na região inguinal / Experimental comparative assay of tensile resistance of greater saphenous vein from ankle and groin

Resumo Contexto A veia safena magna é usada como material de remendo em vários tipos de reconstrução arterial, incluindo no trauma e endarterectomias de carótida e femoral. Houve relatos de ruptura do remendo de safena, particularmente de veias colhidas na região do tornozelo. Há uma necessidade de medição objetiva da resistência tecidual da safena magna. Objetivos Mensurar a força tensional suportada pela veia safena magna e analisar a correlação entre resistência e diâmetro da veia. Métodos As veias foram coletadas durante operações de safenectomia por varizes dos membros inferiores. Foram analisados apenas segmentos sem refluxo. Foram analisados 10 membros de oito pacientes, com um total de 20 espécimes. Os espécimes foram submetidos a ensaio de tração em equipamento eletrônico, obtendo-se os valores de tensão máxima do material em quilogramas-força por centímetro quadrado (kgf/cm2; força máxima dividida pela área de secção transversa do segmento submetido à tração). Resultados A tensão máxima suportada pela veia safena do tornozelo variou de 74,02 a 190,10 kgf/cm2, e a tensão máxima da veia safena da crossa variou de 13,53 a 69,45 kgf/cm2 (p < 0,0001). O coeficiente de correlação de Pearson entre o diâmetro da veia distendida e a tensão máxima suportada foram iguais a -0,852 (correlação inversa moderada a forte). Conclusões A resistência tecidual da veia safena magna do tornozelo é maior do que a da crossa em mulheres submetidas a operação de varizes; há correlação negativa entre o diâmetro da veia e sua resistência tecidual nessa mesma população.

Abstract Background The great saphenous vein is used as patch material in several types of arterial reconstruction, including trauma and carotid and femoral endarterectomy. There have been reports of saphenous patch blowout, particularly of patches constructed with veins harvested from the ankle. There is a need for objective measurement of the resistance of saphenous vein tissues. Objectives To measure the tensile strength of the great saphenous vein harvested at the ankle and groin and analyze the correlation between diameter and tissue strength. Methods Venous samples were harvested during elective saphenous stripping in patients with symptomatic varicose veins. Only segments without reflux were included. Ten limbs from eight patients were studied, providing 20 samples in total. Venous segments were opened along their longitudinal axis and fitted to electronic traction assay equipment to obtain values for material maximum tension in kilograms-force per square centimeter (kgf/cm2; the maximum force resisted by the segment, divided by its cross-sectional area). Results The average maximum tension in the ankle saphenous vein group ranged from 74.02 to 190.10 kgf/cm2 and from 13.53 to 69.45 kgf/cm2 in the groin saphenous vein group (p < 0.0001). The Pearson coefficient for the correlation between vein diameter and maximum tension was -0.852 (moderate to strong inverse correlation). Conclusions Ankle saphenous vein tissue from female patients operated for varicose veins has significantly higher resistance than saphenous vein tissue from the groin and there is an inverse relation between vein diameter and resistance of tissue from the same population.

Backscattered Scanning Electron Microscopy Approach for Assessment of Microvessels under Conditions of Normal Microanatomy and Pathological Neovascularization.

We evaluated the efficiency of an original method for studying of the microvascular bed under conditions of normal microanatomy and pathological neovascularization. The blood vessels, tissues surrounding the stent in the pulmonary artery and subcutaneously implanted titanium nickelide plate, atherosclerotic plaque, and vascular stent with restenosis were examined. The specimens were fixed in formalin and stained in OsO4, embedded into fresh epoxy resin, grinded, polished, and counterstained with uranyl acetate and lead citrate. Numerous vasa vasorum were found in all native vessels. Around the pulmonary artery stent and metal plates, numerous newly formed vessels of small diameter were seen. The intensity of neovascularization in atherosclerosis and carotid stent restenosis differed significantly. Our technique can be successfully used for evaluation of the microvascular bed.

The Reverse Sural Artery Flap: A Reliable and Versatile Flap for Wound Coverage of the Distal Lower Extremity and Hindfoot.

The reverse sural artery flap is a distally based fasciocutaneous or adipofascial flap used for wound coverage of the distal one-third of the lower extremity, ankle, and posterior heel. The flap harvest can be performed without sacrificing major arteries of the lower extremity. It can be elevated and mobilized with relative ease and a short operative time. It provides a good alternative to free tissue transfer in complex lower-extremity wounds with exposed bone, tendon, or hardware. The surgeon must be familiar with the management of venous congestion to improve the success of the flap.

Level and modalities of origin of the small saphenous vein: toward codification of the proximal approach level.

PURPOSE: The proximal approach to the small saphenous vein (SSV) must be performed according to precise anatomical landmarks to respect the esthetic profile of venous insufficiency surgery. In this work, we propose the tip of the lateral malleolus and the lateral edge of the calcaneal tendon as palpable landmarks from which to easily identify the situation of this vein. METHODS: This was a cadaveric dissection study involving 62 members of fresh and embalmed anatomical subjects. We used a horizontal line passing through the tip of the lateral malleolus and the lateral edge of the calcaneal tendon as reference marks. Once the origin of the SSV as dissected, the distances between the saphenous vein and the landmarks were measured. RESULTS: We found that the small saphenous vein was often unique. The origin of this small saphenous vein projected, on average, to 4.40 cm from the horizontal passing through the tip of the lateral malleolus and 1.2 cm from the lateral edge of the calcaneal tendon. CONCLUSION: These two measurements constitute the orthogonal coordinates for the situation of the small saphenous vein origin.

Inter-arterial saphenofemoral junction: A rare anatomical variation.

Several anatomical variations involving the great saphenous vein have been described in the literature. Some of them concern the saphenofemoral junction, including duplication, ectasia, and different numbers of tributaries. In this case series, a rare, distinct variation, the inter-arterial saphenofemoral junction was reported.

The anatomical relationship between the sural nerve and small saphenous vein: An ultrasound study of healthy participants.

Procedures involving the small saphenous vein (SSV) can result in sural nerve (SN) damage due to the proximity of the two structures. The relationship between the SN and SSV has previously been described in cadaveric studies with limited scope on surface landmarks. This study investigates the relationship between the SN and SSV in vivo through ultrasound. Transverse/short-axis ultrasound scans of 128 legs (64 healthy participants) were taken by a single observer using a GE Logiq e ultrasound system with a 5-13 Hz linear transducer (GE Logiq 12L-RS). The SN was identified and traced from the lateral malleolus to the popliteal fossa noting its course and proximity to the SSV. The distance between the SN and SSV was measured at points representing the distal 50% and 25% of the total leg length (the distance between the medial tibial condyle and the inferior edge of the medial malleolus). The SN and SSV were visualized in all participants regardless of BMI and atypical anatomical relationship were noted in 20.3%. The SN pierced the fascia in the distal 25.9% ± 5.3% of the total leg length. The distance between the SN and SSV was 4.06 ± 1.8 mm and 3.4 ± 1.4 mm in the distal 50% and 25% points of the total leg length, respectively. There was no significant effect of sex or body side. The SSV is a viable option for multiple vein harvest. Ultrasound visualization can be a beneficial tool for delineating variations of the SN in relation to SSV prior to surgery. Clin. Anat. 32:277-281, 2019. © 2018 Wiley Periodicals, Inc.

Human Femoral Vein Diameter and Topography of Valves and Tributaries: A Post Mortem Analysis.

The femoral vein (FV) is a clinically important vessel. Failure of its valves can lead to chronic venous insufficiency (CVI) with severe manifestations such as painful ulcers. Although they are crucial for identifying suitable implant sites for therapeutic valves, studies on the topography of FV tributaries and valves are rare. Moreover, the femoral vein diameter (FVD) must be known to assess the morphometric requirements for valve implants. To reassess the anatomical requirements for valve implants, 155 FVs from 82 human corpses were examined. FVDs and tributary and valve topographies were assessed using a laboratory straightedge. The FVD increased from 6 mm in the distal femoropopliteal vein to 11 mm in the iliofemoral vein proximal to the saphenofemoral junction (SFJ). Diameters were significantly bigger in males than females. Height correlated positively with FVD. Distal to the SFJ, within a distance of 38 cm, one to eight valves were present. Up to two valves were present within 10 cm proximal to the SFJ. Individual tributary and valve topography must be considered to ensure appropriate design and successful implantation of a venous valve for CVI therapy in the FV. A suitable implant site would be proximal to the SFJ via an infrainguinal transfemoral access. Clin. Anat. 31:1065-1076, 2018. © 2018 Wiley Periodicals, Inc.

The anatomy and physiology of the terminal thoracic duct and ostial valve in health and disease: potential implications for intervention.

The thoracic duct (TD) transports lymph drained from the body to the venous system in the neck via the lymphovenous junction. There has been increased interest in the TD lymph (including gut lymph) because of its putative role in the promotion of systemic inflammation and organ dysfunction during acute and critical illness. Minimally invasive TD cannulation has recently been described as a potential method to access TD lymph for investigation. However, marked anatomical variability exists in the terminal segment and the physiology regarding the ostial valve and terminal TD is poorly understood. A systematic review was conducted using three databases from 1909 until May 2017. Human and animal studies were included and data from surgical, radiological and cadaveric studies were retrieved. Sixty-three articles from the last 108 years were included in the analysis. The terminal TD exists as a single duct in its terminal course in 72% of cases and 13% have multiple terminations: double (8.5%), triple (1.8%) and quadruple (2.2%). The ostial valve functions to regulate flow in relation to the respiratory cycle. The patency of this valve found at the lymphovenous junction opening, is determined by venous wall tension. During inspiration, central venous pressure (CVP) falls and the valve cusps collapse to allow antegrade flow of lymph into the vein. During early expiration when CVP and venous wall tension rises, the ostial valve leaflets cover the opening of the lymphovenous junction preventing antegrade lymph flow. During chronic disease states associated with an elevated mean CVP (e.g. in heart failure or cirrhosis), there is a limitation of flow across the lymphovenous junction. Although lymph production is increased in both heart failure and cirrhosis, TD lymph outflow across the lymphovenous junction is unable to compensate for this increase. In conclusion the terminal TD shows marked anatomical variability and TD lymph flow is controlled at the ostial valve, which responds to changes in CVP. This information is relevant to techniques for cannulating the TD, with the aid of minimally invasive methods and high resolution ultrasonography, to enable longitudinal physiology and lymph composition studies in awake patients with both acute and chronic disease.

Associação entre variação anatômica da veia safena magna e insuficiência venosa em pacientes à ultrassonografia vascular dos membros inferiores / Association between anatomical variation of the great saphenous vein and venous failure in patients undergoing vascular ultrasound of the lower limbs

97 Artigo Original Associação entre Variação Anatômica da Veia Safena Magna e Insuficiência Venosa em Pacientes Submetidos à Ultrassonografia Vascular dos Membros Inferiores Association between Anatomical Variation of the Great Saphenous Vein and Venous Failure in Patients Undergoing Vascular Ultrasound of the Lower Limbs Ana Cristina Lopes Albricker, 2,3 Ane Graziela Ferreira Andrade, 1 Danila Simões Almeida, 1 Gisely Simões Almeida, 1 Jaider Matheus Monteiro de Andrade, 1 Paola Souza dos Santos, 1 Marcio Vinícius Lins Barros 1,3 Faculdade de Saúde e Ecologia Humana, 1 Vespasiano, MG; Faculdade de Ciências Médicas de Minas Gerais; 2 Centro Especializado em Ultrassonografia, 3 Belo Horizonte, MG - Brasil Resumo Introdução: A anatomia venosa pode apresentar significativa variabilidade, com ampla incidência de afluentes venosos, veias duplicadas, tributárias ou acessórias relacionadas às veias safenas. O reconhecimento e a identificação destas variações são importantes no manejo terapêutico destes pacientes, sendo que a ultrassonografia vascular é o método de escolha na avaliação do sistema venoso periférico. Objetivos: avaliar a associação entre variação anatômica da veia safena magna (VSM) e insuficiência venosa dos membros inferiores em pacientes com varizes primárias dos membros inferiores. Métodos: Foram avaliados consecutivamente pacientes com clínica de varizes de membros inferiores no período de 2014 a 2015, excluindo pacientes com história de cirurgia prévia e trombose venosa profunda. A ecografia vascular foi realizada para exame do sistema venoso superficial, em especial ao estudo da VSM, determinando os diversos padrões de variação anatômica deste vaso e sua associação com a presença de insuficiência venosa e classificação CEAP. Resultados: foram examinados 422 membros inferiores de 211 pacientes, com idade entre 21 e 86 anos, média de 45,7 anos, sendo 81% do sexo feminino, com predomínio de CEAP 1 (43,8%) e 2 (46,2%). Refluxo na VSM foi encontrado em 35,1%. A presença de variação anatômica foi encontrada em 8,8% dos pacientes sendo mais frequente em terço distal da coxa e proximal da perna (27,3%), não sendo observado associação entre a variação anatômica da VSM e CEAP (p = 0,25). Observou-se associação estatisticamente significativa entre ausência de variação anatômica e de insuficiência de VSM (p = 0,03). Conclusão: no presente estudo observou-se variação anatômica da veia safena magna em cerca de 9% dos pacientes, com associação significativa entre insuficiência de veia safena magna e ausência de variação anatômica

ntroduction: Venous anatomy may present significant variability, with a wide incidence of venous tributaries, duplicate or accessory veins related to saphenous veins. The recognition and identification of these variations are important in the therapeutic management of these patients, and vascular ultrasonography is the method of choice in the evaluation of the peripheral venous system. Objectives: To evaluate the association between anatomic variance of the great saphenous vein (VSM) and venous insufficiency of the lower limbs in patients with primary varicose veins of the lower limbs. Methods: Patients with varicose veins were consecutively evaluated in the period from 2014 to 2015, excluding patients with a history of previous surgery and deep venous thrombosis. Vascular ultrasound was performed to examine the superficial venous system, in particular to the VSM study, determining the different patterns of anatomical variation of this vessel and its association with the presence of venous insufficiency and CEAP classification. Results: 422 lower limbs of 211 patients, aged between 21 and 86 years, mean age of 45.7 years, 81% female, with a predominance of APC 1 (43.8%) and 2 (46.2% %). Reflux in the VSM was found in 35.1%. The presence of anatomical variation was found in 8.8% of the patients, being more frequent in the distal third of the thigh and proximal of the leg (27.3%). No association was found between the anatomical variation of MSV and CEAP (p = 0.25). There was a statistically significant association between no anatomic variation and the presence of VSM insufficiency (p = 0.03). Conclusion: in the present study, anatomic variation of the great saphenous vein was observed in about 9% of the patients, with a significant association between insufficiency of the great saphenous vein and no anatomical variation

A pilot study of venous duplex ultrasound parameters in healthy children.

OBJECTIVE: The spectrum of chronic venous disease (CVD) in adults is well documented, whereas there is a paucity of data published commenting on pediatric CVD. We previously identified that there is often venous reflux present in cases of pediatric lower extremity edema despite an alternative confirmed diagnosis. To further assess the clinical significance of this venous reflux, this study aimed to elicit venous parameters in healthy pediatric controls. METHODS: Healthy pediatric volunteers aged 5 to 17 years were recruited for venous reflux study. A comprehensive venous reflux study was performed with the patient standing. Vein diameter, patterns of valvular reflux, and accessory venous anatomy were examined in the deep and superficial venous systems. RESULTS: Eighteen children including 10 boys and 8 girls were studied. Five volunteers were aged 5 to 8 years, six volunteers were aged 9 to 12 years, and seven volunteers were aged 13 to 17 years. Great saphenous vein (GSV) diameter at the saphenofemoral junction significantly increased with age. Deep vein valve closure time (VCT) did not differ significantly between groups, whereas GSV VCT was significantly higher in the 9- to 12-year age group. Incidental venous insufficiency was identified in 60% of children aged 5 to 8 years (n = 3), 50% of children aged 9 to 12 years (n = 3), and 57% of children aged 13 to 17 years (n = 4). All superficial venous reflux was confined to the GSV; there were no cases of isolated deep venous reflux. Reflux was identified at multiple GSV stations in 60% of children. There was no significant difference in incompetent GSV VCT in comparing children with and without deep venous reflux. Accessory superficial veins were identified in 20% of children aged 5 to 8 years (n = 1), 50% of children aged 9 to 12 years (n = 3), and 43% of children aged 13 to 17 years (n = 3). The presence of an accessory saphenous vein was not associated with deep venous reflux in any patient, and only 29% of those with accessory saphenous venous anatomy had evidence of superficial venous (GSV) reflux. CONCLUSIONS: The GSV continues to grow in diameter through the teenage years. Incidental valvular incompetence and GSV reflux are common. The presence of accessory saphenous veins is similarly common and not associated with venous reflux. The clinical significance and natural history of this incidental venous reflux remain unclear. Future research should determine whether these changes seen in the pediatric age group lead to CVD during later years of life.

Dynamic ultrasound-guided short-axis needle tip navigation technique vs. landmark technique for difficult saphenous vein access in children: a randomised study.

Dynamic ultrasound-guided short-axis needle tip navigation is a novel technique for vascular access. After venipuncture, the needle and catheter are further advanced within the vessel lumen under real-time ultrasound guidance with constant visualisation of the needle tip in the short-axis view. This can minimise the risk of transfixing the cannulated vessel. We compared two techniques for non-visible saphenous vein cannulation under general anaesthesia in children weighing ≥ 3 kg and less than four years of age: dynamic ultrasound-guided short-axis needle tip navigation technique (ultrasound group) vs. landmark technique. Venous cannulation was performed by three experienced anaesthetists. The primary outcome measure was first-attempt success rate. Success rate within 10 min was a secondary outcome. A total of 102 patients were randomly allocated to either the ultrasound group or the landmark group. First-attempt success rate was 90% in the ultrasound group compared with 51% in the landmark group, p<0.001, difference 39%, 95% confidence interval (CI) of the difference 23-55%. Success rate within 10 min was 92% in the ultrasound group compared with 63% in the landmark group, p = 0.001, difference 29%, 95%CI of the difference 14-45%. We conclude that, when performed by experienced anaesthetists, the dynamic ultrasound-guided short-axis needle tip navigation technique improved non-visible saphenous vein cannulation in children compared with the landmark technique.

Bedside Vein Mapping for Conduit Size in Coronary Artery Bypass Surgery.

BACKGROUND AND OBJECTIVES: The greater saphenous vein has been used in coronary artery bypass grafting (CABG) for more than 50 years. Endoscopic vein harvesting has greatly reduced the morbidity associated with obtaining the vein, but the quality of the vein could not be assessed before its was exposed surgically or after the endoscopic procedure had been performed. This study was conducted to evaluate the accuracy of preoperative mapping of the greater saphenous vein at the bedside in assessing suitable conduit size for use in CABG. METHODS: Seventy-two consecutive patients undergoing saphenous vein harvesting for use as a conduit during CABG underwent preoperative ultrasonographic vein mapping on the operating table after the leg was positioned for vein harvesting. Vein diameters at 3 distinct locations were measured by ultrasonography after vein harvesting and preparation. Similar linear regression was used to determine the correlation between measurements by ultrasonography and the true vein size after harvesting. Standard methods of computing 95% lower and upper confidence limits for single predicted values were also used. RESULTS: Two hundred twenty measurements were obtained from 72 patients. Mean vein diameters were 3.4 ± 0.9 and 4.6 ± 0.9 mm as measured by ultrasonography and after vein harvest, respectively. True vein size was an average of 1.2 ± 0.4 mm larger than that measured by ultrasonography. Ultrasonographic determination of vein diameters closely correlated with the true vein diameter (correlation coefficient, 0.91; P < .001), and the measurement obtained predicted the true measurement within 1.6 mm with 95% confidence. CONCLUSION: Bedside ultrasonographic vein mapping provides an accurate noninvasive method for preoperative assessment to determine the suitability of the greater saphenous vein for use as a bypass conduit. It is therefore an important component of preoperative planning before CABG.

The importance of great saphenous vein types and segmental aplasia in venous reflux.

PURPOSE: To investigate the relationship among great saphenous vein (GSV) anatomic type, segmental aplasia, and reflux. METHODS: Color Doppler ultrasonography (CDUS) was performed on 475 legs of 277 consecutive patients with venous symptoms between November 2015 and August 2016. Exclusion criteria were previous venous surgery and venous thrombosis. Five GSV types were identified based on the saphenous compartment at thigh level, and segment aplasia and reflux were investigated. RESULTS: The most frequent GSV type was type A, ie, a single GSV extending within the saphenous compartment with no accompanying large parallel tributary (53%), and the least frequent type was type B, GSV duplication (1.3%). Patients with and without reflux showed similar distributions of GSV type (p = 0.389). Segmental aplasia was observed in 117 (24.63%) of 475 legs. The mean age of patients with GSV reflux was compared between patients with and without aplasia (p = 0.798). CONCLUSIONS: The frequency of venous reflux was nearly identical across GSV types. The frequency of segmental aplasia was similar in patients with and without reflux. Despite these similarities, defining GSV type and identifying segmental aplasia can provide guidance for treatment. In particular, type D GSVs, defined by the presence of an anterior accessory branch, should be investigated when performing CDUS. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:332-336, 2017.