The anatomy of the saphenous nerve in the lower leg with particular reference to its relationship to the long saphenous vein

The anatomy of the saphenous nerve in the lower leg was studied in eighty patients undergoing saphenous vein aortocoronary bypass grafting. It is suggested that a knowledge of the described variations in the anatomical relationship of the saphenous nerve and vein should reduce the incidence of operative trauma to the saphenous nerve.     

An improved technique for long saphenous vein harvesting for coronary revascularization

A prospective study was undertaken to assess the functional quality of long saphenous vein for coronary revascularization when it has been harvested by means of multiple small incisions and use of the Mayo "stripper." This avoids a "long cut" and the major wound problems commonly associated with it. Between January, 1979, and July, 1984, 2,439 patients underwent coronary artery bypass graft with long saphenous vein harvested by this technique. No major wound problems occurred, and minor wound problems were seen in only 23 patients (0.9%). Vein quality was assessed by histological studies of veins, postoperative graft angiography, and exercise testing. Both light electron microscopy and scanning electron microscopy demonstrated that the vein was of good quality and that the intima had been preserved. Postoperative graft angiography and exercise testing confirmed high patency rates for the vein grafts (93%). Vein harvesting with this technique is easy, gives good quality vein, both morphologically and functionally, for grafting, is associated with a minimum of wound problems, and has cosmetically superior results.     

Decreased morbidity following long saphenous vein harvesting using a minimally invasive technique: a randomised controlled trial comparing two techniques for long saphenous vein harvest

Objectives  

The objective of this study was to compare the morbidity associated with long saphenous vein harvesting using the traditional open technique (A) against a minimally invasive technique using the Mayo vein stripper (B) that involves multiple short incisions.     

The effect of long saphenous vein stripping on quality of life

PURPOSE: Long saphenous vein (LSV) stripping in the treatment of varicose veins may reduce the recurrence of varices but may also increase morbidity rates. The effect of stripping on health-related quality of life (HRQoL) is unknown. The aim of this study was to examine the effect of LSV surgery, with and without successful stripping, on HRQoL. METHODS: This prospective study comprises 102 consecutive patients who underwent varicose vein surgery that included attempted stripping of the LSV to the knee. HRQoL was assessed before surgery and at 4 weeks, 6 months, and 2 years after surgery with the Aberdeen varicose vein severity score (AVSS; disease-specific) and the Short-Form 36 (SF-36; generic). Patients defined as stripped were those in whom complete thigh stripping to the knee was confirmed with postoperative duplex scanning at 2 years. Patients defined as incompletely stripped were those in whom any LSV remnant was found in the thigh after surgery. Deep venous reflux (DVR) was defined as reflux of 0.5 seconds or more in at least the popliteal vein. RESULTS: Sixty-six of 102 patients (65%) provided complete HRQoL data at all four time points. At baseline, there was no significant difference between patients who were stripped (n = 25) and incompletely stripped (n = 41) in terms of AVSS, SF-36, age, gender, DVR, or CEAP grade. Significantly more patients in the incompletely stripped group underwent surgery for recurrent disease (29/41, 71%, versus 8/25, 32%; P =.002, with chi(2) test). Both groups gained significant improvements in AVSS scores for as much as 2 years. After adjustment for recurrent disease, stripping conferred additional benefit in terms of AVSS at 6 months (median [interquartile range]) (9 [4 to 16] versus 15 [9 to 24]; P =.031) and 2 years (7 [2 to 10] versus 9 [5 to 15]; P =.014), which was statistically significant in patients without preoperative DVR but not significant in patients with preoperative DVR. SF-36 scores were not affected by stripping. CONCLUSION: LSV surgery leads to a significant improvement in disease-specific HRQoL for as much as 2 years. In patients without DVR, stripping to the knee confers additional benefit.     

The short saphenous vein: an alternative to the long saphenous vein for aortocoronary bypass.

The long saphenous vein and internal mammary artery are considered at present to be the best grafts available for coronary artery bypass. Patients who have had bilateral long saphenous vein stripping and who require multiple aortocoronary bypass grafts present a challenge to the cardiac surgeon. The short saphenous vein appears to be a suitable alterative.     

Intra-operative and post-operative flow in the in-situ saphenous vein bypass

We have attempted to further define the hemodynamic properties of the arterialized in-situ saphenous vein. The natural taper of the vein and the presence of arteriovenous fistulas are two unique factors associated with this conduit. Utilizing intra-operative electromagnetic flowmeter (EF) measurements and post-operative duplex ultrasound scanning (DUS), we have studied the natural history of these conduits from the time of their arterialization. The EF mean arterial blood flow in 71 in-situ bypasses was 100.8 cc/ml, range 25-200. No significant correlation was found between these measurements and angiographic runoff, vein diameter, pre- or post-operative Ankle/Brachial Index (ABI) and site of distal anastomosis. Three immediate failures requiring revisions were not predicted by EF flow measurements. Using the unique combination of Doppler ultrasound measurement and real time imaging, afforded by the DUS, fistula flow was determined. These studies showed that terminal bypass segment blood flow is not significantly affected by cutaneous fistula interruption. We found that duplex ultrasound scanning is a useful tool ideally suited to the study of the arterialized saphenous vein in-situ. One of its main advantages is the ability to accurately localize the site and hemodynamic significance of any arteriovenous fistulas.     

Early experience with B mode ultrasound mapping of the long saphenous vein prior to femorodistal bypass.

B mode ultrasound was used to assess and map the long saphenous vein in 20 limbs prior to femorodistal bypass. The assessment was compared with operative findings. Eighteen of 19 adequate veins and 8 of 9 anatomical abnormalities or major divisions were correctly identified. B mode ultrasound allows accurate marking of the vein, facilitating dissection, alerts the surgeon to possible difficulties and is an ideal non-invasive technique for preoperative assessment of the long saphenous vein.     

An assessment of long saphenous venography to evaluate the saphenous vein for femoropopliteal bypass

A long saphenous venogram was performed on a consecutive series of 42 patients (5 bilateral) though in 4 the vein was not satisfactorily demonstrated. In all cases the long saphenous vein was dissected out and its suitability for use for a femoropopliteal bypass compared to the radiological findings. Eleven veins were unusable for a bypass and radiologically these were narrower (mean diameter 2.8 mm) than the veins which functioned satisfactorily (mean diameter 5.0 mm), and had more tributaries (mean 5) than the suitable veins (mean 2). Preoperative venography is a useful technique to identify veins that will be unsuitable for a femoropopliteal bypass and thereby save an unnecessary dissection.     

Sensory abnormalities and bruising after long saphenous vein stripping: impact on short-term quality of life

BACKGROUND: We assessed the impact of postoperative sensory abnormalities and bruising after long saphenous vein (LSV) stripping on short-term quality of life (QOL). METHODS: Seventy patients with LSV incompetence were recruited before surgery. Surgery involved saphenofemoral disconnection, stripping of the LSV in the thigh, and multiple stab avulsions in all patients. Sensory abnormalities (subjective and objective) and bruising were recorded at two follow-up visits (mean, 8 and 47 days). The bruised area was traced manually, and the surface area was estimated by placing the tracing on a square chart. A QOL assessment was performed before surgery and repeated during the second visit by using the Aberdeen Varicose Veins Questionnaire. Minitab version 13.32 was used for statistical analysis. RESULTS: Eight patients either did not complete follow-up or were excluded from the final analysis. Final analysis was performed on 63 limbs in 62 patients (27 men and 35 women; age, 19-75 years). The overall incidence of postoperative sensory abnormality was 40% (25/63 limbs). This included numbness or decreased sensation in 36.5% (23/63), paresthesia in 8% (5/63), and dysesthesia in 1.6% (1/63). Irrespective of the presence of sensory abnormalities, QOL scores improved after surgery (mean change in QOL score, -7.58 and -7.52; SE, 1.1 and 1.3 in those with and without sensory abnormalities, respectively). There was no significant difference either in the degree of improvement in the QOL score (P = .972; t test) or in the proportion of patients with an improved score (P = .69; Fisher exact test) between the groups with and without sensory abnormalities. Postoperative bruising at first follow-up ranged from 28 to 1419 cm(2) (mean, 500.7 cm(2); median, 438 cm(2)). Both groups--those who bruised less than the median value (438 cm(2)) and those who bruised more than the median value--showed improved postoperative QOL scores (mean change in QOL score, -7.64 and -7.46; SE, 1.3 and 1.3, respectively). There was no significant difference either in the degree of improvement in the QOL score (P = .924; t test) or in the proportion of patients with an improved score (P = .422; Fisher exact test). All patients with persistent bruising at the second follow-up (26%) also showed an improvement in the QOL score (mean change in QOL score, -10.29). CONCLUSIONS: Conventional surgery for varicose veins with stripping of the LSV is associated with significant morbidity of sensory abnormalities and bruising. However, this does not adversely affect postoperative improvement in short-term QOL.     

The anatomic relationship between the long saphenous vein and the saphenous nerve. Relevance for radical varicose vein surgery

Radical surgery for varicose veins often includes total stripping of the long saphenous vein. Some surgeons now claim, however, that stripping of the distal part of that vein can be avoided, thereby reducing the risk of damage to the saphenous nerve. Dissection of 60 cadaver legs to demonstrate the relationship between the long saphenous vein and the saphenous nerve indicated that stripping performed from the groin to immediately below the knee would minimize the risk of nerve damage.     

Preoperative saphenous and cephalic vein mapping as an adjunct to reconstructive arterial surgery.

B-mode ultrasound was prospectively evaluated for its ability to preoperatively assess the adequacy of venous conduit for arterial reconstruction. Fifty-one patients who had lower extremity revascularization had real-time imaging of the saphenous and cephalic veins. Veins were judged adequate based on size, compressibility, and absence of sclerosis or intraluminal echoes. All mapped veins were explored and assessed by the standard criteria for suitability. Vein size was determined from completion angiograms, and wound complications recorded and compared with patients who had similar procedures in the 12 months before the use of vein mapping. Preoperative mapping was found to be accurate in 50 to 51 patients (98%). Vein size as determined by B-mode ultrasound correlated well with angiograms, R = 0.8539 overall with R greater than 0.9 in the last 7 months of the study. Wound complications occurred in 2% of the patients who had preoperative mapping and in 17% of the historic controls. Preoperative vein mapping using B-mode ultrasound is an accurate method of determining vein suitability for use in arterial reconstruction. It improves operative planning and can contribute to a reduction in wound complications. Veins determined to be unusable by preoperative scanning need not be explored.     

Venous ulceration and continuous flow in the long saphenous vein.

OBJECTIVE: To determine the clinical significance of continuous flow in the long saphenous vein in limbs with venous ulceration. DESIGN: Retrospective review. PATIENTS AND METHODS: Review of 1608 consecutive limbs undergoing colour duplex scanning for venous disease over a 43 month period. RESULTS: Continuous flow in the long saphenous vein is seen in 8% of limbs with venous ulceration and in 37% of limbs with deep venous obstruction. Sixty-six per cent of ulcerated limbs with continuous flow in the long saphenous vein had deep venous obstruction, 27% had deep venous reflux with cellulitis and 7% had lymphoedema in addition to venous ulceration. CONCLUSION: Continuous flow in the long saphenous vein in patients with venous ulceration should alert the clinician to the possibility of deep venous obstruction. Such limbs should be treated by compression bandaging with extreme caution.     

Open versus endoscopic saphenous vein harvesting: wound complications and vein quality.

BACKGROUND: The saphenous vein is an important conduit for coronary artery bypass grafting. Wound complications from traditional open vein harvesting occur often. Minimally invasive endoscopic saphenous vein harvesting may decrease wound complications. Vein quality may be an issue with endoscopic harvesting. METHODS: We reviewed 568 patients who had bypass grafting and saphenous vein harvesting either endoscopic (group A, n = 180) versus open (group B, n = 388). Both groups were demographically similar and management identical. Wound complication was defined by the need for intervention and included lymphocele, hematoma, cellulitis, edema, eschar, and infection. Multiple vein segments were obtained from 8 patients, 4 from each group, and examined histologically. RESULTS: Wound complications were significantly less in group A (9/180, 5%) versus group B (55/388, 14.2%), p value equal to or less than 0.001. Open harvesting (p< or =0.001), diabetes (p< or =0.001), and obesity (p< or =0.02) were risk factors for wound complication by univariate analysis. By multiple logistic analysis, open harvesting (p< or = 0.0007) and diabetes (p< or =0.0001) were independent risk factors for wound infection. Histologic evaluation of vein samples showed that there was no difference between the groups and vascular structural integrity was maintained. CONCLUSIONS: Endoscopic saphenous vein harvesting was associated with fewer wound complications and infections. Vein quality was not adversely effected because of endoscopic harvesting.     

How to prevent saphenous nerve injury. A personal modified technique for the stripping of the long saphenous vein

BACKGROUND: In literature the incidence of paresthesia caused by long stripping (LS) of the saphenous vein (SV) varies widely. Best results have been reported with the invagination technique by Van Der Stricht. However, this technique is associated with a high incidence of vein rupture and incomplete stripping. The aim of this study is to test a personal technique to avoid the SV rupture and to reduce the incidence of saphenous nerve injury. METHODS: Sixty-eight patients underwent LS of the SV from groin to ankle under monolateral spinal anesthesia on a one-day surgery basis using a personal technique combining external and invaginated saphenous stripping. All patients underwent a clinical re-evalutation 1, 3, 6, 12, 24 and 48 months after the operation. RESULTS: No intraoperative complications were recorded. Stripping of the long saphenous vein was complete in all cases without any rupture of the veins. Only one postoperative hematoma of the leg (1.5%) which was naturally reabsorbed, was recorded; four patients (5.9%) had transitory saphenous nerve injury. Permanent saphenous nerve damage was found in only one of 68 patients (1.5%). All the patients were discharged on the day of operation and we did not register any prolonged hospitalization. CONCLUSIONS: The result of our approach was a very low postoperative complication rate (1.5% of permanent neurological damage) without any rupture of the vein.     

激光闭合治疗大隐静脉曲张术后并发症的分析及预防

目的 探讨半导体激光治疗下肢静脉曲张术后并发症的发生原因及预防措施.方法 对2007年3月至2011年3月收治的大隐静脉曲张患者200例(共234条患肢)的临床资料进行回顾性分析.结果 术后随访时间4～46个月,有138条肢体出现并发症,发生率为59.0％(138/234),部分肢体可同时存在2种以上的并发症,其中皮下淤血、青紫、血肿发生率为16.7％(39/234);大隐静脉主干、小腿局部条索状硬结为15.0％(35/234);患肢皮肤水肿或肿胀为12.8％(30/234);不同程度的皮肤灼伤为10.7％(25/234);隐神经损伤导致皮肤感觉异常为0.85％(2/234),以上并发症经过治疗均能痊愈.结论 激光治疗下肢静脉曲张具有明显创伤小、安全、可靠的微创优势,规范化操作,可有效降低并发症的发生率.     

The saphenous vein: derivation of its name and its relevant anatomy.

Generally, when the origin of the word saphenous is discussed, most affirm that the term derives from the Greek word safaina, which means "evident." The ancient Greeks knew only the caudal portion of the vein, and neither the Greeks nor the Romans used the term saphena. In fact, the term first appeared in the writings of Avicenna. In contrast, the term saphenous is derived from the Arabic el safin, which means "hidden" or "concealed." Ancient Arabic physicians knew the anatomy of superficial veins of the human body and its extremities because they performed therapeutic bleeding. Arabic physicians phlebotomized the distal portion of the greater saphenous vein (GSV) at the ankle. Such phlebotomies were never performed on the proximal portions of the GSV because they were not superficial enough to be clearly evident. As a consequence, the proximal GSV was called el safin, or "the concealed." The modern reader will recognize that based on duplex examination, the GSV is correctly identified on the basis of its deep position with the superficial fascia covering it. This information may be useful in modern saphenous vein surgery in identifying the proximal portion of the GSV.