Drainage pattern of the tributaries of Great Saphenous vein at thigh in South Indian population – A cadaveric study - PDF Document

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  1. Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 410-419 Original article: Drainage pattern of the tributaries of Great Saphenous vein at thigh in South Indian population – A cadaveric study Dr.T.Preethi Ramya1, Dr.Anjana.TSR2, Dr.Jeyanthi.C.Gnanadeepam3, Dr. Sheela Grace Jeevamani4 1,2,3 – Government Kilpauk Medical College, 4 – Karpagam Faculty of Medical Sciences and Research. Corresponding author: Dr.T.Preethi Ramya , Department of Anatomy, Government Kilpauk Medical College, Kilpauk, Chennai-600010. Abstract: Introduction: The anatomy of great saphenous vein with regard to the drainage pattern of its tributaries at saphenofemoral junction shows much variation. In order to define the precise anatomy of the tributaries of Great saphenous vein, a study was conducted on the drainage pattern aiming to assess the most frequently occurring pattern in South Indian population. Materials and methods: The present study was done in 44 cadaveric lower limb specimens belonging to both sexes of South Indian population by dissection method and the details of the drainage pattern were recorded, analysed and compared with those of the previous studies. Results: The anterolateral tributary drained in common with superficial circumflex iliac vein and superficial epigastric vein in majority of specimens. In 4% of specimens, double GSV was reported. Conclusion: The knowledge of variations in the drainage pattern of the tributaries of great saphenous vein helps prevent recurrence of varicosity even after surgical intervention or thermo ligation procedures. vein into the femoral vein at fossa ovalis 6 is situated Introduction: 2.5-3.5cm inferolateral to the pubic tubercle 7, 10.8 The superficial veins of lower limb begin in the foot cm from anterior superior iliac spine 8, one and half forming two separate channels, the Great (long) inches below the inguinal ligament.4 Sometimes the saphenous vein and Small (short) saphenous vein. Great saphenous vein is duplicated9,10. The tributaries The formation of great saphenous vein is found to be highly variable and it usually originates from the of great saphenous vein at the level of ankle include medial side of the dorsum of the foot.1 It ascends the medial marginal vein. In the leg, three tributaries anterior to the medial malleolus of Tibia, then it draining the front of the leg, the tibial malleolar passes along the medial border of tibia and reaches region and the calf are present distal to the knee. The the knee, posterior to the medial edge of patella. It tributary draining medial malleolar region is called travels further on the medial aspect of thigh to reach the posterior arch vein, first described by Leonardo the saphenous opening.2 The great saphenous vein Da Vinci.2 In its course, the great saphenous vein is closely related to saphenous nerve11 and external begins by the union of dorsal digital vein of medial pudendal artery.12 side of great toe with the medial end of dorsal venous arch.3,4,5 The level of termination of great saphenous 410 www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858

  2. Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 410-419 In the thigh, the tributaries are grouped as The dissection was carried out by placing two posteromedial tributaries, anterolateral tributaries and incisions, one horizontally and another vertically in peri inguinal tributaries13,14. The posteromedial vein the thigh region. The horizontal incision extended is sometimes double and quite often called as from anterior superior iliac spine to pubic tubercle accessory saphenous vein. The anterolateral vein of and vertically from pubic tubercle to medial the thigh courses along the lower half of femoral malleolus along the medial aspect throughout. The triangle to end in great saphenous vein. The peri- skin and superficial fascia was reflected, then the inguinal tributaries namely the superficial epigastric, veins were isolated and separated from the superficial circumflex iliac and superficial external surrounding tissue. Its entry into femoral vein was pudendal veins drain into great saphenous vein with noted. The tributaries of great saphenous vein from 15,16,17 Sometimes the different modes of union. ankle, leg and thigh were noted. The drainage pattern tributaries drain into the Great saphenous vein in a of the periinguinal tributaries were further studied in conventional type with a ‘vein star’ shape. 18 detail. Apart from this, the drainage pattern was Thomas S Glasser18 (1943), demonstrated nineteen grouped based on the classification proposed by venous drainage patterns based on the dissection of Glasser, Daseler and Chun et al and the results of the fossa ovalis (saphenous opening) region of hundred present study were compared with those of the cadaveric lower limb specimens. Daseler19(1956), authors. A compiled tabulation describing the observed eight different patterns of drainage drainage patterns of the tributaries at saphenofemoral following dissection at the upper end of great junction formulated by Glasser and Daseler is given saphenous vein in 550 specimens. Chun et al20 in table 1. (1992), studied the different drainage pattern of Observations and results: saphenous tributaries in 249 lower limbs of Korean Tributaries at thigh: population. The drainage pattern of tributaries 1. Periinguinal Tributaries: presents ample variation. Failure to ligate all A)Superficial epigastric vein(Fig.1): superficial veins increases the appearance of The SEV drained directly into GSV in 50% varicosities even after high ligation and stripping of of limb. The SEV drained in common with great saphenous vein. SCI and AL tributary in 36%. In 10% of limbs the SEV drained along with SCIV Aims and objectives: The present study aims at giving a comprehensive alone . orientation on the drainage pattern of superficial The least common pattern observed in 4% tributaries of great saphenous vein at sapheno of specimens was the drainage of SEV along femoral junction. The results are correlated with with those of previous authors’ study. EPV . Materials and methods: B) Superficial circumflex iliac vein(Fig.2): 44 adult lower limbs from 22 embalmed cadavers This tributary drained directly into the GSV at SFJ in belonging to both sexes from the Institute of 40% of the limbs .In the remaining limbs , the vein Anatomy, Madras Medical College were obtained. drained in combination with the periinguinal 411 www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858

  3. Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 410-419 tributaries . the majority of specimens 36% showed a 2. Anterolateral Vein of Thigh: pattern wherein the SCIV drained along with SEV The percentage of specimens belonging to different and AL tributary . In 10% of the limbs the vein modes of drainage of anterolateral vein of the thigh is drained along with SEV only .and in 12% of limbs , shown in table 2. the vein drained with AL tributary alone. 3. Posteromedial vein of thigh: The percentage of specimens belonging to different C) Superficial external pudendal vein(Fig.3): In 90% of specimens, the SEPV drained directly into modes of drainage of anterolateral vein of the thigh is shown in table 3. GSV. In 6% of specimens , the EPV drained along with PM tributary and in 4% the vein drained by joining with SEV. Figure 1: shows A) SEV draining directly into GSV, B) SEV in combination with SCIV and ALV, C) SEV and SEPV draining with a common trunk. Figure 2: A) shows SCIV draining directly into GSV, B) shows SCIV draining in common with ALV. 412 www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858

  4. Indian Journal of Basic and Applied Medical Research; June 2016: Vol. Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 4 3, P. 410-419 Figure 3: shows A) SEPV draining directly into GSV, B) SEPV in common with PMV. Figure 3: shows A) SEPV draining directly into GSV, B) SEPV in common with PMV. Figure 4: shows double GSV with double SEP Figure 4: shows double GSV with double SEPV. Figure 5: Comparison of drainage pattern between present study and Daseler’s study. Figure 5: Comparison of drainage pattern between present study and Daseler’s study. 411 413 www.ijbamr.com P ISSN: 2250 www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858

  5. Indian Journal of Basic and Applied Medical Research; June 2016: Vol. Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 4 3, P. 410-419 Figure 6: shows A) Type I(A), B) Type II(B), C) Type III(C), D) Type IV(D) of Daseler’s classification. Figure 6: shows A) Type I(A), B) Type II(B), C) Type III(C), D) Type IV(D) of Daseler’s classification. Figure 6: shows A) Type I(A), B) Type II(B), C) Type III(C), D) Type IV(D) of Daseler’s classification. Figure 7: shows A) Type V(E), B) Type VI (F) Figure 7: shows A) Type V(E), B) Type VI (F) – “Vein star” shape, C) Type VIII(H) of Daseler’s study. , C) Type VIII(H) of Daseler’s study. Comparison of drainage pattern between present study and Glasser's study and Glasser's study Comparison of drainage pattern between present study 40 35 30 Percentage 25 20 15 10 5 0 I C I DII II B II C II D III A III B III C III D IV A IV B IV C IV D V A V B B V V C I A I B I C A GLASSER STUDY(%) 37 6 2 2 2 6 9 9 2 1 3 3 1 6 1 6 1 6 3 3 1 PRESENT STUDY(%) 30 0 2 2 4 6 35 12 4 0 2 0 0 0 0 0 0 0 4 4 1 Figure 8: Comparison of drainage pattern between present study and Glasser’s study. Figure 8: Comparison of drainage pattern between present study and Glasser’s study. 414 412 www.ijbamr.com P ISSN: 2250 www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858

  6. Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 410-419 TABLE 1: DRAINAGE PATTERN AT SAPHENO FEMORAL JUNCTION ACCORDING TO GLASSER AND DASELER ( COMPILED ) S NO PATTERN GLASSER DASELER SCIV, SEPV and SEV drain at fossa ovalis. PMV and ALV drain below fossa ovalis. 1. I A 2. PMVs and ALVs – multiple I B 3. ALV – Large and drains at fossa ovalis. TEV – inconstant I C I (A) 4. ALV and PMV drain into fossa ovalis. I D 5. PMV forms a common trunk with SEPV II A V (E) ALV, SEV and SCIV drains by forming a common trunk into GSV. 6. II B VI (F) 7. ALV and SCIV drains by forming a common trunk II C VIII (H) 8. SEV and SEPV form a common trunk and drain into GSV. II D IV (D) 9. PMV present. Double SEPV s present. III A 10. Double SEPV s drain at fossa ovalis. III B 11. SEV drain into GSV below fossa ovalis III C 12. SCIV drains into FV III D 13. Collaterals drain into FV IV A 14. ALV and SCIV form a common trunk. Collateral veins into FV. IV B III(C) 15. ALV drains at fossa ovalis. SEV drains into FV. IV C PMV s and ALV s have small caliber. SCIV and SEPV drain into FV. 16. IV D 17. ALV drains into FV V A 18. Double GSV joins at Fossa ovalis. V B 19. GSV drains into FV one inch below the fossa ovalis. V C DASELER’S STUDY: Type II (B) - SEV and SCIV forms common trunk. Type VII(C) - ALV and SEV forms common trunk and 413 415 www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858

  7. Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 410-419 drains into GSV. PMV-Posteromedial vein, ALV-Anterolateral vein, SCIV-Superficial Circumflex Iliac Vein, SEV-Superficial Epigastric Vein, SEPV-Superficial External Pudendal Vein, GSV- Great Saphenous Vein, FV – Femoral Vein. TABLE 2: DRAINAGE PATTERN OF THE ANTERO LATERAL TRIBUTARY OF GREAT SAPHENOUS VEIN. S.No Drainage Into GSV No of cases Percentage A) At Fossa Ovalis 1. Directly 19 38 2. In common a) With SCIV and SEV 18 36 b) With SCIV only 6 12 c) With TEVand SCIV 1 2 B) Below Fossa Ovalis 3. Directly 6 12 SCIV-Superficial Circumflex Iliac Vein, SEV-Superficial Epigastric Vein, SEPV-Superficial External Pudendal Vein, TEV – Thoraco Epigastric Vein. 414 416 www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858

  8. Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 410-419 TABLE 3: DRAINAGE PATTERN OF POSTEROMEDIAL TRIBUTARY OF GREAT SAPHENOUS VEIN . S.no Drainage Into GSV No of cases Percentage A)At fossa ovalis 1. Directly 3 6 2. Incommon With external pudendal vein 3 6 B)Below fossa ovalis 3. Directly 44 88 TABLE 4: DRAINAGE PATTERN AT SAPHENO FEMORAL JUNCTION BASED ON CHUN ET AL CLASSIFICATION S.no Vein DIRECT % COMMON % Chun Present Chun Present 1. PMV 82.3 94.2 17.7 5.8 2. ALV 67.1 50.6 32.9 49.4 3. SCIV 83.1 39.4 16.9 61.6 4. SEV 77.1 48.3 22.9 51.7 5. SEPV 95.2 90.2 4.8 9.8 417 415 www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858

  9. Indian Journal of Basic and Applied Medical Research; June 2016: Vol.-5, Issue- 3, P. 410-419 90% of specimens respectively. But the SCIV was Discussion: Expertize in venous anatomy and its variations are found to drain in combination with other tributaries necessary for the interventional treatment modalities. in majority of specimens (62%). The ALV and SEV Surgical and minimally invasive procedures require drained directly and in combination equally. The the knowledge on the drainage pattern of superficial pattern of drainage when compared to Chun et al veins at sapheno femoral junction. study, SCIV and SEV showed much variance. In In the present study, type II B was the most majority of specimens, the anterolateral tributary commonly observed pattern which was four times drained into the GSV either directly or forming a higher than that of Glasser’s study. The second common trunk along with SCIV and SEV at fossa common pattern observed was IA, which was slightly ovalis, whereas the posteromedial vein was found to less than Glasser study. drain directly into the GSV below fossa ovalis. The types IC and IIA matched with Glasser’s study. Conclusion: The unrecorded patterns were The primary application of this research was to IB,IIIA,IIIB,IIIC,IIID,IVA,IVB,IVC,IVD,VA and emphasise the variations in the drainage pattern of VC. the superficial tributaries of GSV at sapheno femoral Duplicated great saphenous vein was found in 4% in junction that should potentially be considered during accordance with Glasser’s study(Fig.4).The most ligation, stripping or thermo ablation procedures for common observation seen in 35% of specimens in the primary varicose vein treatments. The significant present study was that all three peri-inguinal pattern of drainage observed distinctly in the South tributaries drained into the GSV by a common Indian population in whom the present study was trunk(VI-F) which was near equivalent to Daseler’s conducted showed the anterolateral vein draining into study(Fig.6,7). A strikingly constant observation in the GSV, forming a common trunk with SCIV and the present study was the presence of a large and SEV. The GSV was duplicated in 4% of specimens. constant anterolateral tributary draining into the The presence of double SEPV was seen in 2% of GSV(I-A). In contrast to Daseler’s observation, the specimens. The knowledge of this drainage pattern is study showed Type( I-A) to be twice the percentage significant, failing which the tributaries may be of occurrence. The type VII(G) was not noted even in missed or left open during various procedures done a single specimen in the present study. for the treatment of varicose veins. The percentage of specimens classified according to Acknowledgements: Chun et al was compared with the author’s study and We sincerely thank Dr. Christilda Felicia Jebakani, shown in table 4. The tributaries, PMV and SEPV former Director, Institue of Anatomy, Madras were found to drain directly into GSV in 94% and Medical College, for her guidance and support. References: 1.Hollinshead W.H. Anatomy for Surgeons. The Back and Limbs. Volume 3. 3rd edition. Harper & Row. Philadelphia. 1992. P.607-610. 416 418 www.ijbamr.com P ISSN: 2250-284X , E ISSN : 2250-2858

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