The Hip: Preservation, Replacement and Revision

Veins of the Lower Extremity


- See: Venous Repair

- Discussion:
    - veins accompany the arteries of the lower limb, and those that parallel the large arteries of leg are paired;
    - five major venous structures of leg are greater and lesser saphenous veins, posterior & anterior tibial veins, & peroneal veins;

- Greater Saphenous Vein:
    - begins on the medial side of foot and passes up medial side of the leg, across medial side of knee, continues upward to end in the femoral vein in the femoral triangle;
    - it originates from the medial marginal vein of foot & ascends medially along the leg, accompanied by saphenous nerve ;
    - greater saphenous vein empties into the femoral vein, and the lesser saphenous vein empties into the popliteal vein;
    - branches of saphenous vein:
           - superficial epigastric
           - superficial  circumflex iliac
           - superficial external pudendal
           - accessory saphenous

- Lesser Saphenous:
    - lesser saphenous vein begins in the lateral marginal vein of foot & ascends posterior to the lateral malleolus of fibula, accompanied
              by sural nerve  on lateral margin of achilles tendon;
    - in proximal half of the leg, the lesser saphenous vein is proximate to medial sural cutaneous nerve;
    - small saphenous vein  begins along lateral margin of foot & courses upward along posterior side of leg;
              - it ends in the popliteal vein;


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- Saphenous Vein Harvest:

    - perform harvest thru a series of longitudinal incisions in thigh and the calf overlying the course of the vein, depending on length of vein required;
    - attempt to identify the saphenous nerve which accompanies vein from femoral condyle to the ankle;
    - duplications of a portion of the saphenous vein are not infrequent, & care must be taken to clearly identify the main saphenous vein channel and avoid creating skin flaps during the dissection;
    - after exposure of required length of vein, dissection is deepened in calf to expose the recipient vessel to confirm its adequacy and insure sufficient length;
    - technical aspects for in situ saphenous vein preparation;
    - once vein is exposed, irrigate vein topically w/ papaverine solution (120 mg in 250 ml of warmed LR solution) to prevent spasm;
    - major tributaries of the vein are next divided between fine ligatures;
           - do not place ties flush w/ main trunk as this may cause intimal damage;
           - leaving tributary stumps too long, however, risks creating a nidus for thrombus formation;

- Vein Preparation:
    - after the vein has been removed, an irrigation cannula is attached by ligature to its caudal end;
    - gentle hydrostatic dilitation is performed to relieve spasm & too reveal unrecognized small side branches;
          - use physiologic saline w/ heparin 25,000 Units/400 cc w/ 60 mg papaerine;
          - use warmed balanced salt solution, 120 mg papaverine and 30 ml of heparinized blood;
                - note that pressures > than 500 mm Hg, achieved w/ hand held synringe, which will achieve endothelial denudation & eroding subendothelial basement membrane;
                - hence, consider avoiding this step;
    - vein integrity is better maintained in a buffered, colloid containing solution at 4 deg C, as opposed to warm saline;
    - cold blood or saline (4 deg) storage for 1 hr after atraumatic dissection without distension largely preserved endothelium, although saline caused mural edema;

- Vessel Size Discrepancy:
    - if the size discrepancy is < 50%, gentle dilation of the smaller vessel to the size of the larger and direct end to end repair is performed;
    - if smaller vessel is < 50 % of  the larger vessel, perform a beveled cut of smaller vessel not to exceed 30 deg and gentle dilitation will permit end to end anastomosis;
    - if the larger vessel is greater than twice the size of the smaller vessel, end to side anastomosis is recommended



The anatomy of the greater saphenous venous system.

Technical note: a quick and simple method of obtaining venous access in traumatic exsanguination.

Optimal techniques for harvesting and preparation of reversed autogenous vein grafts for use as arterial substitutes: a review.

A clinical technique for prevention of spasm and preservation of endothelium in saphenous vein grafts.

Short saphenous vein grafts as an aid to microsurgical reconstruction of the lower extremity.

A prospective, randomized trial of Unna's boot versus Duoderm CGF hydroactive dressing plus compression in the management of venous leg ulcers.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, January 28, 2015 10:24 am