Venous system anatomy constitutes the fundamental
of the clinical phlebology and is essential for
the accurate diagnosis and treatment of venous
disorders.[
6] The venous system anatomy of the lower
limb are highly variable; however, it is within a
systematic order.[
7] The veins of the lower limb can
be examined in three groups: deep veins, superficial
veins, and perforating veins.[
8] These are located in
two compartments, namely the deep and superficial
compartments. The deep compartment is delimited
by the muscular fascia and contains deep veins, while
the superficial compartment is delimited deeply by
the muscular fascia and superficially by the skin
containing the superficial veins.[
6] Perforating veins
can be only defined as the vascular communications
between the veins of these two compartments,
crossing through the holes in the muscular fascia.
Within the superficial compartment, the separate
saphenous compartment lies on the dorsum of the
foot up to the inguinal ligament with a characteristic ultrasonographic view of the ‘saphenous eye' or
‘Egyptian eye' (Figure
1).[
7,
8] This saphenous
compartment deeply bounded by the muscular fascia
and superficially by the saphenous fascia.[
9] The
saphenous fascia, which was previously defined
and then abandoned as Colles or Scarpa fascia, is
the membranous layer of the subcutaneous tissue
overlying the GSV and its roots, as well as the dorsal
arch of the foot.[
6,
10] The saphenous compartment
contains saphenous vein and accompanying nerves
and arteries, whereas the tributaries and accessory
veins lie externally.[
6]
The accessory saphenous veins are the venous
structures which lie in parallel and coursing
superficially either anteriorly or posteriorly to
the GSV outside the saphenous compartment.[6]
Anterolateral and posterolateral veins of the thigh
are the tributaries of the anterior and posterior
accessory saphenous veins, respectively. Several types
of anastomosis regarding the drainage of an accessory
saphenous vein may be observed. It may drain
directly into the femoral vein (below or above to the
SFJ), GSV or into one of its tributaries (external
pudendal vein, superficial epigastric vein, superficial
circumflex iliac vein).
In the light of all these anatomic review and the
setting of the nomenclature, some questions can be
asked on the reported case. Firstly, what was the reason
for the development of an isolated AASV insufficiency
without affecting the GSV? Was AASV unprotected compared to the GSV? What protected the GSV?
Could GSV be left untreated, as it was normal?
As aforementioned, the AASV lies subcutaneously
outside the saphenous compartment, making it more
vulnerable to any venous hypertension rather than the
GSV which lies within the saphenous compartment.
Being buried in such a protective compartment may
also explain the etymological origin of the saphenous
vein which thought to be derived from the Arabic word
‘al Safin' meaning ‘hidden'. This connective sheath
surrounding the GSV opposes the dilatation of the vein
by serving a protective external cuff around the GSV.
However, this surrounding sheat is not present around the AASV.[9] Additionally, contraction of the thigh
muscles may modify the diameter of the GSV, as it
happens in the deep veins.[9] Another possible reason for
the development of an insufficiency in the AASV may
be its fragile wall, compared to the relatively thicker
saphenous type media layer. As the usual caliber of
the GSV in our case without any visible reflux could
not be left untreated, it was ablated. Otherwise, if
the GSV was left untreated, the reflux would shift
back into the GSV, instead of the AASV, soon after
the ablation of the AASV, since the terminal valve
of the SFJ was already insufficient. This insufficient
valve would eventually damage the previously intact
pre-terminal valve and would cause the GSV to
become gradually insufficient and dilated. Therefore,
to prevent further recurrences regarding the GSV, it
should be treated prophylactically, if the accessory vein
drains into the GSV at any level. However, the GSV
may be left untreated, when an insufficient accessory
vein drains individually into the femoral vein without
any anastomotic relationship with the GSV.
In our case, two separate sheaths were introduced
simultaneously into the GSV and the AASV, as seen
in Figure 1a. If these two veins were cannulated
separately instead of being simultaneous, the
swelling effect of the tumescent anesthesia would
deteriorate the Duplex US image, complicating the
percutaneous access. In addition, endovenous thermal
ablation procedure is performed under the tumescent
anesthesia in which the gross amount of fluid
containing local anesthetic is injected perivenously.
If any of these veins was cannulated first and the
other was remained uncannulated, the access to the
remaining uncannulated vein might be difficult
or even impossible after subsequent application of
the tumescent anesthesia.[11] As a result, they were
cannulated together before application any tumescent
anesthesia.
Although the sequence of ablation is not critical,
a particular interest should be given to the AASV, as
it has a proximity to the skin.[12] The amount of the
tumescent anesthesia should be kept high to protect
the overlying skin from the thermal injury.[11] The
venous tributaries are not necessarily extirpated, as
they originate from the insufficient AASV. They will
eventually fade away, as their primary feeding source
is treated.
Anterior accessory saphenous vein is present nearly
50% of the patients and it is the third common cause
of the chronic venous insufficiency.[5] In physical examination and Duplex US investigation findings
excluding the presence of the AASV may cause
misdiagnosis, undertreatment, and possible
recurrences.[13] Detailed preoperative Duplex US
imaging is, therefore, necessary to figure out any
anatomic description.[7]
In conclusion, we suggest that the isolated AASV
insufficiencies should be treated together with the
GSV. When they have a connection with each other,
the endovenous thermal ablation procedure is effective
in this treatment.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.
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