Chapter 9 - The Greater Saphenous Vein

Chapter(9(*(The(Greater( Saphenous(Vein( Ronald(Bush,(MD,(FACS( Peggy(Bush,(APN,(CNS,(MSN( 2013(

Welcome'to'the'Vein'Experts'Online' Educa6onal'CME'Program.( Original'Release'Date:'12/16/13( Termina6on'Date:'1/31/2016( Price:((25.00(for(Vein(Experts(Members(&( $40.00(for(Non*Members(*(Processing/CME(Fees(

• 'This(acQvity(has(been(planned(and(implemented(in(accordance( with(the(accreditaQon(requirements(and(policies(of(the( AccreditaQon(Council(for(ConQnuing(Medical(EducaQon((ACCME)( through(the(joint(providership(of(The(University(of(Toledo(and( VeinExperts.org.( • The(University(of(Toledo(is(accredited(by(ACCME(to(provide( conQnuing(medical(educaQon(for(physicians.( • ( The(University(of(Toledo(designates(this(enduring(acQvity(for(a( maximum(of(1.00(AMA#PRA#Category#Credits™.((Physicians(should( claim(only(credit(commensurate(with(the(extent(of(their( parQcipaQon(in(the(acQvity.( ((

For(nurses,(we(are(also(able(to(issue(a(cerQficate(of(aZendance(staQng(the(course(is( AMA(approved,(which(may(be(eligible(for(credit.((Nurses(are(responsible(for( submi[ng(the(cerQficate(to(their(board.((Please(note(only(one(cerQficate(can(be( issued(for(each(purchase.( ( Disclosures:( ( Ronald'Bush,'MD,'FACS,(faculty(and(planning(member(discloses(he(is(on(the(Speaker’s( Bureau(for(Dornier/Refine(USA(and(is(contracted(with(Water’s(Edge(Dermatology(and( Soffer(Health.(( Richard'L.'Mueller,'MD,(faculty(and(planning(member,(discloses(he(receives(grant/research(support( from(Vascular(Insights,(LLC(

Ariel'Soffer,'MD,(FACC,(faculty(and(planning(member,(discloses(he(is(on(the(Speaker’s( Bureau(for(Cutera(,(consults(for(Angiodynamics,(&(does(research(for(BTG.( Peggy'Bush,'APN,(planning(member,(has(no(disclosures(or(financial(interests(and(is( employed(by(Midwest(Vein(&(Laser(Center.( Becky'Roberts,(planning(member,(has(no(financial(interest(or(other(relaQonships(with( any(manufacturer(of(commercial(product(or(service(to(disclose(

Mission:( (Our(objecQve(is(to(provide(current(evidence(based( informaQon,(as(well(as(new(technology(that(is(being( developed(for(the(treatment(of(venous(disease(presented( in(a(virtual(format.(( (( Target'Audience:( (The(target(audience(for(this(acQvity(includes(physicians( and(other(health(care(professionals(in(Cardiology,( Dermatology,(IntervenQonal(Radiology,(Phlebology,( Surgery,(Vascular(Surgery,(Wound(Care(Specialists(who( care(for(paQents(with(venous(disease.((

Steps'to'successfully'complete'this'ac6vity:( CME'Credit'Instruc6ons( Steps'to'successfully'complete'this'ac6vity:( Register(for(CME(acQvity(&(pay(your(CME(fees.( Read(the(Vein(Journal(Chapter(8,(enQtled(‘The'Greater' Saphenous'Vein.’'Take(the(post(test((score(of(80%(or(greater( must(be(achieved.((A(pdf(copy(of(the(exam(can(be(emailed(to( you(if(requested).( Scan(and(email(post(test(and(evaluaQon(to(( pbush@veinexperts.org(or(you(can(fax(completed(paperwork( to(937*281*0200.(( You(will(be(contacted(by(the(University(of(Toledo(CME(office( for(instrucQon(of(how(to(sign(on(and(print(your(cerQficate.((

Technical(Support( Email(your(quesQons/concerns( to(pbush@veinexperts.org((or(you(can(call(us( at(407*900*8346(and(we(will(respond(in(24( hours.( (( '(

The(Greater(Saphenous(Vein( •  This(acQvity(describes(relevant(factors( concerning(the(greater(saphenous(vein((GSV).( The(secQons(include(anatomy,(histology,(and( methods(of(treatment.((

ObjecQves( • IdenQfy(anatomy(and(physiology(of(the( greater(saphenous(vein(as(it(relates(to(venous( disease.( • Recognize(the(difference(in(injury(between( radio(frequency(and(laser(ablaQon.( • JusQfy(the(use(of(non*ablaQve(approaches(to( chronic(venous(disease(

The(Saphenous(Vein( • First(decide(if(the(greater(saphenous(vein( (GSV)(needs(to(be(treated( • Saphenous(sparing(procedures(do(have(a(role( in(chronic(venous(disease( • To(treat(the(GSV,(you(assume(that(reflux(is( retrograde(or(that(antegrade(flow(has( damaged(the(GSV(beyond(the(point(of(normal( funcQon(

GSV(Anatomy( • JuncQonal(branches(–(Should(be(spared(in( both(thermal(ablaQon(and(surgery( • Maintaining(flow(at(the(juncQon(helps(prevent( clot(propagaQon( • LigaQng(these(branches(is(reason(for( neovascularity(formaQon( • Two(valves(are(related(to(the(SFJ( • Terminal( • Sub*terminal(

Terminal(Valve(

Sub*Terminal(Valve( • 2*3(cm(distal(to(the( Terminal(Valve( • Between(the(terminal(and( sub*terminal(valve(are( the(branches(of(the( juncQon( • Hence,(this(area(is(the( true(SFJ( • Terminal(valve(someQmes( difficult(to(idenQfy,(but( usually(present(

SFJ(JuncQon(With(Branches(

GSV(Anatomy( • The(first(branch(aoer(the(sub*terminal(valve(is( the(Vein(of(Giacommini( • There(are(2(areas(are(of(special(interest( regarding(valves(and/or(possible(perforators( • Upper(thigh(perforator((Dodd’s)( • Hunter’s(Canal(–(May(be(a(valve(or(perforator(

• Thigh(perforators(connect(to(the(femoral(vein( • Below(the(knee(the(GSV(divides(into(the( anterior(branch(and(the(posterior(branch(

GSV(Anatomy( • 3*4”(below(the(knee( commonly(there(is(a( perforator((Boyd’s)(now( called(the(paraQbial( perforator( • Always(try(to(start(the( ablaQon(below(this(level( if(possible( • Decreases(new( saphenous(insufficiency(

GSV(Anatomy( • At(mid*calf,(another(perforator(is(commonly( present(formally(called(Sherman’s( • These(two(perforators(are(commonly( associated(with(recurrent(veins( • If(possible,(start(the(ablaQon(below(the( paraQbial(perforator,(at(least(paraQbial(1.( Based(on(the(REVATA(study,(this(will(decrease( the(incidence(of(recurrent(vein(formaQon(

GSV(Anatomy( • Posterior(Qbial(perforators(connect(the( posterior(Qbial(vein(to(the(posterior(branch(of( the(saphenous.(There(are(three(levels(of(these( perforators.(Formerly(known(as(CockeZ’s( perforator( ( • May(be(avenue(of(venous(hypertension(in( formaQon(of(venous(ulcers(

CockeZ’s(Perforator(

GSV(Anatomy( • Varices(are(branches(that(connect(to(the( saphenous(vein( • There(is(an(exit(and(re*entry(point(for(variceal( branches( • Always(do(a(phlebectomy(at(the(exit(point( when(doing(thermal(ablaQon( • Doing(an(exit(phlebectomy(prevents( spontaneous(thrombosis(of(variceal(branches( aoer(EVLT(or(RF(of(the(GSV(

GSV(Anatomy( • Controversy(exists(about(need(to(treat(every( saphenous(vein(that(refluxes( • ASVAL( • CHIVA( (

• In(most(cases,(any(vein(over(8(mm(should(be( treated(since(valvular(pathology(is(irreversible(

GSV(Anatomy( • Current(treatment(opQons( • High(ligaQon(stripping( • Endothermal(ablaQon( – Laser( – RF(

• Mechanical(chemical(ablaQon( • Foam(sclerotherapy( • New(treatment(opQons(include(glue(and(steam(

GSV(Anatomy( • With(laser(ablaQon(at(least(60(joules/cm( recommended(for(any(laser(wavelength( • Mechanism(for(thermal(injury(is(convecQve( with(laser(and(conducQve(with(RF( • Slight(edge(in(effecQveness(with(laser(ablaQon( • Always(start(ablaQon(distal(to(juncQonal( branches(to(maintain(inflow(at(juncQon(

GSV(Anatomy( • Clo[ng(occurs(with(eventual(collagen( deposiQon(at(3*4(months( • Perforators(are(an(important(factor(in( recanalizaQon( • More(about(perforators(in(Chapter(10((

Conclusion( • For(thermal(ablaQon,(use(adequate(energy( • Start(ablaQons(at(mid*calf(if(possible( • Perforators(should(be(watched(for(possible( role(in(recanalizaQon(

References( Bush(R,(Bush(P,(Flanagan(J,(et(al.(Factors(associated(with(recurrence:(3(year( results(of(the(REVATA((Recurrent(veins(aoer(themal(ablaQon)(study.(Jour#Vasc# Surg(2012;55(2)2012:297.( ( Fuller(W,(RaiQ(M,(Bush(R.(Modelling(of(heat(conducQon(along(vein(walls(in( endovenous(laser(treatment.(The(Internet(Journal(of(Bioengineering.(2011;5:( Number(1.(DOI:(10.5580/1e73( ( PiZaluga(P,(Chastanet(S,(Rea(B,(Barbe(R.(Midterm(results(of(the(surgical(treatment( of(varices(by(phlebectomy(with(conservaQon(of(a(refluxing(saphenous(vein.(Jour( Vasc(Surg(2009;50:107*118.( ( Theivacumar(N,(DellagrammaQcas(D,(Beale(R,(Mayor(A,(Gough(M.(Factors( influencing(the(effecQveness(of(endovenous(laser(ablaQon((EVLA)(in(the( treatment(of(the(great(saphenous(vein(reflux.(Eur(Jour(Vasc(Endo(Surg(2008;35(1): 119*123.( ( (

Exam( Complete'the'exam'&'evalua6on'below'and' email'your'results'to'pbush@veinexperts.org' along'with'your'contact'informa6on.'( '( A'score'of'80%'or'greater,'must'be'achieved'on' the'post\test'and'be'completed'in'less'than'3' a]empts.''

Exam( 1.(If(the(juncQonal(branches(are(ligated(and(cloZed(the( following(may(occur:( a. Neovascularity( b. Clot(extension( c. Both(a(and(b( d. Neither(a(or(b( ( (

Exam( 2.Thigh(perforators(( a. Are(important(in(recanalizaQon(of(a(thermally( ablated(vein( b. Are(randomly(distributed(throughout(the( saphenous(vein( c. Connect(the(saphenous(vein(with(the(profunda( femoral(vein(

Exam( 3.(Thermal(ablaQons(with(laser(( a. Use(at(least(30(joules/cm( b. AblaQon(should(be(started(at(knee(level( c. Are(successful(due(to(conducQve(energy( d. None(of(the(above(

Exam( Posterior(Tibial(Perforators( a.(May(be(important(in(venous(ulcers( b.(Connect(to(the(peroneal(vein( c.(Exit(point(of(the(anterior(branch(of(the(GSV( d.(Play(minimal(in(the(role(of(venous( hypertension( (

EvaluaQon( How(well(did(this(acQvity(present(the(objecQves?( (( Excellent((Good( ( (SaQsfactory( ( (Poor(( (( (( How(do(you(rate(the(overall(usefulness(of(the(online(material(to(meeQng(your(needs?(( (( Excellent((Good( (( (SaQsfactory( ( (Poor(( (( (( How(do(you(rate(the(overall(presentaQon(material?(( (( Excellent((Good( ( (SaQsfactory( ( (Poor(( ((

EvaluaQon( Was(any(commercial(bias(presented(in(the(material?(( ( No( (Yes((Please#explain)#(( ____________________________________________________(( (( I(will(be(able(to(change(my(clinical(pracQce(as(a(result(of(parQcipaQng(in(this( acQvity.( (( Yes((No(( (( (( What(topics(about(venous(disease(would(you(like(to(hear(about(in(the(future?(( (( ____________________________________________________((

AddiQonal(Comments/ RecommendaQons(( (

( _______________________________________ _______________________________________( (_______________________________________( ((( _______________________________________ _______________________________________( _______________________________________(

Contact(InformaQon( Name(&( CredenQals_______________________________________________( (( Address( ________________________________________________________( (( Phone(Number( ___________________________________________________( (( Email(address(___________________________________( ((