venous mapping

Question 1

what types of pre-operative venous mapping are there? (4)

Answer 1

In-situ femoral -distal bypass
Reversed femoro-popliteal
CABG (carotid arterial bypass graft)
Endoscopic perforator ligation

Question 2

what are the 4 veins that can be used for potential harvest (from most common and preferred to least)?

Answer 2

great saphenous vein
lesser saphenous vein
cephalic or basilic vein
radial artery (for CABG)

Question 3

how does the le venous system work

Answer 3

Two systems (Deep venous system, Superficial venous system)

Connected by perforating veins
Drains into the central venous system
IVC, returns to Right atrium

Question 4

what does the following describe….

carries 85% blood volume
Imbedded deep within the muscles
Has adjacent artery
Paired in the calf

Answer 4

deep venous system

Question 5

___________ is Between superficial and deep facial planes in thigh

__________ Carry blood from superficial system to deep
Perforate through deep facial plane

*Venous system have many anatomical variants

Answer 5

Superficial system

Perforating (Communicating) Veins

Question 6

which vein is

Anterior to medial malleolus, courses medially up leg
Joins deep system at CFV (saphenofemoral junction)

Carries approx. 15% of venous blood volume in leg.
Often anomalous, with double systems (8%), or non-continuous (25%)

No adjacent artery

Answer 6

Superficial system Greater Saphenous Vein (GSV)

*longest vessel in

Question 7

what is this?

how many valves?

~ how big?

Answer 7

the GSV or “Saphenous Eye”
Bound anteriorly by superficial fascia & posteriorly by deep fascia

Valves ~4 in calf, ~6 in thigh
Size ~ 2-3 mm calf, 4-6 mm thigh

Question 8

what are the SFJ tributaries?

Answer 8

Question 9

what are these?

Answer 9

SFJ Tributaries
AL – Anterolateral
PM – Posteromedial
SEP – (Superficial external) pudendal
SE – Superficial epigastric
SCI – Superficial circumflex iliac

Question 10

label

Answer 10

Question 11

what vessel

Posterior aspect of calf
Between heads of gastrocnemius muscles, “stocking seam”
Course from postior, lateral ankle
Typical confluence is at popliteal vein, saphenopopliteal junction (SPJ)

Answer 11

Superficial system: Lesser (Small) Saphenous Vein (LSV)

Question 12

In_______ % of population LSV will enter femoral vein
Other variants include joining GSV, V. Giacomini

does it have an adjacent artery

Proximal portion lies between ____ & __________l layers

Size: _____ mm

Answer 12

20-30

no

superficial, deep fascia

4-7

Question 13

which vein

Posterior medial branch in thigh connects to small sapenous

connecting GS to LS

9% of population

Answer 13

V. of Giacomini

Question 14

which vessel is the

Main tributary to GS
Arises posterior to medial malleolus, join GSV below knee
Perforators to tibial veins

Answer 14

Posterior arch vein

Question 15

what are the perforator vein regions…

Answer 15

Proximal thigh - Hunterian
Distal thigh - Dodd’s
Knee - Boyd’s
Ankle/Calf - Cockett’s

Question 16

how can you tell this is a perforator.

Answer 16

look for hyperechoic line o th edeep fascia and search for a hole. this is where the perforator is.

Question 17

is this a normal perforator. how can you tell?

Answer 17

yes. flow is from superficial to deep.

Question 18

describe the difference b/t a suitability study and mapping.

Answer 18

Suitability exam:
Determine if vein “suitable” for use
No need to mark

Vein mapping exam:
Pt scheduled for surgery
Mark leg

Question 19

what exam determine if deep system patent, determines vein size, Duplicated, Small, Large and incompetent, Thrombus, Wall irregularities

Answer 19

suitability study.

*u can’t take out the superficials if deep is thrombosed as they will be the only vessels feeding the leg.

Question 20

what position do you ut the pt for a suitability exam.

what is evaluated?

Answer 20

Reverse Trendelenburg or semi-Fowler’s (upper body and head elevated)

deep system evaluation for patency: Normal DVT exam groin to pop

Superficial system: GS evaluated routinely, maybe bilat
LS as requested or if GS unsuitable
7.5-14 MHz for superficial system

Question 21

where do u start/stop when evaluating the greater saph.

what do u deterine

Answer 21

Start at SFJ in transverse and follow GSV to ankle

Determine:
Continuous or dichotomous
Duplicated (bifid)
Follow tributaries to see if rejoin GSV
Thrombus or wall irregularities
Measure at: upper, mid, lower thigh; upper, mid, lower calf
Bifid – measure both systems

Question 22

how much does the vein expand when arterialized?

Answer 22

80-100%

Question 23

what doyou need to remember when measuring the gsv?

Answer 23

Diameter
Don’t compress
2 techniques
Average 2 perpendicular measurements*
Measure across at angle
>2.5 mm better
<2.0 unsuitable

Question 24

how do you evaluate the small saph

Answer 24

Leg dependent, sitting on edge bed
Same technique as GS
Measure – proximal, mid, distal
Proximal – SPJ or does it join femoral, etc.

Question 25

how do you evaluate the perforators?

Answer 25

patient sitting, leg dependent
patient standing
scan fascia for “holes”

Question 26

what techiniques can be used for vein mapping?

what needs to marked for ligation.

Answer 26

Two techniques depending on complete vein exposure for harvest or in-situ graft

Vein harvest will allow surgeons to see vein and ligate perforators, so marking them less essential

In-situ graft will leave vein in place, perforators and communicators need to be marked for ligation

Question 27

Venous Mapping for Harvest

Answer 27

Same technique as suitability, but need further investigation and marking

Vein will be exposed, so perforators not needed

Large branches can be marked to help with vein removal

Question 28

what approach is used to eval the perforator - fascia

Answer 28

Transverse, medial approach,
Scan straight down to ankle
Scan for defects in deep fascia
Move transducer one probe width
and repeat scan
Proceed until entire calf
Circumference is scanned

Image in transverse
Keep vein in center of screen, this correlates with mark on transducer
“mark” leg periodically every few centimeters down length of GSV
Straw or needle cap – indent skin
“Sonomarking”
Mark large tributaries