The Giacomini Vein and its pathologicalflows

Stefano Ermini MDFlorence - Italy

I have no actual or potential conflict of

interest in relation to this

program/presentation.

Disclosure

Stefano Ermini MD

Contraction flux

Relaxation flux

Contraction= inward flow Relaxation= outward flow

The most common situation in a SPJ is that of an inward( centripetal) flow during musclecontraction and an outward( centrifugal ) flow during muscle relaxation.

Muscle pump contraction and relaxation and flow directions in the SPJ

Incompetent SPJ refluxing during the muscle relaxation phase

Slide 3

Contraction flux Relaxation flux

Contraction = outward flow Relaxation= outward flow( in some cases)

During the muscle contraction, an outward flow from the SPJ can occur. In some cases, the flow follows the same direction in both contractive and relaxation phases . This outward contraction flow results from an increasing pathologic pressure.

SPJ that presents an outward flow during both contraction and relaxation

Slide 4

This contractive centripetal flow in the Popliteal fossa can give origin to a centripetal flow in the Giacomini Vein and this can can occur in 2 differentsituations:1 - In case of deep vein obstruction. This flow is a part of a compensative circuit(vicarious flow )2- without deep obstruction, due to a functional deep vein stenosis or othercauses - This situation is the object of this presentation

1 2

Slide 5

If the flow that originates from the popliteal fossa, passes through the Giacomini vein and re-enters into the deep vein through the SFJ , the patient is completely asymptomatic and no varicose vein is visible

In this situation the re-entry point is placedabove the escape point and the flow goesupwards into the Giacomini vein thanks to a hypertensive pressure gradient

Slide 6

Dee

pve

ins

LSV

Re-entry point A

Re-entry point B

SSV

Escape point

If the Giacomini Vein drainsinto an incompetent GSV and a re-entry point isplaced below the escapepoint, a centripetal flow also exists in the Giacomini vein during musclerelaxation.

Contractive FlowRelaxation Flow

Slide 7

Dee

pve

ins

LSV

Re-entry point A

Re-entry point B

SSV

Escape point

Dee

pve

ins

LSV

Re-entry point A

Re-entry point B

SSV

Escape point

Contraction Relaxation Slide 8

The siphon effect explains the presence of a relaxation centripetal flow in the Giacomini v. The siphon effect occurs when a tube in an inverted U shape causes a liquid to flow upwards, above the surface of the reservoir, without pumps, powered by the fall of the liquid as it flows down the tube under the pull of gravity, and discharges at a level lowerthan the surface of the reservoire it comes from ( http://en.wikipedia.org/wiki/Siphon).The real siphon effect works in a open circuit. In the venous system the circuit is closedand the effect of gravity’s potential energy is charged by muscle pump activity.

Tank A

Tank B

The Siphon Effect

Tank A

Tank B

Slide 9

A contractive centripetal reflux is submitted to muscle pump contractive pressure. This pressure is much higher than the relaxation gradient that originates during the relaxation phase of the muscle pump and that creates a “conventional” escape point.

This means that this flow cannot be interrupted with the same positive results that we achieve for the SFJ or for a

conventional situation in the SPJ.

Differences between a contractive centripetal reflux and a relaxing centrifugal conventional escape point

Slide 10

Consideration about the escape point treatment

1. A flow that originates during muscle pump contraction is submitted to a high lateral pressure

2. A flush ligation in the popliteal fossa is frequently not correctly performed for anatomical reasons.

These two events combined lead to a frequent SPJ “flush” ligation recurrence

N° Recurrences Venous stump Cavernoma Contractiveoutward flow

SFJ 475 144 (30,3%) 36 (6,5%) 0

SPJ 18 6 (30%) 6(30%) 6 (30%)

( Personal archive from January 2007 to January 2014 )

Slide 11

Strategy Treatment

Goals: To preserve the contractive centripetal flow in the Giacomini vein, draining it

directly into the deep system To only treat the vicious recirculation ( private circulation) that originates during

relaxation without interrupting the contractive centripetal flow To reach a good cosmetic and functional result

Slide 12

Surgical Treatments and Results

15 strategies on the Giacomini v.4 strategies on the GSV 1 ligation of the Giacomini v. flush to the SSV arc

Surgery was performed on 20 patients( Follow up minimum 3 months , maximum 3 years)

Slide 13

Disconnection of the Giacomini vein flush to the SSV arc

Gastrocnemiousperforator

Slide 14

The same surgical disconnection obtains different effects: In situation A the systolic flow is preserved In situation B the systolic flow is NOT preserved

A B

Strategy on the Giacomini Vein Slide 15

Strategy on Giacomini v

No perforatorbefore surgery

Systolic flow 1 week later

No Systolic flow 1 week later

GiacThrombosis1 week later

15 10 6 4 1

What happens when the systolic flow is interrupted by the tributary disconnection?

Zero Deep vein thrombosis

2 recurrences ( new tributary originating from the Giacomini v.) in the first 12 months

2 recurrences =10 % of the entire group20% of the cases without systolic flow re-entry perforators

Slide 16

The worst thing that we can do in a situation like this is to destroy the saphenous trunk.

Slide 17

Thanks for your attentionStefano Ermini M.D.

( Florence - Italy )