|Year : 2015 | Volume
| Issue : 4 | Page : 134-138
Risk Factors and Saphenofemoral Junction in Varicose Veins
Kshitij Manerikar1, Arjinder Pal Singh Bawa2, Abhilash Kumar Pithwa3, Gurjit Singh1, Harshwardhan Shrotri4, Somnath Gooptu1
1 Department of Surgery, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
2 Department of Community Medicine, Army College of Medical Sciences, New Delhi, India
3 Department of Surgery, Military Hospital Kirkee, Armed Forces Medical College, Pune, Maharashtra, India
4 Department of Radiology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
|Date of Web Publication||13-Apr-2016|
Department of Surgery, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Varicose veins (VVs) are dilated, tortuous, subcutaneous veins. It is common condition causing substantial morbidity. Prevalence of VVs ranges between 5% and 30% in the adult population. Surgery is one of the common modality of its treatment. A complete knowledge about anatomical variation at saphenofemoral junction (SFJ) and variations in tributaries of great saphenous vein (GSV) is important while dealing with such patients effectively. It will help in reducing chances of recurrences and complications.
Methods: A prospective non-randomized study of fifty patients was carried out in our hospital between May 2014 and May 2015. Diagnosis was established by clinical examination and supplemented with venous duplex ultrasound study. Patients were subjected to trendelenburg's operation, stripping of GSV with hook phlebectomy of affected perforators.
Results: A total of fifty patients were studied in this study, in which tobacco chewing was the most common associated risk factor with primary VVs, and it was observed in 46% of patients. Amongst them, twenty patients were obese with body mass index of more than 25 kg/m 2 . Location of SFJ was a mean of 2.24 ± 0.55 cm inferior and 3.77 ± 0.61 cm lateral to the pubic tubercle on duplex ultrasound and 2.35 ± 0.42 cm inferior and 3.73 ± 0.58 cm lateral intraoperatively, both of which had nonsignificant P value. The number of tributaries varied from 2 to 6 at the first 5 cm from SFJ. There were two and six tributaries in one patient each whereas three tributaries were observed in 42% patients. The most frequent consistent branch was a superficial inferior epigastric vein, seen in 98% of patients. The least frequent branch was posterior accessory saphenous vein, seen only in 2% of patients. The external pudendal artery was crossing SFJ anteriorly in 38% and posteriorly in 56%, and it was not identified in remaining 4% patients.
Conclusion: Our study showed the nonsignificant difference in Duplex ultrasound and intraoperative finding of SFJ location with respect to pubic tubercle; hence, one can plan a precise incision with the help of duplex ultrasound marking preoperatively. One must look for all tributaries for ligation which will prevent recurrence of varicose vein as variation in numbers and location of tributaries was remarkable in our study.
Keywords: Duplex ultrasound, great saphenous vein, pubic tubercle, saphenofemoral junction, tributaries, varicose veins
|How to cite this article:|
Manerikar K, Singh Bawa AP, Pithwa AK, Singh G, Shrotri H, Gooptu S. Risk Factors and Saphenofemoral Junction in Varicose Veins. Indian J Vasc Endovasc Surg 2015;2:134-8
|How to cite this URL:|
Manerikar K, Singh Bawa AP, Pithwa AK, Singh G, Shrotri H, Gooptu S. Risk Factors and Saphenofemoral Junction in Varicose Veins. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2019 Oct 19];2:134-8. Available from: http://www.indjvascsurg.org/text.asp?2015/2/4/134/180110
| Introduction|| |
Varicose veins (VVs) are dilated, tortuous subcutaneous veins. It is an extremely common condition causing substantial morbidity. Prevalence of VVs ranges between 5% and 30% in the adult population.  The word "varicose" is derived from the Latin word "varix," which means twisted. The adoption of the erect position by man is thought to have greatly influenced the development of venous diseases of the lower limbs.
VVs can be diagnosed by diligent clinical examination. Duplex ultrasound investigation of the lower limb is a reliable tool to confirm the location and competence of saphenofemoral junction (SFJ).
Flush ligation at the SFJ with the femoral vein after ligating and dividing the known and unknown tributaries (trendelenburg's procedure) is the most commonly employed method of treating saphenofemoral incompetence in primary VVs.
Among various venous anatomical variations in lower limbs, most important and significant variations occur at SFJ. The junction is identified by commonly used surface marking which is usually stated to lie 2.5 cm inferior and 4 cm lateral to the pubic tubercle. A complete knowledge about anatomical variation in SFJ and variations in tributaries of great saphenous vein (GSV) is important during surgery and ensuring that the junction is safely managed in least aggressive and most effective way.
Variations in the venous anatomy at SFJ are the major reason resulting in recurrence of VVs following surgery. Precise incision over SFJ, its ligation and that of its tributaries will help in reducing the incidence of recurrence. A study showed that the major causes of recurrences of VVs were identification of GSV stump with non ligated tributaries, a completely intact SFJ, nonidentification of bifid system, and presence of nonligated junctional tributaries. 
The present study was undertaken to note accurate location of SFJ. Compare the accuracy of preoperation duplex ultrasonography with intraoperative findings and to record variations in tributaries at surgery, in patients with primary VVs of lower limbs. This study also assessed variations in SFJ and risk factors of primary VVs.
| Materials and Methods|| |
A prospective non-randomized study of fifty patients was carried out in our hospital between May 2014 and May 2015. Demographic details of all patients were recorded. Detail history and examination of both lower limbs were performed.
Diagnosis of incompetent SFJ and/or incompetent perforators was established by clinical examination and further confirmed by venous duplex ultrasound studies of the lower limb venous system using micromaxx ultrasound system with linear probe C60e/5-2 MHz (low frequency) and linear probe HFL38/13-6 MHz (high frequency) and was performed by the same experienced sonographer.
The SFJ was marked in both lower limbs using duplex ultrasound scan. All patients underwent trendelenburg's operation, stripping of GSV, and hook phlebectomy of affected perforators. Dissection of the SFJ was carried out using 4 cm oblique incision, 2 cm lateral, and 1 cm inferior to pubic tubercle with its center over the SFJ. The incision was carried down through the subcutaneous tissue, and the GSV was identified.
SFJ was identified. The exact location of SFJ was measured with reference to the pubic tubercle. The number and the name of tributaries were noted within first 5 cm from SFJ. The presence or absence of the external pudendal artery (EPA) at SFJ and its relationship to it was recorded.
Descriptive statistics were calculated by measuring mean, standard deviation (SD), and proportions with 95% confidence interval. Inferential statistics were scored by using analysis of variance, Chi-square test (to compare independent proportions). Paired t-test was used to compare two methods of identifying SFJ distance from pubic tubercle. P < 0.05 was considered as statistically significant. Graphical presentation was done by using Microsoft Excel.
| Results|| |
Out of fifty patients, 36 were male and 14 were female [Table 1]. The mean age of patients was 44 (range: 18-70 years).
Among fifty patients, 66% patients were <50 years of age and remaining 34% were more than 50 years of age (mean = 44, SD = 15.1) [Table 2].
Tobacco chewing was the most common associated risk factor, and it was observed in 46% of patients followed by prolonged standing which was noted in 44% of patients. There was no significant association between history of VVs as it was observed only in 8% patients [Table 3].
Body mass index (BMI) of more than 25 kg/m 2 , mean being 24.62 kg/m 2 , and SD = 5.10 were noted in 40% of patients [Table 4].
Location of SFJ in our study was a mean of 2.24 ± 0.55 cm inferior and 3.77 ± 0.61 cm lateral to the pubic tubercle on duplex ultrasound. It was 2.35 ± 0.42 cm inferior and 3.73 ± 0.58 cm lateral to pubic tubercle intra operatively. Difference was insignificant (P > 0.05) [Table 5] and [Figure 1], [Figure 2] and [Figure 3].
|Figure 1: Left side pubic tubercle to saphenofemoral junction - lateral and inferior distance on duplex ultrasound imaging. Description - 1: Great saphenous vein, 2: Femoral artery, 3: Femoral vein, 4: Center of saphenofemoral junction, and 5: Pubic tubercle (lateral distance: 4.1 cm, inferior distance: 3.2 cm)|
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|Figure 2: Intraoperative left pubic tubercle to saphenofemoral junction - inferior distance. Description - 1: Pubic tubercle, 2: Center of saphenofemoral junction, 3: Medial side, 4: Lateral side, 5: Cranial side, and 6: Caudal side (Inferior distance: 2.9 cm)|
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|Figure 3: Intraoperative left pubic tubercle to saphenofemoral junction - lateral distance. Description - 1: Pubic tubercle, 2: Center of saphenofemoral junction, 3: Medial side, 4: Lateral side, 5: Cranial side, and 6: Caudal side (lateral distance: 4.5 cm)|
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|Table 5: Comparison of accuracy of location of saphenofemoral junction on duplex ultrasound and intraoperative measurements |
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The number of tributaries varied from 2 to 6 at first 5 cm from SFJ. The mean number of them was 3.78 with an SD of 0.99. There were minimum of two tributaries in one patient and maximum of six tributaries in one patient [Table 6] and [Figure 4] and [Figure 5].
|Figure 4: Right saphenofemoral junction with its six tributaries. Description - 1: Femoral vein, 2: Great saphenous vein, 3: Saphenofemoral junction, 4: Superficial circumflex iliac vein, 5: Superficial inferior epigastric vein, 6: Superficial external pudendal vein, 7: Unnamed tributary, 8: Posteromedial thigh vein, 9: Anterolateral thigh vein, 10: Cranial side, 11: Caudal side, 12: Lateral side, and 13: Medial side|
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|Figure 5: Left saphenofemoral junction with its two tributaries. Description - 1: Femoral vein, 2: Great saphenous vein, 3: Superficial circumflex iliac vein, 4: Superficial inferior epigastric vein, 5: Saphenofemoral junction, 6: Cranial side, 7: Caudal side, 8: Medial side, 9: Lateral side|
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The most frequent and consistent branch was a superficial inferior epigastric vein, seen in 98% of patients followed by superficial circumflex iliac vein, seen in 92% of patients. The least frequent branch was posterior accessory saphenous vein which was recorded in only 1 case [Table 7].
In our study, we also made diligent search for EPA during all surgical exploration, and its relation to SFJ was recorded. We noticed that EPA was not visualized in two patients. EPA was crossing anterior to SFJ in 40% and seen posterior in 56% of patients [Table 8].
|Table 8: External pudendal artery relation with saphenofemoral junction |
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| Discussion|| |
It is mandatory to have sound knowledge of normal anatomy and its anomalies while performing surgery at any location. Recurrent VVs after surgery is a common problem which has different causes such as inadequate assessment for the presence of deep venous thrombosis (DVT), anatomical variation at SFJ, postoperative neovascularisation. Incompetent surgery due to improper marking of incision, which may be away from the inguinal crease leading to incomplete ligation of all branches of the superficial system is one of the most important preventable cause of recurrent VVs.  Precise knowledge of anatomy at SFJ is important to plan incision. Ligation of all tributaries will prevent recurrence following surgery.
The exact etiology of VVs is still unclear, but there has been a better understanding of the pathogenesis in recent years. The most important risk factors for VVs include female sex, older age, positive family history, obesity, high numbers of pregnancies, history of VVs or DVT, and occupations involving prolonged standing. 
According to our study, most common risk factor for VVs was consumption of tobacco seen in 46%. Other associated risk factors were prolong standing, smoking, number of pregnancies, and family history of VVs or DVT which were 44%, 26%, 26%, and 22%, respectively. In our study, history of VV or DVT and history of surgery for VV did not have a significant impact on the development of disease and it was seen only in 12% and 8%, respectively. Winterborn et al. in their study found that, past history of DVT and previous incomplete surgery for VVs were important factors for recurrence. 
The mean age of patients according to Hemmati et al. was 45.03 years (range: 17-81 years) in his study of 228 patients.  We had similar findings and mean age in our study was 44 years (range: 18-70). In our study, 66% of patients were <50 years of age and 34% were more than 50 years of age with a female: male ratio of 1:2.57.
BMI of patients in our study group showed that 40% patients had BMI more than 25 kg/m 2 whereas 60% of them were with normal BMI ranging between 18.5 and 24.99 kg/m 2 , indicating no specific relationship of BMI with respect to disease prevalence.
Variation in location of SFJ and importance of ligation tributaries with respect to the successful outcome of operation is well known. Study done by Mirjalili et al. stated that center of SFJ was 2.4 ± 0.6 cm lateral (range: 1.0-4.5 cm) and 1.0 ± 0.9 cm inferior (range: 2.5-4.0 cm) to pubic tubercle in his hundred patients.  In our study, SFJ was located 2.24 ± 0.55 cm inferior and 3.77 ± 0.61 cm lateral to the pubic tubercle on duplex ultrasound done preoperatively and whereas intraoperatively it was found to be 2.35 ± 0.42 cm inferior and 3.73 ± 0.58 cm lateral to pubic tubercle, respectively. Determination of SFJ by duplex ultrasound and its actual location on exploration did not show a significant difference. However, preoperative marking of SFJ by duplex ultrasound will help in the precise planning of incision.
In our study, the number of tributaries at the first 5 cm from SFJ was between 2 and 6. According to the study of Donnelly et al. number of tributaries varied from 1 to 10,  whereas another study done by Vaz et al. in 189 patients, it ranged from 1 to 7.  Therefore one should make concentrated effort to locate all tributaries precisely so as not to miss any which may cause recurrence.
Most frequent number of tributaries was 3 (42%) in our study. Pourhassan et al. had similar findings of three tributaries (57.4%) in his study.  Another study of 228 patients quoted figure of 4 (71.20%) as the most common frequency of tributaries. 
We found a superficial inferior epigastric vein as the most common and consistent tributary of SFJ which was seen in 98% followed by superficial circumflex iliac vein (92%).
In Hemmati et al.'s study, the most common tributary was the superficial external pudendal vein,  whereas Pichot et al. recorded superficial epigastric vein and superficial circumflex iliac vein as the most common tributaries.  We did not encounter lateral venous system and intersaphenous vein in our study.
This shows that there is a significant variation in the number of different tributaries in individual, which can vary from minimum of 2 to maximum of 10 as per available literature. Most common tributary in different studies also shows variation. ,
In order to avoid inadvertent injury to EPA resulting in arterial bleeding, deliberate search for the same must be made; hence, knowledge of its location and variation will be useful. According to one study, EPA was present in all of their patients and it was crossing SFJ anteriorly in 39.5% and posteriorly in 60.5%.  We found the presence of EPA in 96% of our patients and among them it was passing anterior to SFJ in 40% and posterior in 56%. We found that EPA was unidentifiable in two patients. Similar finding was seen in a study where EPA was not identifiable in every patient. ,
| Conclusion|| |
Our study showed no difference in location of SFJ by preoperative duplex ultrasound and its subsequent confirmation as intraoperative finding; hence, duplex ultrasound marking preoperatively is advisable for planning a precise incision. Location of SFJ as a mean of 2.24 cm inferior and 3.77 cm lateral to the pubic tubercle on duplex ultrasound imaging preoperatively can be taken as the center of the planned incision. One must look for all tributaries for ligation which will prevent recurrence of varicose vein since variation in numbers and location of tributaries is considerable according to our study.
Among modifiable risk factors, tobacco chewing and smoking should be abandoned to reduce the chances of developing VVs. Following simple ergonomics rules, avoiding continuous prolong standing might be the most significant factor in decreasing the prevalence of this disease.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Raffetto J, Eberhardt RT. Chronic venous disorders: General considerations. In: Cronenwett JL, Johnston W, editors. Rutherford's Vascular Surgery. 7 th
ed. Philadelphia, PA: Saunders Elsevier; 2010. p. 831-40.
Egan B, Donnelly M, Bresnihan M, Tierney S, Feeley M. Neovascularization: An "innocent bystander" in recurrent varicose veins. J Vasc Surg 2006;44:1279-84.
Gad MA, Saber A, Hokkam EN. Assessment of causes and patterns of recurrent varicose veins after surgery. N Am J Med Sci 2012;4:45-8.
Henke PK. Venous pathology. In: Cronenwett JL, Johnston W, editors. Rutherford's Vascular Surgery. 7 th
ed. Philadelphia, PA: Saunders Elsevier; 2010. p. 171-2.
Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: Late results of a randomized controlled trial of stripping the long saphenous vein. J Vasc Surg 2004;40:634-9.
Hemmati H, Baghi I, Talaei Zadeh K, Okhovatpoor N, Kazem Nejad E. Anatomical variations of the saphenofemoral junction in patients with varicose veins. Acta Med Iran 2012;50:552-5.
Mirjalili SA, Muirhead JC, Stringer MD. Redefining the surface anatomy of the saphenofemoral junction in vivo
. Clin Anat 2014;27:915-9.
Donnelly M, Tierney S, Feeley TM. Anatomical variation at the saphenofemoral junction. Br J Surg 2005;92:322-5.
Vaz C, Machado R, Rodrigues G, Dias da S, Nogueira C, Loureiro T, et al
. Anatomical variation of the saphenofemoral junction: A prospective study in a population with primary superficial venous insufficiency. Angiol Cir Vasc 2013;9:6-10.
Pourhassan S, Zarras K, Mackrodt HG, Stock W. Recurrent varicose veins. Surgical procedure - Results. Zentralbl Chir 2001;126:522-5.
Pichot O, Sessa C, Chandler JG, Nuta M, Perrin M. Role of duplex imaging in endovenous obliteration for primary venous insufficiency. J Endovasc Ther 2000;7:451-9.
La Falce OL, Ambrosio JD, Souza RR. The anatomy of the superficial external pudendal artery: A quantitative study. Clinics (Sao Paulo) 2006;61:441-4.
Henriet JP. Sapheno-femoral venous confluence and the external pudendal network: Anatomical data and new statistics. Phlebologie 1987;40:711-35.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]