Small Saphenous Research Articles

Summary of diagnostic and characteristic parameters of C0 to C2 patients based on the CEAP2020 classification

ObjectivesHemodynamic changes in C0 to C2 according to the clinical/etiological/anatomical/pathophysiological classification have not been analyzed extensively. We intend to investigate the characteristics of early stage venous disease using venous clinical severity score (VCSS), heaviness/ache/swelling/throbbing/itching (HASTI) score and duplex ultrasound (DUS) derived parameters. MethodsFrom Aug. 2020 to Jul. 2021, consecutive patients were categorized according to the clinical/etiological/anatomical/pathophysiological 2020 classification. The vein diameter (mm), reflux time (s), cross-sectional area (cm2), peak and mean reflux velocity (cm/s), and total reflux volume (mL) were documented in the superficial system and deep system. VCSS and HASTI scores were assessed and DUS parameters were analyzed. A P value of less than .05 was considered statistically significant. ResultsWe studied 257 consecutive patients (142 female) with 371 limbs. The mean age was 50.96 ± 13.27 years (range, 20-81 years; median, 53 years) with an average body mass index of 24.03 ± 2.96 kg/m2 (range, 17.00-33.06 kg/m2; median, 23.67 kg/m2). The proportion of clinical (C) category was as followed: 47 C0S (12.67%), 45 C1 (12.13%), and 279 C2 (75.20%). There were 42.6% of C0 and 62.2% of C1 associated with some form of venous reflux, Pr (pathology [P]-reflux). Reflux of the great saphenous vein above the knee (GSVa) was the most commonly affected vein segment from C0-2. C1 differed from C0 only by age and severity scores with a cut-off value of 1 for both VCSS and HASTI. Larger saphenous veins diameter (GSV and small saphenous vein) were seen in Pr (P-reflux) than Pn (P-none) of C0 cases. Larger deep vein diameters (common femoral vein, femoral vein, and popliteal vein) were evident in Pr versus Pn of C1 cases. In C2, the popliteal vein, saphenofemoral junction, and GSVa were dilated in Pr cases. ConclusionsBoth HASTI and VCSS were discriminative from C0 to C2. C0 differed from C1 by age and severity scores as DUS characteristics were not significantly different between the two groups. Vessel diameter played a discriminative role in distinguishing Pn versus Pr cases in each C0-2 category. GSVa was the most frequent reflux segment irrespective of reflux types.

Non-randomized comparative study of three methods for great saphenous vein ablation associated with mini-phlebectomy; 48 months clinical and sonographic outcome

BackgroundVaricose veins are one of the earliest clinical features of superficial venous insufficiency (SVI) of the lower limbs that affects around 20–40% of the population with a lot of burden on patients’ quality of life (QoL) and health systems if left untreated. They are defined as subcutaneous veins in the lower extremities which are dilated to ≥3 mm in diameter in the upright position and retrograde flow of >0.5 s in duration. (VVs) could occur in the great saphenous vein (GSV) or small saphenous vein (SSV) and/or in any of their tributaries. MethodsA prospective non-randomized comparative study for three methods of treatment of varicose veins was conducted. All symptomatic varicose veins with Clinical, Etiological, Anatomical, Pathophysiological (CEAP) Clinical classes of 2 or greater and demonstrated venous reflux with a duration of 0.5 s or greater on duplex ultrasound imaging GSV larger than 10 mm in diameter by duplex ultrasound were included. ResultsA total of 150 patients with 183 legs in all three groups are treated. The mean age of the patients in all groups was comparable (37.32) years, and a total of 87% were women. Demographic and preoperative clinical features, presentations, and anatomic characteristics were comparable in all groups. Disfigurement was the main presenting complaint in all. All postoperative complications were significantly higher in the group of surgery over 48 months of follow up the degree of satisfaction measured by VCSS score was highest among the RFA group followed by the EVLA group. ConclusionThe results of our study suggest that the long-term results of endovenous thermal ablation methods (EVLA, RFA) are superior to open surgery for the management of varicose veins, with the RFA group showing better results in terms of improvement in QoL based on VCSS compared to the EVLA group.

Options in the treatment of superficial and deep venous disease in patients with Klippel-Trenaunay syndrome

ObjectiveKlippel-Trenaunay syndrome (KTS) is a congenital mixed mesenchymal malformation syndrome that includes varicose veins, capillary and venous malformations, lymphatic abnormalities, and hypertrophy of various connective tissue elements. The purpose of the present study was to describe the clinical characteristics and outcomes in a subset of patients with KTS in whom venous interventions, including iliofemoral venous stenting, were performed after failure of conservative therapy. MethodsA single-center retrospective data review of 34 patients with KTS who had undergone interventions for venous disease between January 2000 and December 2020 was performed. ResultsTheir mean age was 38.4 ± 17.5 years (range, 12-80 years). No gender predilection was found. Of the 34 patients, 61% had had all three features of the classic triad for KTS. Varicose veins were present in all 34 patients (100%), and 30% had had a history of bleeding varicosities. Most patients (79%) had CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) class ≥C4. Of the 34 patients, 30% had a history of deep vein thrombosis and/or pulmonary embolism. Factor VIII elevation was the most common thrombophilia condition (12%). The venous filling index was elevated at baseline (5.9 ± 5.1 mL/s) and did not normalize despite intervention (3.5 ± 2.3 mL/s; P = .04). The superficial venous interventions (n = 35) included endovenous laser therapy; stripping of the great saphenous vein, small saphenous vein, anterior thigh vein, or marginal vein; ultrasound-guided sclerotherapy; and stab avulsion of varicose veins. One coil embolization of a perforator vein was performed. Deep interventions (n = 19) included endovenous stenting (n = 15), popliteal vein release (n = 3), and valvuloplasty (n = 1). The venous clinical severity score had improved from 9.4 ± 4.5 to 6.2 ± 5.6 (P = .04). The visual analog scale for pain score had improved from 5.5 ± 2.7 to 2.5 ± 3.3 (P = .008). Healing of ulceration was noted in 75% of the patients. Significant improvements in the total pain (P = .04) and total psychological (P = .03) domains were noted in the 20-item chronic venous disease quality of life questionnaire. ConclusionsSuperficial and deep venous interventions are safe and effective in patients with KTS when conservative therapy has failed. Iliofemoral venous stenting is a newer option that should be considered in the treatment of chronic deep venous obstructive disease in patients with KTS in the appropriate clinical context. An aggressive perioperative deep vein thrombosis prophylaxis protocol should be in place to reduce thromboembolic complications in these patients.

Radiofrequency Ablation of Incompetent Short Saphenous Vein: a Case Series

Short saphenous vein (SSV) incompetence proved to be an obstacle in chronic venous insufficiency (CVI) treatment in the endovascular era. In our study, we used to prove that radiofrequency ablation could be done safely with low incidence of side effects. In this prospective case series study, 34 patients suffered from leg varicosity (either primary or recurrent) attended to outpatient clinic and were referred for duplex scan to ensure SSV incompetency. SSV ablation was done using radiofrequency catheter. Operative findings were recorded, and patients were followed for up to 12 months post-surgical procedure to look for complications or recurrences. Successful obliteration of short saphenous vein was done in 52 legs with mean diameter 4.9 SD 1.0 mm and operative time 37.5 SD 13.7 min, the incidence of sural nerve paresthesia was 9%, and no reported cases with DVT. On 12-month follow-up, VCSS reduced significantly from 13 (IQR 12) to 3 (IQR 6) and AVVQ reduced significantly from 27.1 (IQR 18.8) to 5.6 (IQR 7.2); the rate of short saphenous vein obliteration was 98.1% at 6 months and 94.2% at 12 months. Radiofrequency ablation can be recommended for patients with incompetent SSV.

Diameter-reflux relationship of the saphenous vein in the C0-C3 patients of chronic venous disease.

To evaluate the relationship between the saphenous vein's diameter and reflux and determine the cut point of the saphenous vein's diameter that indicates lack of reflux. A retrospective cohort study conducted in 807 limbs underwent the venous ultrasound for 36months. The saphenous vein's diameter in the reflux and non-reflux groups was evaluated. The receiver operating characteristics (ROC) curve was constructed to determine the saphenous vein's diameter that maximizes the summation of sensitivity and specificity for saphenous vein reflux in C0-C3 patients. The reflux group had a significantly greater diameter than a non-reflux group at four great saphenous vein (GSV) levels and two small saphenous vein (SSV) levels (p-value < 0.001). The venous reflux correlated significantly with GSV diameter at all four GSV levels and two SSV levels (p-value <0.001). The ROC area of the diameter at four GSV levels ranges from 0.59 to 0.69. The optimal cut-off diameter for GSV reflux is 3.8mm at the proximal thigh, 2.8mm at the distal thigh, 3.2mm at the proximal calf, and 2.5mm at the distal calf. The ROC area of the diameter at two SSV levels ranges from 0.66 to 0.67. The optimal cut-off diameter for SSV reflux is 2.5mm at the proximal calf and 2.3mm at the distal calf. The saphenous vein's diameter has been proved to be significantly correlated with the presence of reflux in duplex ultrasound in all lower limbs' levels. Unfortunately, the study's cut point diameter is considered poor accuracy and is not an accurate measurement to use as the screening test for the presence of reflux.

Causes and symptoms of varicose veins

Background: Varicose veins are a common disease that cause edema, heaviness, pigmentation, and skin ulcers, ultimately affecting the quality of life. Various treatments have recently been developed; therefore, clinicians need to understand the anatomy, pathophysiology, risk factors, and symptoms of varicose veins to provide optimal treatment.Current Concepts: Lower extremity veins are composed of deep, superficial, perforating, and communicating vein systems, and the main axial superficial veins are composed of the great and small saphenous veins. Venous circulation primarily relies on muscle pumps in the foot and calf. Pressure on the sole and contraction of calf muscles compress the veins, sending blood upward or to the deep vein system. Varicose veins are caused by valvular abnormalities, muscle pump failure, etc., and associated risk factors include age, pregnancy, obesity, and family history. The main symptoms include heaviness, fatigue, and edema.Discussion and Conclusion: Varicose veins have complex anatomical structures and are developed by various factors. Therefore, appropriate treatments should be selected considering patients’ symptoms, anatomical structure, and economic aspects.

Pain Outcomes Following Mechanochemical Ablation vs Cyanoacrylate Adhesive for the Treatment of Primary Truncal Saphenous Vein Incompetence

Endovenous thermal ablations (ETAs) are recommended as first-line treatment for truncal vein reflux, have a short recovery time, and are cost-effective. However, ETAs are associated with discomfort during tumescent anesthesia infiltration. To minimize discomfort, nonthermal, nontumescent ablation techniques had emerged in the form of mechanochemical ablation (MOCA) and cyanoacrylate adhesive injection (CAE). To assess pain scores immediately after truncal ablation using a 100-mm visual analog scale and 10-point number scale to compare pain-related outcomes following mechanochemical ablation vs cyanoacrylate adhesive treatment. The Multicenter Randomized II Clinical Trial Comparing Mechanochemical Ablation vs Cyanoacrylate Adhesive for the Treatment of Primary Truncal Saphenous Veins Incompetence study was a prospective multicenter randomized clinical trial conducted at 3 sites between November 2017 and January 2020. Inclusion criteria were primary great or small saphenous varicose veins; exclusion criteria included recurrent varicose veins, current deep venous thrombosis, or serious arterial disease. There were 392 participants screened, 225 were excluded, and 167 participants underwent randomization. Four participants did not receive allocated intervention and were included in the intention-to-treat analysis. Follow-up took place at 2 weeks, and 3, 6, and 12 months. Patients with primary truncal vein incompetence were randomized to receive either MOCA or CAE. The primary outcome measure was pain score immediately after completing truncal ablation using a 100-mm visual analog scale (VAS) and a 10-point number scale. Secondary outcome measures included degree of ecchymosis, occlusion rates, clinical severity, and generic and disease-specific quality of life (QoL) scores. Of 167 study participants, 99 (59.3%) were women, and the mean (SD) age was 56 (15.8) years. Overall, 155 truncal veins treated (92.8%) were great saphenous veins. Demographic data and baseline status were comparable between treatment groups. A total of 73 patients (47%) underwent adjunctive treatment of varicosities. Overall median (IQR) maximum pain score after truncal treatment was 23 mm (10-44) on the VAS and 3 (2-5) on the number scale, showing no significant difference in median (IQR) pain measured by VAS (MOCA, 24 [11.5-44.7] mm vs CAE, 20 [9.0-42.0] mm; P = .23) or by number scale (MOCA, 4 [2-5] vs CAE, 3 [2-4]; P = .18). Both groups demonstrated significant and comparable improvement in clinical severity, generic and disease-specific QoL scores, and complete occlusion rates. Four patients treated with CAE developed minor complications (superficial thrombophlebitis and thrombus extensions). To our knowledge, this was the first randomized clinical trial directly comparing nontumescent ablation techniques. The study demonstrated that the MOCA and CAE techniques have a similar periprocedural pain score. ClinicalTrials.gov Identifier: NCT03392753.

Evaluating Potential Autologous Bypass Grafts with Tomographic Three-Dimensional Ultrasound Compared with Standard Color Duplex

Vein mapping using duplex ultrasound (DUS) is a routine in selecting optimal autologous bypass grafts (aBG) but is time consuming and operator-dependent. Tomographic three-dimensional (3D) ultrasound (tUS), using free-hand electromagnetic tracking, allows cardiac and vascular surgeons to view 3D images of the entire length of the potential bypass graft. This study compares tUS with DUS in the evaluation of potential autologous grafts for coronary and lower limb bypass. Both DUS and tUS imaging of 434 potential autologous grafts (364 long, 22 short saphenous veins, and 48 radial artery) immediately before bypass surgery were compared. The time in minutes to evaluate each aBG was recorded. Surgeons scored the quality of the aBG at operation. A score of 5 was in complete agreement with preoperative imaging with scores of 4 considered "good". Most operating surgeons (113, 57%) preferred interpreting the tUS images and felt that this technology could replace DUS completely. The choice of aBG would have been changed as a result of tUS images in 64 (32%) cases. DUS imaging took a mean (+/-sd) of 08:26±04:44minutes compared with only 01:00±00:25minutes for tUS (P<0.001). However, processing the tUS images, which is currently done manually by the vascular scientist, took significantly longer at 19:31±12:41minutes compared with 09:03±09:12minutes for reporting DUS (P<0.001). Surgeons preferred to see tUS images of the potential aBG themselves rather than relying on DUS reports. tUS images were significantly quicker than DUS to acquire but needed more processing time.

Anterior accessory great saphenous vein as a cause of postoperative recurrence of veins after radiofrequency ablation.

There are problems of postoperative relapse of veins after radiofrequency ablation (RFA). The study aims to analyze the causes of postoperative recurrence of veins after RFA. 928 patients with varicose veins of the lower extremities, clinical classes C2-C4 according to the CEAP classification, were treated in the ambulatory surgery centers using RFA. The causes of varicose recurrence showed that it was caused by: a) high fusion of the anterior accessory great saphenous vein (AAGSV) with great saphenous vein (GSV) directly in the saphenofemoral junction (SFJ), which was not revealed by preoperative ultrasound (1.7%); a long stump of the GSV after the RFA (7.8%); progression of varicose disease with the small saphenous vein (SSV) and formation of new reflux associated with insufficiency of the saphenopopliteal junction (SPJ) (4.7%); d) insufficiency of perforating veins of the tibioperoneal group (Sherman, Boyd), as well as Gunter (3.8%); e) neovascularization with dilation of small vessels in the area of the saphenofemoral junction (0.97%). A comparative assessment of the quality of life (QL) after different surgery methods 3 years after implementation was carried out. Thus, QL in all patients who underwent surgery significantly improved than before surgery. However, after the RFA GSV+AAGSV, the patients had better QL by all scales than those who underwent only RFA GSV. Operations performed simultaneously on GSV and AAGSV have better functionality than GSV-only RFA.

A single-center experience of anterior accessory saphenous vein endothermal ablation demonstrates safety and efficacy

ObjectiveEndothermal ablation is well-established for the treatment of the great and small saphenous veins. Data are lacking for treatment of the anterior accessory saphenous vein (AASV). The purpose of this study was to evaluate the safety and efficacy of AASV treatment using endothermal ablation. MethodsThis retrospective review included 314 limbs at a single academic institution from 2016 to 2018 using the institutional Vascular Quality Initiative database. All limbs had documented AASV reflux. Baseline characteristics were evaluated including age; sex; ethnicity; clinical, etiology, anatomy, pathophysiology classification; Venous Clinical Severity Score (VCSS); and vein diameter. Outcomes relating to procedure safety and efficacy included treatment modality and length, successful ablation on postoperative imaging, postprocedural clinical outcomes, incidence of endothermal heat-induced thrombosis (EHIT), and any postprocedural complication. ResultsA total of 314 consecutive limbs were identified from 2016 to 2018. The preprocedure VCSS scores were available for 312 limbs and averaged 6.13 ± 3.33. A history of varicose veins were reported in all limbs with 49.4% (n = 155) having previously undergone a procedure. The most common presenting symptom was mild edema in 52.5% (n = 165). Vein diameter and assessment of reflux were obtained by venous duplex ultrasound (DUS) examination. The largest AASV diameter was available for 304 limbs, averaging 7.93 ± 2.69 mm. Treatment modalities included radiofrequency ablation (RFA) in 59.2% (n = 186), endovenous laser ablation (EVLA) in 37.9% (n = 119), and isolated microphlebectomy in 2.9% (n = 9). In all, 38.5% (n = 121) of limbs underwent concomitant microphlebectomy at the time of EVLA. The total treatment length was obtained in 297 limbs, averaging 23.0 cm ± 12.0. Postoperatively, 94.6% of limbs (n = 297) were prescribed compression stockings. Postoperative DUS examination was performed in 312 limbs, revealing successful ablation in 96.5% (n = 303) with 2 limbs (0.6%) developing an EHIT, both treated with therapeutic enoxaparin for 1 week. Repeat DUS examination revealed thrombus resolution in one limb; the other patient was lost to follow-up. VCSS scores after the procedure were available for 145 limbs and averaged 4.45 ± 2.31. This was a statistically significant decrease from preprocedure VCSS scores (P < .01). Average duration of follow-up was 2.2 years, with two limbs lost to follow-up. Of the nine limbs (3.5%) whose initial procedure failed, five (56%) were treated using RFA and four (44%) were treated using EVLA. There were no other postoperative complications. ConclusionsOur experience over a 3-year period for treating the AASV shows it to be safe and effective in a broad range of disease severity with an improvement in VCSS and a low incidence of EHIT. Additionally, RFA and EVLA exhibit similar treatment efficacy. Long-term follow-up data are needed.

Flowthrough Omental Flap for Vascularized Lymph Node Transplant of the Lower Extremity.

Vascularized lymph node transplantation is a surgical approach for the treatment of chronic lymphedema. However, there is no clinical standard for flap placement nor vascular anastomoses. The authors propose a novel flowthrough configuration for an omental vascularized lymph node transplant in the popliteal space. To prepare the popliteal space for an omental free flap, the medial popliteal fat pad and medial head of the gastrocnemius muscle were debulked. Venous anastomoses were completed with vein couplers, joining the right gastroepiploic vein to the medial sural venae comitantes and the left gastroepiploic vein to the lesser saphenous vein. Arterial anastomoses were hand sewn, joining the right gastroepiploic artery to the proximal medial sural artery and the left gastroepiploic artery to the distal medial sural artery, to create the flowthrough configuration. A retrospective review of patients who underwent this procedure at a single institution was performed. Six patients with chronic lymphedema of the lower extremity underwent vascularized lymph node transplantation from June of 2019 to November of 2020. Five patients underwent at least 3 months of postoperative surveillance, with no postoperative complications reported. In this technique contribution, the authors describe a novel flowthrough configuration for an omental free flap to the popliteal space. The popliteal space offers an aesthetically favorable recipient location when appropriately prepared. The medial sural vessels are ideal recipient vessels for the flowthrough omental flap. Therapeutic, IV.

Incompetent saphenous vein in patients with lower leg dermatitis and cramps

We recruited lower leg dermatitis patients at our department between 2018 and 2021. The patients were divided into two groups, those with incompetent great saphenous vein and/or small saphenous vein (Group 1; n = 8) and those without (Group 2; n = 22). The prevalence of cramps and/or aching in Group 1 patients was significantly higher than that in Group 2 patients.

Presence of Popliteal Vein Reflux Increases the Rate of EHIT After Small Saphenous Vein Closure

Venous insufficiency in the small saphenous vein (SSV) is significantly less common than venous insufficiency in the great saphenous vein. However, the effect of popliteal vein reflux on SSV closure procedural outcomes has yet to be studied.

Association between the saphenous vein diameter and venous reflux on computed tomography venography in patients with varicose veins.

Three-dimensional computed tomography venography is a useful tool to identify increased saphenous vein diameter and provides a complementary road map for surgery in patients with varicose veins. In this study, we investigated the correlation between saphenous vein diameter on computed tomography venography and venous reflux detected on duplex ultraonography. We enrolled 152 patients (213 extremities) who underwent endovenous laser ablation therapy, following high ligation of the saphenofemoral junction between January 2014 and December 2019. All patients underwent preoperative computed tomography venography evaluation. The saphenous vein diameter was measured on computed tomography venography, and venous reflux was evaluated in the operating room using Doppler ultrasonography. Among the 152 patients included in the study, 61 showed varicose veins affecting the bilateral extremities. Among the 213 extremities investigated, 165 (77.5%) and 48 (22.5%) extremities showed varicosities involving the greater and lesser saphenous veins, respectively. Among all extremities, venous reflux was detected in 172 (80.8%). The mean diameter of the greater saphenous vein measured 5 cm distal to the saphenofemoral junction was 8.07±1.82 mm in patients with reflux and 5.11±1.20 mm in patients without reflux (p < .05). The small saphenous vein diameter measured 5 cm distal to the saphenopopliteal junction was 7.65±1.74 mm in patients with reflux and 5.04±1.80 mm in patients without reflux (p < .05). Based on the receiver operating characteristic curve, the greater saphenous vein threshold diameter of 5.880 mm measured 5 cm distal to the saphenofemoral junction was the optimal cut-off value to predict reflux (sensitivity 91.4%, specificity 81.8%). The lesser saphenous vein diameter of 5.285 mm measured 5 cm distal to the saphenopopliteal junction was the optimal cut-off value to predict reflux (sensitivity 94.9%, specificity 75.0%). Vein diameter cannot be used as an absolute reference for venous reflux; however, it may have predictive value in patients with varicose veins. Computed tomography venography based measurements of vein diameter may serve as a useful diagnostic tool to predict venous reflux and recommend treatment.

Clinical Results and Cost Effectiveness of Radiofrequency and Cyanoacrylate Compared with Traditional Stripping for Treating Varicose Veins

Disease of the venous system is an underappreciated public health problem. Minimally invasive treatments based on radiofrequency ablation (RFA) or cyano-acrylate adhesive ablation (CA) have almost entirely replaced surgical stripping (SS) of the great and short saphenous veins. The purpose of this study is to compare the outcome 3 years after SS, RFA, or CA by assessing complications and reintervention and performing a cost-effectiveness analysis.

Clinical image of short saphenous varicose vein mimicking neuroma.

Clinical image of short saphenous varicose vein mimicking neuroma.

Combined Treatment of the Anterior Accessory Saphenous Vein and the Great Saphenous Vein

The anterior accessory saphenous vein (AASV) is a common source of primary and recurrent lower extremity varicose veins. Reflux in the AASV can occur independently or simultaneously with great saphenous vein (GSV) reflux. A number of published reports describe recommendations and treatment of symptomatic refluxing AASVs, but descriptions of combined treatment are sparse. Treatment options for ablation of the AASV include both thermal and non-thermal techniques, and results are equivalent to ablation of the great and small saphenous veins. Although not commonly performed, concomitant ablation of the AASV and the GSV is effective and safe, and can be accomplished with minimal additional time. Concomitant treatment is an appropriate option that should be discussed with the patient.

Incidence and patterns of lymphatic drainage to the epitrochlear and popliteal sentinel lymph nodes in malignant melanoma of the distal extremities: a single‐institution retrospective study

In most cutaneous melanomas of the distal extremity, sentinel lymph nodes (SLNs) are identified in the axillary or inguinal basin; however, they may be occasionally found in the epitrochlear or popliteal basins. The incidence and patterns of lymphatic drainage to the epitrochlear or popliteal SLNs are unclear. To clarify the incidence and clinical characteristics of melanoma draining to these ectopic SLNs, we performed a retrospective study of the patients with distal extremity melanoma who underwent SLN biopsy at the National Cancer Center Hospital between April 2010 and December 2017. We identified 27 patients with melanoma of the distal upper extremity and 113 patients with melanoma of the distal lower extremity. All patients with distal upper and lower extremity melanomas had SLNs in the axillary and inguinal basins. Epitrochlear SLNs were found in 14.8% (4/27) of the patients with upper extremity melanoma, and the frequency increased by 36.4% (4/11) when the primary melanoma was located in the basilic vein area (P = 0.00188). Popliteal SLNs were found in 21.2% (24/113) of the patients with lower extremity melanoma, and the frequency increased by 37.9% (22/58) when the primary melanoma was located in the lesser saphenous vein area (P < 0.0001). The incidence of SLNs identified in the epitrochlear or popliteal basin is not uncommon, and physicians need to be aware of these ectopic SLNs, especially when the primary melanoma is located in the basilic vein or lesser saphenous vein areas accordingly.

Anatomical variability of superficial veins of the lower limb in human fetuses

Background. Modern minimally invasive methods have radically changed the clinical landscape of varicose vein surgery and shortened recovery time after surgery. All these changes became possible thanks to the constant deepening of knowledge about the topographical and anatomical features of the great and small saphenous veins in different periods of human ontogenesis. Objective is to find out the topographical and anatomical relationships of the great and small saphenous veins in human fetuses of 4-8 months. Methods. The research was carried out on preparations of the lower extremities of 26 human fetuses of 81.0-310.0 mm parietal-coccygeal length (PCL) without external signs of anatomical deviations or anomalies in the development of bone, fascial-muscular, and vascular-nervous structures of the lower extremities using macromicroscopic preparation, injection of vessels and morphometry. Results. In human fetuses of 4-8 months, the great saphenous vein passes directly under the fascia of the lower leg, partly in the subcutaneous tissue, since the formation of the latter is continuing at this stage of ontogenesis. In the majority of the examined fetuses, a classical version of the topography of the great and small saphenous veins of the right and left lower limbs was observed. In some cases, variability in the number of inflows of superficial veins, additional saphenous veins, and various anastomoses between additional and great and small saphenous veins was revealed. The most interesting, from our point of view, were the anatomical variants of the superficial veins of the lower limb in fetuses of 180.0, 195.0, 220.0, and 265.0 mm PCL. Conclusions. In the fetal stage of human ontogenesis, the anatomical variability of the superficial veins of the lower limbs was established, which is characterized by the variability of the shape, topography, and bilateral asymmetry of the inflows of the great and small saphenous veins and the formation of venous anastomoses. In one case, a left anterior additional saphenous vein was detected, and in two fetuses, a left posterior additional saphenous vein was detected. The coincidence of the topography of the subcutaneous veins of the right and left lower extremities was noted in 87.5% of the fetuses. Significant gender differences in the topography of the large and small subcutaneous veins in human fetuses were not found. The revealed variants of the fetal topography of the great and small saphenous veins are important for the correct interpretation of phlebographic research data and the individual strategy of the most rational method of surgical intervention.

ЗНАЧЕНИЕ ГОНАРТРОЗА В РАЗВИТИИ ВАРИКОЗНОЙ БОЛЕЗНИ НИЖНИХ КОНЕЧНОСТЕЙ

Objective: To evaluate the role of arthritis of the knee joint in the development and progression of varicose veins of the lower extremities. Methods: An observational cross-sectional cohort study was conducted on 180 patients. There were 56 (31.1%) males and 124 (68.9%) females with VVs of the lower extremities. The VVs' clinical features were studied according to the presence or absence of knee osteoarthritis. The study group (SG) included 88 patients with KOA in combination with VVs. The control group (CG) comprised 92 people suffering from VVs and not having a degenerative joint disease of the knee. Both groups of patients were comparable in terms of basic demographic parameters, disease duration and body mass index. Results: In the SG, oedema and skin trophic changes of the lower limbs (lipodermatosclerosis, eczema) were observed in 39 and 21 cases, respectively. The number amounts to 68.2%, which was 33.4% more compared to the percentage of the CG cases (34.8%, n=32). In the presence of KOA, a varicose transformation of both saphenous veins and their tributaries was more often noted in 36 (40.9%) cases, whereas in CG patients, VVs development occurred only in 6 (6.5%) cases. On the contrary, an isolated varicose transformation of the great saphenous vein (GSV) and its tributaries was more common among CG compared to SG patients, at 93.5% and 55.7%, respectively. Among the examined cohort, the incidence of isolated disease of the small saphenous vein (SSV) and insufficiency of its ostial valve had no significant difference between SG and CG patients and occurred in 3.4% and 6.5% of cases, respectively. In SG patients, concurrent incompetence of the ostial valves of the GSV and SSV (n=39; 44.3%) and insufficiency of leg perforating veins (n=60; 68.2%) were more often noted. In the CG, perforator reflux and incompetence of the communicating veins were present only in 6 (6.5%) and 32 (34.8%) patients, respectively. The mean GSV ostial diameter in SG and CG patients was significantly different and amounted to 12.1±1.4 mm and 8.2±0.9 mm, respectively. Varicose dilatation of the superficial veins of both lower extremities was most often noted in the SG than in CG, 90.9% and 39.1% of the patients, respectively. There was a direct correlation between the KOA stage and such factors as VVs class (r=0.58; p&lt;0.001), the laterality of lower limbs involvement (r=0.63; p&lt;0.001) and disease recurrence (r= 0.59; p&lt;0.001). Conclusion: Degenerative joint disease of the knee, in which the locomotor function of the limb is impaired, can act as one of the risk factors for the development or progression of varicose transformation of the superficial veins of the lower extremities. Therefore, further research is needed to study the lower limb biomechanics in patients with VV, with and without KOA. Keywords: Varicose veins, knee osteoarthritis, venous hypertension, ostial valve incompetence.