Superficial Circumflex Iliac Vein Research Articles

Resurfacing of multiple adjacent defects with free multipaddle SCIAP flaps

BackgroundThe efficient resurfacing of multiple adjacent defects (MADs) requires precise reconstructive strategy. Various approaches (e.g., several flap transferring or prelamination of the recipient site) have been reported, but recipient-site impairments, pain, long hospitalization, and low cost-benefit results fatefully considered them as compromise approaches. This study aims to evaluate the feasibility of MADs reconstruction with free multipaddle superficial circumflex iliac artery perforator (SCIAP) flaps. MethodsFrom Dec 2015 to Dec 2020, we enrolled patients with upper and lower extremity defects treated with various multipaddle SCIAP flaps (2-paddle, 3-paddle, and 4-paddle). Patient demographics and outcomes of each group were collected. ResultsThirty-two, 21, and 6 patients underwent 2-paddle, 3-paddle, and 4-paddle SCIAP flaps transfers, respectively. All multipaddle SCIAP flaps survived without vascular problems, and the donor sites were closed directly. Except for 3 cases of 2-paddle SCIAP flaps drained by superficial circumflex iliac vein venous return, most cases (n = 56) were drained by venae comitans. Minor complications, including partial flap necrosis (4 cases) and lateral femoral cutaneous nerve palsies (11 cases), were treated conservatively. All patients were satisfied with the reconstructive outcome. ConclusionMultiple adjacent defects reconstruction is still a Gordian knot and lacks a golden standard. The free multipaddle SCIAP flap was demonstrated as a promising alternative, not only enriching its versatility but also initially highlighting the “replace need with need” reconstructive demand.

Venous anatomy of the superficial circumflex iliac artery perforator flap: A cadaveric and clinical study

Reconstructive surgeons frequently face challenges with free tissue transfer when transplanted flaps are thicker than intended. This is especially pronounced in lower limb cases, where the soft tissue below the knee is thin. The supra-fascial superficial circumflex iliac perforator (SCIP) flap overcomes this problem, but venous congestion remains a concern. We aim to examine the venous anatomy of the SCIP flap through cadaveric dissections and clinical data analyses to enhance the understanding of the venous anatomy and reduce venous congestion in future procedures. Eight cadaveric groins underwent venous dye injection and dissection to identify the superficial circumflex iliac vein (SCIV) and venae comitantes (VC) vascular networks. The venous anatomy was studied for dominant drainage. From April 2015 to December 2019, we conducted 102 SCIP flap reconstructions, mainly using the superficial circumflex iliac artery's superficial branch. Clinical data were analyzed and correlated with cadaveric dissections. SCIP flaps were categorized into three groups: dual drainage (VC and SCIV) in group I, SCIV-only in group II, and VC-only in group III. Correlations between clinical cases and cadaveric dissections revealed the SCIV as an independent drainage system with oscillating links to the VC. The SCIV is approximately twice the diameter of the VC, and the area of each vascular network suggests codominance. No significant difference in flap loss or venous congestion rates was noted when SCIV was the sole drainage, compared with VC or dual drainage. The SCIP flap with one artery and SCIV anastomosis, exhibits low venous congestion rates. Surgeons should consider SCIV for safe SCIP flap reconstruction.

Deep inferior epigastric vessels for free scapular flap phalloplasty

We aimed to present our 20-year experience of using the deep inferior epigastric vessels as recipient vessels for free scapular flaps phalloplasty and evaluate the outcomes. Penile reconstruction was performed using a free scapular flap between 2000 and 2020 by the same surgical team. Deep inferior epigastric vessels were used in all the cases. The surgical techniques and outcomes were described. Overall, 73 patients used the deep inferior epigastric artery (DIEA) as the recipient artery. Regarding the recipient veins, 2 veins were anastomosed in 72 (98.6%) patients, 1 deep inferior epigastric vein (DIEV) was used in 1 patient, 2 DIEV in 14, 1 DIEV + superficial inferior epigastric vein (SIEV) in 13, 1 DIEV + superficial circumflex iliac vein (SCIV) in 38, great saphenous vein (GSV) + SCIV in 4, and GSV + SIEV in 3. The mean age and body mass index of the study cohort was 28 years and 24.3 kg/m2, respectively. The shortest follow-up time was 7 months. Eleven patients had flap-related complications. Three patients were readmitted to the operating room within 24 hours, and 2 of them underwent salvage procedures with venous revision. Two patients lost the entire flap. One patient with 3-cm distal portion necrosis required surgical intervention. Three patients experienced urethral necrosis. DIEA is a suitable receptor artery for inflow. The DIEV, SIEV, and SCIV are available options for venous drainage according to the patient anatomical characteristics. The GSV can be an excellent backup for outflow and salvage procedures.

The Pedicled Anterolateral Thigh Flap for Donor Site Closure after a Large Superficial Circumflex Iliac Artery Perforator Flap Harvest

Summary: The superficial circumflex iliac artery perforator (SCIP) flap is useful for covering defects in the extremities because its pedicle size can match many recipient options. However, when harvesting a large flap, skin grafting of the donor site is not highly recommended because of the mobility of the hip joint and occasional lymphorrhea. Here, we present a case of a successful reconstruction of a defect in the lower leg after sarcoma resection, using a large SCIP flap. A 58-year-old man underwent resection of a large soft tissue tumor in the lower leg, resulting in a 16 × 14 cm defect. A 25 × 14 cm SCIP flap was harvested from the groin, and the superficial circumflex iliac artery and the superficial circumflex iliac vein were anastomosed to the saphenous artery and the great saphenous vein, respectively, in an end-to-end fashion. For coverage of the groin donor site, a 25 × 8 cm pedicled anterolateral thigh (ALT) flap was harvested from the ipsilateral lateral thigh and was pulled through a subcutaneous tunnel to the groin. The additional operative time for pedicled ALT flap elevation and transfer was approximately 15 minutes. With this pedicled ALT flap, the donor site of the SCIP flap could be closed directly over a drain. The follow-up at 3 months showed complete survival of both flaps, and the patient was able to walk with a cane. The pedicled ALT flap allows for direct closure of the donor site after a large SCIP flap harvest.

Anatomical variations of the great saphenous vein at the saphenofemoral junction. A cadaveric study and narrative review of the literature.

The great saphenous vein is the lower limb's longest and thickest-walled superficial vein. Its anatomy is complex, while its anatomical variations are widespread. This study aimed to illustrate the anatomy and variations of the great saphenous vein at the saphenofemoral junction. The study was conducted on 75 fresh-frozen cadaveric lower limbs. Cadavers with evidence of prior leg surgery or trauma and any congenital abnormality or gross deformity were excluded. The saphenofemoral junction was studied in detail with emphasis on the number, incidence, draining pattern of tributaries, and duplication of the great saphenous vein. Out of the 75 cadaveric lower limbs, 57.3% were obtained from males, and 42.7% were obtained from females. The mean age of the cadaveric lower extremities was 66.6years (range 42-91). The number of tributaries at the saphenofemoral junction varied from 0 to 7, with a mean of 3.8. The most frequent number of branches was 4-5 in 61.3% of cases. The most consistent tributary was the superficial external pudendal vein, while the posterior accessory great saphenous vein was the least frequent tributary. 80% of the branches drained into the saphenofemoral junction directly (53.3%) or by a common trunk (26.7%%). The most frequent common trunk was the superficial epigastric and superficial circumflex iliac vein (10.7%). The rest 20% of the tributaries drained directly into the common femoral vein. The commonest branch reaching the common femoral vein was the superficial external pudendal vein (10.7%). Duplication of the great saphenous vein was observed in 2.7% of the cases. There is a significant variation of tributaries at the saphenofemoral junction regarding the number, incidence, draining pattern of branches, and duplication of the great saphenous vein.

PC8. Prophylactic Axillary Lymphovenous Bypass Using the Branched Vein Graft Technique

PURPOSE: Prophylactic lymphovenous bypass reduces the risk of lymphedema after axillary lymph node dissection (ALND). Extensive axillary dissection often creates a large gap between disrupted lymphatic vessels and potential recipient veins. The wide distribution of lymphatics throughout the lateral axilla further compounds the difficulty of including all injured vessels for bypass. We describe the technical details and preliminary clinical outcomes of patients who underwent prophylactic lymphovenous bypass using a branched vein graft (BVG) from the superficial circumflex iliac vein (SCIV). METHODS: A retrospective review was performed, focusing on operative details and clinical results. Technique: A 8-10 cm BVG containing valves is harvested from the SCIV and coupled to an appropriate recipient vein. A 27-gauge cannula is used to intubate the BVG lumen at various branch openings as appropriate. This allows a 10-0 suture to be passed outward through the cannula. Lymphatic vessels are then captured and intussuscepted into the BVG with 4 - 6 mm of overlap, without any bunching or kinking. Upon completing the bypass, the intussuscepting suture is removed to avoid lymphatic obstruction. Valves in the graft prevent reflux. RESULTS: Seven patients were identified for inclusion. A median of 3 disrupted lymphatic vessels were encountered per case (range 1-5). Follow-up was 3 weeks to 6 months. Six patients demonstrated no clinical evidence of lymphedema. 1 patient had trace swelling localized to the thumb at 2 months. CONCLUSION: The branched vein graft technique effectively facilitates the immediate bypass of multiple injured lymphatics over a wide area after ALND.

Real-time Navigation for Vascularized Lymph-node Transplantation Using Projection Mapping with Indocyanine Green Fluorescence.

The medical imaging projection system (MIPS) is a real-time surgical navigation device using indocyanine green (ICG) emission signals and active projection mapping. The difference between the object and the projected image is within 1 mm, and the time lag is within 0.1 seconds. We herein report the application of the MIPS to vascularized lymph-node transplantation (VLNT) surgery for lower extremity lymphedema to detect inguinal lymph nodes and perform color-coded navigation surgery for lymph-node resection. A left superficial inguinal lymph node was planned to be used as a donor for VLNT to the right lower leg in a 73-year-old woman with lower extremity lymphedema. Under general anesthesia, multiple intradermal injections of 0.1 ml of ICG were administered around the left inguinal donor site. The MIPS showed a clear linear projection image from a lateral injected point connecting to a lateral superficial inguinal lymph node. The left superficial circumflex iliac artery and vein were dissected for vascularized VLNT. Intraoperative real-time MIPS navigation continuously guided the transection plane colored by ICG fluorescence signals without shifting the visual focus from the surgical field. This is the first report of the intraoperative use of ICG projection mapping for VLNT donor-site surgery. The MIPS was able to visualize functional lymph nodes to facilitate minimally invasive donor-site surgery.

Cranial Tributary Ablation of the Saphenofemoral Junction during Laser Crossectomy of the Great Saphenous Vein.

Objectives: Anterior accessory saphenous vein (AASV) insufficiency is one of the most common causes of recurrent varicose veins after endovenous thermal ablation (EVTA) for great saphenous vein (GSV) insufficiency. The purpose of this study was to evaluate the efficacy and safety of cranial tributary ablation (CTA) during laser crossectomy (LC) of the GSV.Methods: We reviewed 182 limbs in 171 patients undergoing EVTA aiming for LC with a 1470-nm diode laser. In the CTA group, either the superficial circumflex iliac vein or the superficial epigastric vein was directly ablated during LC. The result was compared between the CTA (n=63) and control (n=119) groups using follow-up duplex ultrasound performed for 6 months after EVTA.Results: Initial success rate of CTA was 69%. The AASV occlusion rate (90% vs. 63%, p<0.001) and the flush GSV occlusion rate (68% vs. 30%, p<0.001) at 6 months were better in the CTA group. No major adverse events were observed.Conclusion: CTA during LC of the GSV is a safe and effective approach to achieve better flush or AASV occlusion rates after EVTA. It is occasionally technically demanding but can be a feasible option. Further investigation is needed to confirm our results.

Superficial Circumflex Iliac Artery Perforator Flap Elevation Using Preoperative High-Resolution Ultrasonography for Vessel Mapping and Flap Design.

The superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has gained acceptance among reconstructive microsurgeons, the minimal donor site morbidity being its greatest advantage. The purpose of this article is to introduce the use of preoperative ultrasonography to facilitate elevation and to avoid postoperative complications of the SCIP flap. Preoperative mapping of the SCIA and the superficial circumflex iliac vein (SCIV) using a high-resolution ultrasound system were performed in patients undergoing reconstruction using a free SCIP flap. The skin paddle was designed placing the SCIA and the SCIV in the middle of the flap. Preoperatively marked SCIA and SCIV were found intraoperatively in all cases. The skin paddle design for sufficient arterial inflow and venous drainage resulted in no postoperative flap complications. The use of a preoperative high-resolution ultrasound system significantly facilitates elevation of the SCIP flap, notably via the following 2 points: 1) pedicle can always be found under the markings made with preoperative ultrasonography, 2) satisfactory perfusion of the flap can be guaranteed via a safe flap design that includes preoperatively marked vessels within the skin paddle.

Venous superdrainage using superficial circumflex iliac vein in deep circumflex iliac artery perforator flap with iliac crest for oromandibular reconstruction

The deep circumflex iliac artery perforator flap with iliac crest (DCIAPF) is considered a favourable single-flap option for oromandibular reconstruction. The aim of this study was to evaluate the effectiveness of venous superdrainage using the superficial circumflex iliac vein (SCIV) in the DCIAPF for oromandibular reconstruction. The data of 22 patients (12 female, 10 male) aged 10–76 years (median 53 years) who underwent simultaneous oromandibular reconstruction with a DCIAPF were reviewed retrospectively. Eleven patients received the DCIAPF with SCIV for superdrainage (group A) and another 11 patients received the conventional single-pedicled DCIAPF flap (group B). No flap loss occurred in either group. Venous congestion due to relative venous insufficiency was significantly more frequent in group B (P=0.045). There was no significant difference in the incidence of partial flap necrosis and wound dehiscence, or in the total operation time between the two groups. Superdrainage using the SCIV has the potential to reduce the incidence of venous congestion due to relative venous insufficiency in DCIAPF used for oromandibular reconstruction.

Analysis and Classification of Postcatheterization Femoral Arteriovenous Fistulas Based on Color Doppler Examinations.

To analyze and classify arterial supply and venous drainage of postcatheterization femoral arteriovenous fistulas (AVFs). A review of extremity Doppler reports identified 77 femoral AVFs in 75 patients. Doppler exams were reviewed retrospectively. Fistulas were classified as above or below the common femoral artery bifurcation and subclassified based on the location of arterial inflow and venous outflow. Arterial inflow originated above the femoral bifurcation in 32 cases. The communication was between the common femoral artery and the superficial circumflex iliac vein in 25 of 32 cases and between a branch of the common femoral or external iliac artery and the common femoral or external iliac vein in 4 of 32 cases. In 3 of 32 cases, AVFs arose from the common femoral artery, but the venous outflow was not determined. Arterial inflow originated from the superficial femoral artery in 23 cases. Venous outflow originated from the common femoral vein in 10 of 23 cases, the femoral vein in 7 of 23 cases, and the lateral circumflex femoral vein in 6 of 23 cases. Arterial inflow originated from the deep femoral artery in 12 cases. Venous outflow originated from the common femoral vein in 6 of 12 cases and from the lateral circumflex femoral vein 6 of 12 cases. In 8 cases, the AVF originated below the bifurcation, but the arterial inflow was not classified. In 2 cases, it was impossible to determine if the AVF originated above or below the bifurcation. Iatrogenic femoral AVFs arise above the femoral bifurcation more often than previously recognized. Classification based on the arterial inflow and venous outflow provides a straightforward means of describing these fistulas.

Anatomy of the arterial and venous systems of the superficial inferior epigastric artery flap: A retrospective study based on computed tomographic angiography

This study was performed to investigate the arterial and venous anatomy of superficial inferior epigastric artery (SIEA) flaps using multidetector-row computed tomography angiography (MDCTA). We hypothesized that applicability of the SIEA flap has been underestimated in previous studies. We retrospectively analyzed the results of preoperative MDCTA of the bilateral lower abdominal walls in 72 consecutive patients. We assessed the presence and branching pattern of the superficial inferior epigastric artery, superficial inferior epigastric vein (SIEV), superficial circumflex iliac vein, and venae comitantes (VC) of the superficial inferior epigastric artery. We also assessed the internal diameter of the SIEA at its origin. The SIEA was present on 133 sides (92.4%), and the mean internal diameter was 2.0 mm. The internal diameter of the SIEA was ≥2.0 mm on 102 sides (70.8%). The VC drained into the superficial circumflex iliac vein on 68 sides (47.2%) and to the SIEV on 30 sides (20.8%). An internal diameter of the SIEA of ≥2.0 mm at its origin on preoperative imaging can be a good criterion for exploring the artery during lower abdominal flap harvest. The VC is the dominant drainage vein over the SIEV in some patients, and it communicates with the superficial circumflex iliac vein in almost half of patients. These findings can increase the safety of breast reconstruction with an SIEA flap.

Application of free ilioinguinal flap for repair of hand skin and soft tissue defects

Objective To investigate the clinical effect of individualized free ilioinguinal flap in repairing hand skin and soft tissue defects. Methods From January 2013 to December 2017, 97 cases of hand skin and soft tissue defects were treated with free ilioinguinal flap. There were 63 cases of superficial circumflex iliac artery flap (26 cases of superficial circumflex iliac artery flap with iliac bone), 15 cases of superficial abdominal artery flap and 19 cases of combined flap of superficial circumflex iliac artery and superficial abdominal artery (7 cases of lobulated flap). The area of skin defects ranged from 4 cm×6 cm to 11 cm×23 cm. During the operation, end to end anastomosis of flap artery and the end branch of radial artery in 5 cases, end to side anastomosis of radial artery in 58 cases, end to side anastomosis of ulnar artery in 20 cases, end to side anastomosis of common digital artery in 14 cases. All the superficial circumflex iliac veins and superficial abdominal veins were repaired (a concomitant vein were repaired at the same time in 31 cases). The donor site was sutured directly after flexion of hip and knee without skin grafting. Three weeks, 1.5 months, 3 months, 6 months, 1 year and 2 years after the operation, the healing of donor area and the appearance and sensory recovery of recipient area skin flaps were observed. Results Postoperatively 94 cases survived successfully. Arterial crisis occurred in 1 case and venous crisis in 2 cases. 2 cases received surgical exploration and 1 case received conservative treatment. After that, 1 case survived smoothly and 2 cases suffered skin necrosis. Subcutaneous soft tissue survived after secondary escharectomy and survived after skin grafting. In one case of abdominal donor site, the incision dehiscence occurred in the first week of walking upright after operation, and healed after secondary suture. The remaining donor sites achieved primary healing. The follow-up period ranged from 0.5 to 1.5 years. The flaps were soft and slightly swollen, and the sensation returned to S2 or S3. There were only linear scars in the abdominal donor site. Conclusion According to the skin and soft tissue defects in the recipient area of the hand, the individualized free ilioinguinal flap transplantation can meet the different needs of the recipient area. The donor site is concealed, the cutting area is large, and it can be directly sutured. It belongs to the axial skin flaps. The blood vessels are constant, the cutting is convenient, the main blood vessels are not destroyed, and the operation time is short. Therefore, it is one of the ideal methods to repair the skin and soft tissue defects of limbs. Key words: Hand injuries; Surgical flaps; Skin and soft tissue defects; Free; Individualized

Understanding the vascular anatomy of zone IV in DIEA perforator flaps

Introduction: Due to a longstanding controversy over the perfusion reliability of zone IV current this area is routinely discarded despite the mechanism behind zone IV necrosis not being fully understood. The authors review and investigate the vascular anatomy of zone IV with the aim of outlining the reasons for necrosis.Methods: A literature search and review of archival injection studies performed by the authors was undertaken to identify the arterial and venous maps of the abdomen. Unembalmed abdominal wall and full body specimens were used for cadaveric studies to demonstrate the arterial anastomotic patterns and venous drainage pathways of the deep inferior epigastric, superficial inferior epigastric, superficial circumflex iliac and intercostal systems.Results: Cadaveric injection studies demonstrated the presence of true and choke anastomoses between all lower abdominal arterial branch systems. Venous studies found that the dominant venous drainage is through large caliber superficial epigastric and circumflex iliac veins, a system which is interrupted in flap elevation and redirected to the perforator venae comitantes, with inter-territory communicating oscillating veins also becoming a limiting factor between territories.&#x0D; Conclusion: The mechanism behind the common failure of zone IV in the DIEP flap is explained with studies demonstrating both potential arterial and venous limiting factors. The authors conclude that the mechanism is indeed multifactorial, however suggest that when zone IV in DIEP tissue transfer is required, fat below Scarpa’s fascia is excised and the contralateral SIEV is preserved for use as an additional venous anastomosis.

Understanding the vascular anatomy of zone IV in DIEA perforator flaps

Introduction: Due to a longstanding controversy over the perfusion reliability of zone IV current this area is routinely discarded despite the mechanism behind zone IV necrosis not being fully understood. The authors review and investigate the vascular anatomy of zone IV with the aim of outlining the reasons for necrosis.Methods: A literature search and review of archival injection studies performed by the authors was undertaken to identify the arterial and venous maps of the abdomen. Unembalmed abdominal wall and full body specimens were used for cadaveric studies to demonstrate the arterial anastomotic patterns and venous drainage pathways of the deep inferior epigastric, superficial inferior epigastric, superficial circumflex iliac and intercostal systems.Results: Cadaveric injection studies demonstrated the presence of true and choke anastomoses between all lower abdominal arterial branch systems. Venous studies found that the dominant venous drainage is through large caliber superficial epigastric and circumflex iliac veins, a system which is interrupted in flap elevation and redirected to the perforator venae comitantes, with inter-territory communicating oscillating veins also becoming a limiting factor between territories.&#x0D; Conclusion: The mechanism behind the common failure of zone IV in the DIEP flap is explained with studies demonstrating both potential arterial and venous limiting factors. The authors conclude that the mechanism is indeed multifactorial, however suggest that when zone IV in DIEP tissue transfer is required, fat below Scarpa’s fascia is excised and the contralateral SIEV is preserved for use as an additional venous anastomosis.

Determining the origin of superficial venous reflux in the groin with duplex ultrasound and implications for varicose vein surgery.

The purpose of this paper was to describe patterns of superficial reflux in the groin with respect to the terminal valve (TV), which is located at the saphenous opening to the common femoral vein, the great saphenous vein, and its tributary veins. This study included 2019 legs with chronic venous insufficiency that received endoluminal varicose vein treatment because of varicosities with insufficiency of the saphenofemoral junction (SFJ). In a preoperative duplex ultrasound investigation of the superficial vein system, reflux after provocation in the SFJ, great saphenous vein, cranial veins (superficial external pudendal vein, superficial epigastric vein, superficial circumflex iliac vein), and anterior and posterior accessory saphenous veins was recorded and classified on the basis of the origin of reflux. In 1348 legs (66.8%), the reflux had its origin exclusively in the common femoral vein. In 170 legs (8.4%), the reflux had its origin in the common femoral and cranial veins. In 430 legs (21.3%), the insufficiency was due to saphenocranial reflux only. In 71 legs (3.5%), the origin of reflux could not be determined. Reflux in the SFJ does not involve the TV in 24.8% of the legs, implying that routine high ligation and ablation close to the TV might be overtreatment in these patients.

Free groin flap for aesthetic and functional donor-site closure of the anterolateral thigh flap

Better methods for anterolateral thigh flap donor-site reconstruction are desirable in cases when direct closure is impossible. Multiple surgical strategies have been attempted, and each has its shortcomings. The use of a contralateral free groin flap to repair the anterolateral thigh flap donor site is investigated in this report. From October 2015 to February 2016, free groin flaps were harvested on six patients for aesthetic and functional donor-site closure of the anterolateral thigh flap, which could not be directly closed. In these cases, the reverse-flow distal portion of the descending branch of the lateral circumflex femoral artery and vein were used as recipient vessels and anastomosed to the superficial circumflex iliac artery and vein, respectively. One flap had presented a few blisters on the distal margin; the other five flaps fully survived without any complications. Patients were highly satisfied with the aesthetic outcomes of both the anterolateral thigh area and the groin site. Although with theoretical risks of compromised venous blood flow, free groin flaps are an effective strategy for closure of massive anterolateral donor-site defects and can be safely performed with thoughtful planning and meticulous microsurgical techniques.

Non-Invasive Imaging of Preoperative Mapping of Superficial Veins in Free Flap Breast Reconstruction.

Non-Invasive Imaging of Preoperative Mapping of Superficial Veins in Free Flap Breast Reconstruction.

Absence of the infrarenal inferior vena cava

A 29-year-old woman presented with mild lower limb pain and edema for almost 15 years, with slowly growing varicose veins in the right leg. She had a previous history of severe pulmonary infection when she was 10 years old, when a venous access was obtained in the right groin by great saphenous vein dissection. Duplex ultrasound examination showed dilated superficial veins in the right leg, with no saphenous or deep vein reflux. Iliac veins were not seen. Contrast-enhanced computed tomography (CT) demonstrated absence of the iliac veins and inferior vena cava (IVC) below the renal veins. The examination showed that drainage of the lower limbs was mainly by the ovarian vein on the left side and by the abdominal wall veins on the right side, mainly the superficial epigastric and the superficial circumflex iliac veins (A and B). Thrombophilia screening was unremarkable, and clinical treatment was adopted with compression stockings with 20 to 30 mm Hg pressure. She had early improvement of edema and relief of symptoms.

Hydrogen Peroxide Priming of the Venous Architecture

Previous studies of venous anatomy lack the detail of their arterial counterparts because of (1) the technical challenge of retrograde perfusion against competent valves and (2) anterograde venous perfusion failing to adequately delineate the area of interest. We introduced a novel technique: retrograde hydrogen peroxide priming that dilates veins and renders valves incompetent, thereby facilitating complete cadaveric venous perfusion. The superficial and deep venous systems of 41 hemiabdomens and 20 hemichests of unembalmed human cadavers were primed by retrograde injection with 6% hydrogen peroxide. Specimens were then injected with lead oxide contrast, radiographed, and dissected. In five hemiabdomens, the valves were mapped by dissection. Results were compared with archival venous studies of six total body injections, six abdominal lipectomy specimens, and two intraoperative venograms of delayed transverse rectus abdominis musculocutaneous flaps. Unprecedented venous filling of the anterior torso was demonstrated. Two types of superficial-to-deep venous connections were defined: large venae communicantes and small venae comitantes. Venae communicantes (>2 mm) formed major connections between large superficial and deep veins, mostly within 5 cm of the umbilicus in the abdomen, the axilla and fifth or sixth intercostal space parasternally. Seventy-four percent of venae communicantes coursed with arteries greater than 1.0 mm. Four major longitudinal valved subcutaneous pathways of the superficial inferior epigastric vein and superficial circumflex iliac vein were defined bilaterally with large avalvular transverse connections in the midline and small-caliber connections laterally that explain venous complications seen sometimes in transverse abdominal flaps. Retrograde hydrogen peroxide priming of veins in cadavers renders valves incompetent and facilitates detailed venous studies that help refine flap design and explain venous complications.