Hemodynamic Assessment and Strategy Treatment of Giacomini

Varicose Veins

Stefano Ermini M.D. Florence

Giacomini Vein It is an N2 vein, like the LSV and the SSVIt is a transversal vein that goes from the SPJ to the SFJ and drains the perineal veins

Valve Orientation in the Giacomini Vein

Origin from an escape point placed above

Flow in the Giacomini vein occurs during the relaxation phase of the muscle pump

Origin from an escape point placed above

The varicose vein can originate from the Giacomini above or below the perineal intersection

By the interposition of the Giacomini v. , the perineal reflux can give origin to GSV

varicose veins

In relation to the re-entry point disposition different patterns are possible

Pelvic escape point

Giacomini Vein

Visible varicose Veins

Pelvic escape point

Giacomini Vein

Gluteal perforator

Deep v

ein

s

LSV

SSV

Giacomini varicose veins originate from an escape point placed below

This pattern only occurs in the case of a contractive centripetal flow in the popliteal fossa , in absence of

deep vein obstruction

Various hemodynamic patterns and the presence or not of varicose veins are possible in relation to the re-entry point’s

disposition

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 placed above the escape point and the flow goes upwards into the Giacomini vein thanks to an hypertensive pressure gradient

Deep v

ein

s

LSV

Re-entry point A

Re-entry point B

SSV

Escape point

If a re-entry point is placed below the escape point, a centripetal flow also exists in the Giacomini vein during muscle relaxation.

Deep v

ein

s

LSV

Re-entry point A

Re-entry point B

SSV

Escape point

Deep v

ein

s

LSV

Re-entry point A

Re-entry point B

SSV

Escape point

Contraction Relaxation

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 lower than 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 closed and the effect of gravity’s potential energy is charged by muscle pump activity.

Tank A

Tank B

The Siphon Effect

Tank A

Tank B

= Perforator

Hemodynamic patterns of relaxation centrifugal flow

Strategy treatment

Pelvic escape point Popliteal fossa escape point

Risk of escape point recurrence for anatomical reasons

Impossibility to perform an efficient treatment of an escape point submitted to the pressure of the muscle pump and with anatomical difficulties Common solution

Preservation of the N2 Network to drain the pathogenic flow directly in the deep system using the N2 perforators

Strategy treatment of Giacomini varicose veins originating from a perineal escape point

Goals: To reduce the centrifugal flow rate treating the escape point To preserve all N2 systems, competent or incompetent, to avoid

varicose vein recurrence in case of escape point treatment failure. To reach a good cosmetic and functional result

1

21 = escape point treatment2 = tributary disconnection

Strategy treatment of Giacomini varicose veins originating from the popliteal fossa

Goals: To treat the escape point only when it is hemodynamically and

anatomically possible , or in alternative To preserve the contractive centripetal flow in the Giacomini,

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

The tributary disconnection leads to:1) The maintenance of the contractive centripetal flow

in the SFJ in a Giacomini perforator

2) The interruption of the vicious recirculation (venous shunt)

or in