Upload
stefano-ermini
View
6.975
Download
3
Embed Size (px)
DESCRIPTION
Citation preview
Giacomini varicose veins originating from the Popliteal Fossa
Stefano Ermini MDFirenze
Giacomini varicose veins originating from the Popliteal Fossa
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
Dee
p ve
ins
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.
Dee
p ve
ins
LSV
Re-entry point A
Re-entry point B
SSV
Escape point
Dee
p ve
ins
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
Between January 2007 and January 2014, 50 Giacomini systolic shunts have been checked in a
group of 1669 Incompent GSV and 311 Incompetent SSV
( 2.5 % of all checked saphenous varicose veins)
Shunt Type 1 Shunt Type 2 Shunt Type 3 Escape Point Classification
SPJ Popliteal Perforator Gastrocnemious Perforator
34 casi su 50
68%14 casi su 50
28%2 casi su 50
4%
Systolic Flow
Diastolic Flow
Shunt Type A
Re-entry point disposition classification
5 casi su 50
10%
Systolic Flow
Diastolic Flow
Shunt Type A + II
Without GVS involvement With GVS involvement
4 casi su 50
8%
Systolic Flow
Diastolic Flow
Shunt Type B
5 casi su 50
10%
= Perforator
Shunt Type B + II
Without GVS involvement With GVS involvement
Nessun caso osservato
Shunt Type C
8 casi su 50
16%
Shunt Type D
12 casi su 50
24%
Shunt Type E
Without GVS involvement With GVS involvement
31 casi su 50
62%
29 casi su 50
58%
With or Without Giacomini Systolic Flow Re-Entry Perforator
The perforator is situated before the tributary origin : 3 cases
31 shunt type E21 without perforator10 with perforator
2 shunt type D2 without perforator0 with perforator
Zero shunt with perforator observed
With or Without Giacomini Systolic Flow Re-Entry Perforator
The perforator is situated after the tributary origin : 7 cases
31 shunt type E21 without perforator10 with perforator
Zero shunt with perforator observed
Strategy Treatment
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
20 Surgical Treatments
15 strategies on the Giacomini v.4 strategies on the GSV ( 2 shunt type B and 2 type E)1 Flush ligation of the Giacomini v.
Surgery has been performed in 20 patients( Follow up minimum 3 months , maximum 3 years)
Disconnection of the Giacomini vein flush to the saphenous arc(1 case)
Gastrocnemious perforator
Surgical treatmentShunt Type E = 11 casesShunt Type D = 2 casesShunt Type A = 2 cases
Hemodynamic effects of the Giacomini tributary disconnection are different depending on the presence or not of natural destination points of the systolic flow.
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 Giacomini v
No perforator before surgery
Systolic flow 1 week later
No Systolic flow 1 week later
GiacThrombosis 1 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
The worst thing that we can do in a situation like this is to destroy the saphenous trunk.
Thanks for your attentionStefano Ermini M.D.