Disclosure John Mauriello, M.D.

I disclose the following financial relationship(s):

•Speaker/Honoraria: Angiodynamics

•Consultant/Advisory Board: Biolitec, Inc.

Important Nerves During Venous Ablation

John Mauriello, MD, FACPh Bradenton, Florida

Important Nerves during Venous Ablation

• Saphenous N.

• Sural N.

• Tibial N.

• Common Peroneal N.

Nerves of importance during Ablation

Why?

• Saphenous N.

• Sural N.

• Tibial N.

• Common Peroneal N.

Campbell WB, France F, Goodwin HM. Medicolegal claims in vascular surgery.

Ann Roy Coll Surg Engl 2002;84:181-4

Atkin GK, Round T, et al. Common peroneal nerve injury as a complication of short saphenous vein surgery. Phlebology 2007;22;3-7.

Nerve damage is the most common cause of

litigation following varicose vein surgery/prcedures.

Ted King, M.D.

Murakami G, Negishi N, et al. Anatomical relationship between saphenous vein and cutaneous nerves. Okajimas Folia Anat Jpn 1994; 71(1): 21-33.

•Studied 148 lower limbs of 74 cadavers • In the thigh, GSV rarely had a close relationship with the saphenous nerve.

• In the leg, GSV frequently ran intimately along the saphenous nerve

– 59.5% in the middle third of the leg – 83.1% in the lower third of the leg – More than half of the latter showed an adhesive relationship where the epineurium of the saphenous nerve was seen histologically to be attached to adventitia of vein

• SSV was often located close to sural nerve – Adhesive relation between SSV and sural nerve was rarely observed.

Anatomical relationship between saphenous veins and superficial nerves

Nerve Injury during stripping (2,341)

• Great saphenous vein (GSV) stripping in 1,963 limbs. Nerve injury of 4.9%.

Small saphenous vein (SSV) stripping in 570 limbs. Nerve injury of 2.5%.

• Full-length stripping accounted for almost 40% of the all cases.

GVS stripping had 9% & SSV had 4.5% nerve injury.

Masaki K, Tetsuyan N, et al. Safety of Outpatient Vein Stripping under Local Anesthesia and Propofol Sedation. Japanese Journal of Phlebology 2006;17:11-16.

Saphenous neuropathy following EVLA

• Four studies reported saphenous paresthesias

in 1 % to 36·5* % of limbs.

Mundy L, et al. Systematic review of endovenous laser treatment for varicose Veins. British Journal of Surgery 2005; 92: 1189–1194.

*Chang C-J, Chua J-J. Endovenous laser photocoagulation (EVLP) for varicose veins.

Lasers Surg Med 2002; 31:257–262. At six months this was 2.8% and 0 at end of study.

The saphenous nerve will lie (about 3 cm) posterior and deep to the vein. Variations do exist but rarely is it adjacent to the vein.

Courtesy of Olympia Anesthesia Associates, P.C., a resource affiliate of neuraxiom.com. Available at http://www.neuraxiom.com/html/saphenous_block.html .

Above the knee

Ted King, M.D.

GSV

Fascicle

Epineurium

Saphenous fascia

Deep fascia

Below the knee

Cross section of SaphC.

No Nerve Saphenous Nerve

Above knee Below Knee

Saphenous Nerve

Sclerotherapy: treatment of varicose and telangiectatic leg veins. MP Goldman

Sensory nerve to medial calf, ankle and

foot.

Sural Nerve

• Sural nerve is the most frequently used sensory nerve in nerve transplantations.

• Though the sural nerve is considered to be a sensory nerve, some motor fibers have been found in 4.5% of nerves.

Amoiridis G, Schols L, et al. Motor fibers in the sural nerve of humans. Neurology 1997;49:1725-8. Nayak S. Sural nerve and short saphenous vein entrapment-a case report. Indian Journal of Plasrtic Surgery. 2005;38:171-172.

Sural neuropathy following EVLA

• Reported to be 01- 4.42 %.

1Proebstle TM, Gul D, et al. Endovenous laser treatment of the lesser saphenous vein with a 940-nm diode laser: early results. Dermatol Surg 2003; 29: 357–361. 2Gibson KD, Ferris BL et al. Endovenous treatment of the short saphenous vein: efficacy and complications. J Vasc Surg 2007;33:614-618.

Conclusion Puncturing the SSVs at the mid-calf will decrease post-operative paresthesia without affecting the recanalizations rates. This is due to the very close relationship of the SSV with sural nerve in it’s course from the distal calf to the ankle,

Sural Nerve

Courtesy of Diana Neuhardt, RVT Left

Sural nerve

SSV

Much closer

Sural Nerve

Sclerotherapy: treatment of varicose and telangiectatic leg veins. MP Goldman

Sensory nerve to the lateral calf, ankle, foot &

heel.

Tibial Nerve

•Motor / Sensory N.

•Can't stand on tiptoes (no plantar flexion).

•No sensation to sole of foot.

Sciatic nerve

Left Popliteal Fossa

Common Peroneal Nerve

1Lucertini G, et al. Injury to the CPN during surgery of the SSV. Phlebology 1999;14:26-28.

2Atkin GK, et al. CPN injury as a complication of SSV surgery. Phlebology 2007;22:3-7.

3Balasubramanium R, et al. The relationship between the SPJ and the CPN: a cadaveric study. Phlebology 2009;24:67-73.

• Incidence 2 - 4.7%1-2 during surgery of SSV.

• Incidence during AP or EVTA ?? Under reported.

• Higher the termination of SPJ the closer is the CPN3.

• One cadaver3 the SPJ & CPN was 1.3 mm apart.

Mean of 16.7 mm.

Common Peroneal Nerve

Left Popliteal Fossa

Sciatic nerve

•Motor / Sensory N.

•Foot Drop

•No sensation to top of foot

Common Peroneal Nerve

Danger zone near the fibular head.

Common Peroneal Nerve

Left lateral Knee

Danger zone

Common Peroneal Nerve

Cross section Long axis

CPN CPN

Scan by Joseph Zygmunt, Jr. RVT

Conclusion

• With good ultrasound equipment you can see nerves. If you look for them.

• The more distal the closer is the saphenous and sural nerves to their respective veins.

• Be cautious when doing AP near the fibular head.