COMMON PATTERNS OF ABNORMAL VEINS: GUIDE AND SUMMARY BY REGION
Regional Anatomy of Varices
To build up venous insufficiency diagnostic skills, a regional approach to the frequently and commonly observed anatomical patterns can be useful. Artificially dividing the leg into eight quadrants—lateral, medial, anterior, and posterior, both above and below the knee—is the approach for this chapter (Figure 5-1). The goal is to provide both the novice and experienced phlebologist a visual guide to the common (and occasionally less common) pattern of abnormal veins that one is likely to encounter in everyday practice. A regional approach, while allowing for a “cookbook” type reference, leads to some unavoidable repetition in the discussion and presentation, because many veins extend through different regions or have tributaries that cross many boundaries. Clinical photographs accompanied by simplified diagrams and tables can facilitate rapid identification of the root causes of an unfamiliar pattern of reflux, but there is no substitute for a complete understanding of normal venous anatomy.
Overview of the Quadrants of the Upper Thigh: 1. Medial Thigh. 2. Posterior Thigh. 3. Lateral Thigh. 4. Anterior Thigh.
Pudendal. Most proximally, visualization of blue reticular to 3–4 mm varicose veins can be seen extending from external genitalia (Table 5-1). These indicate reflux through the pudendal tributary of the great saphenous vein (GSV). These genital veins, when varicose, may cause pain during sexual intercourse as they become engorged with increased blood flow. Overall pain is usually worse during the progesterone phase of the menstrual cycle, a common theme of medical history. In early stages of pudendal reflux, the saphenofemoral junction (SFJ) is not involved and treatment is easily performed (Figure 5-2). Pudendal varicosities arising without associated saphenous reflux typically course only several centimeters on the proximal medial thigh. They are typically not associated with varicosities below the mid-thigh. Years after treatment, reflux may occur within the GSV beginning at the SFJ. It should be emphasized to the patients that this is not related to the previous treatment but represents a natural progression of venous disease and is almost predictable if left untreated.
TABLE 5-1Region 1—Medial Thigh ||Download (.pdf) TABLE 5-1 Region 1—Medial Thigh
Incompetent saphenofemoral junction
Hidden reflux at saphenofemoral junction (only palpable on standing)
Superficial axial branch veins (medial tributaries) of GSV
Hunterian perforator connection—mid-thigh
Distal saccular saphenous vein dilation (just above knee)
Resistant telangiectatic matting (just above knee)
Pudendal vein varicosities on the uppermost medial thigh extending upward to the genitalia. Rapid response to sclerotherapy or phlebectomy is typical.
Bulging GSV at inguinal fold from SFJ reflux. Although ...