GIACOMINI VARICOSE VEINS ORIGINATING FROM THE POPLITEAL FOSSA

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.