The arch of the great saphenous vein: anatomical bases for failures and recurrences after surgical treatment of varices in the pelvic limb. About 54 dissections

[Anatomical bases of external pudendal artery injuries during surgical treatment of pelvic limb varices]

INTRODUCTION

External pudendal artery is a collateral branch of the common femoral artery which is the primary blood supply to the penis or the clitoris. Its relationship with the venous arch of the great saphenous vein and its afferents in femoral triangle, are very narrow. This often entails injuries during crossectomy and great saphenous vein stripping. These lesions can cause sexual dysfunction.

METHODS

This study reports the case of a dissection of 22 inguinal regions in 13 men and 9 women who underwent surgical treatment of the femoral triangle. The distribution and the relationship between the external pudendal artery and the venous arch of the great saphenous vein are studied.

RESULTS

Single external pudendal artery is the most common. All external pudendal arteries originate from the common femoral artery. The most common type of relationship is between the sub-crossing of the venous arch of the great saphenous vein and a single external pudendal artery. Moreover, we recorded a pre-crossing, an alternate crossing and some relationship with the common femoral vein and the afferences of the venous arch of the great saphenous vein. Some surgical techniques expose more or less to external pudendal artery injury.

CONCLUSION

This study confirms previous data but shows some peculiarities about the relationship between the venous arch of the great saphenous vein and external pudendal artery.

Female Pelvic Vein Embolization: Indications, Techniques, and Outcomes

Until recently, the main indication for pelvic vein embolization (PVE) in women was to treat pelvic venous congestion syndrome (PVC) but increasingly, patients with refluxing pelvic veins associated with leg varicosities are also being treated. A more unusual reason for PVE is to treat pelvic venous malformations, although such lesions may be treated with sclerotherapy alone. Embolotherapy for treating PVC has been performed for many years with several published studies included in this review, whilst an emerging indication for PVE is to treat lower limb varicosities associated with pelvic vein reflux. Neither group, however, has been subjected to an adequate randomized, controlled trial. Consequently, some of the information presented in this review should be considered anecdotal (level III evidence) at this stage, and a satisfactory ‘proof’ of clinical efficacy remains deficient until higher-level evidence is presented. Furthermore, a wide range of techniques not accepted by all are used, and some standardization will be required based on future mandatory prospective studies. Large studies have also clearly shown an unacceptably high recurrence rate of leg varicose veins following venous surgery. Furthermore, minimally or non-invasive imaging is now revealing that there is a refluxing pelvic venous source in a significant percentage of women with de novo leg varicose veins, and many more with recurrent varicosities. Considering that just over half the world’s population is female and a significant number of women not only have pelvic venous reflux, but also have associated leg varicosities, minimally invasive treatment of pelvic venous incompetence will become a common procedure.