The classic saphenofemoral junction and its anatomical variations

Background The intraoperative anatomy of the saphenofemoral junction can vary from the 'textbook' description of six independent proximal tributaries: three medial - superficial external pudendal, deep external pudendal and the posteromedial thigh branch - and three lateral - superficial epigastric, superficial circumflex iliac and the anterolateral thigh branch. Varicose veins can recur following inadequate initial open surgery with failure to identify, ligate and divide these tributaries. An appreciation of common anatomical variations could minimise recurrence rates following surgery. This study aimed to identify common anatomical variations within our patient cohort. Methods This prospective observational study documented diagrammatically the anatomy of saphenofemoral junction in a consecutive series of 172 patients undergoing unilateral, primary saphenofemoral junction ligation for symptomatic superficial venous insufficiency. Diagrams recorded the number of tributaries and their relationship to the saphenofemoral junction, the existence of bifid systems and the relationship of the external pudendal artery to the saphenofemoral junction. Results In sum, 110 women and 62 men with a mean age of 47.2 (IQR 21-77) years were studied. The median number of saphenofemoral junction tributaries was 4 (IQR 0-7). In 74 cases (43.0%), at least one tributary drained directly into the common femoral vein (IQR 0-4), commonly the deep external pudendal (91.9%). The anterolateral thigh branch was identified in 62 cases (35.8%) and the posteromedial thigh branch in 93 cases (53.8%). The external pudendal artery was identified in 150 cases (87.2%) and was superficial to the great saphenous vein in 36 cases (20.9%). Conclusions Significant variations exist in the saphenofemoral junction anatomy. Familiarity with anatomical saphenofemoral junction variations is imperative to ensure operative success and reduce recurrence. Thorough dissection of the common femoral vein is necessary not only to ensure all proximal tributaries are identified and ligated but also as a safety mechanism in preventing avulsion trauma of direct common femoral vein tributaries.