The surgical anatomy of varicose veins

Varicose veins are managed largely in ignorance of important aspects of normal anatomy. In a study of 60 dissected legs the following observations were made: 1. The long saphenous vein--normally lies on the deep fascia enclosed with an envelope of fibrous tissue, which presumably compresses the vein rhythmically on exercise to aid centripetal flow. Thick walled and straight it is never varicose, and, communicating regularly with only one or two of the 60 or so perforating veins in the lower limb, its removal by stripping in operations for varicose veins is unjustifiable. In 18% of legs its femoral part is thin walled, superficial, and sometimes multipartite: in such legs varicose veins are commoner than usual, a point of aetiological interest. 2. The tributaries of the long saphenous vein--below the knee normally drain indirectly into it via an arch vein lying parallel but in a posterior and superficial plane, communicating with it both above and below. To reach it, for instance, the pre-tibial tributaries must cross the long saphenous vein. Varicosities of these tributaries and the arch vein therefore overlie the long saphenous vein and are sometimes attributed to it. Similarly the upper end of the arch vein is often erroneously thought to be the long saphenous vein itself dilated up to an incompetent thigh perforator. 3. Perforating veins--are found all over the limb but mainly at intermuscular septa. Minor ones communicate with small muscle veins, major ones with the main deep veins. The major ones medially above the ankle differ from the rest in running a short (1 cm) and unprotected course from subcutaneous fat to posterior tibial veins through the wide gap between soleus and tibia. They are therefore peculiarly susceptible to damage, and their incompetence is peculiarly direct an its effect, which anatomical weakness may account for the prevalence of medial venous ulceration.