3
© 2007
Schattauer GmbH
Frequency and exact position of valves in
the saphenofemoral junction
D. Mühlberger, L. Morandini, E. Brenner*
Department of Anatomy, Embryology and Histology, Division for clinical-functional Anatomy
(Director: o. Univ.-Prof. Dr. Helga Fritsch), Innsbruck Medical University
Keywords
Schlüsselwörter
Mots clés
Summary
Zusammenfassung
Résumé
Greater saphenous vein, vein valves, varicose veins
V. saphena magna, Venenklappen, Varikose
Background: Varicose veins are common. As venous
valves are included in the pathological development of varices they have been studied by many authors. Nonetheless,
the exact position of valves is unclear. Material and method: The exact position of the valves in the greater saphenous vein was studied macroscopically from the saphenofemoral junction up to 25 cm distally in situ on 72 cadavers
with a total of 140 veins. Results: A terminal valve existed
in 88.5% in the range of 0 to 1.4 cm and a preterminal
valve was present in 89.2% in the range of 1.4 cm to 8.2
cm distally to the saphenofemoral junction. In about a fifth
of the cases a third valve could be identified. Conclusion:
Our results suggest, that the recent general agreement that
there are always a terminal and a preterminal valve has to
be negated.
Phlebologie 2007; 36: 3–7
V
aricose veins are common and
nearly a fifth of the population is
affected (3). In the Bonn veinstudy a pathological reflux into the superficial venous system was found in 19.5% of
3072 participants (25). Also in the study at
Tübingen (4026 patients) apparent varicose
veins were detected in 15% (11).
It is a general agreement that the valves
of the greater saphenous vein are involved in
the pathological process, as the total number
of valves above the knee is greater in healthy
than in varicose veins (7, 20). But it is still
unclear if
● primarily the valves are damaged or
● the vein wall weakness is the primary
trigger for varicose veins.
Veine grande saphène, valves veineuses, varices
Hintergrund: Varizen sind häufig. Da die Venenklappen
in den pathologischen Prozess involviert sind, wurden sie
von zahlreichen Autoren studiert; allerdings ist die absolute Position der Venenklappen noch unbekannt. Material
und Methode: Die exakte Position der Venenklappen der
V. saphena magna wurde makroskopisch von der saphenofemoralen Mündung bis 25 cm distal an 140 Venen in 72
Leichen untersucht. Resultate: Eine terminale Klappe fand
sich in 88,5% in einem Bereich von 0,0 bis 1,4 cm ab Mündung. Eine präterminale Klappe fand sich in 89,2% zwischen 1,4 cm und 8,2 cm distal der Mündung. Ein etwa einem Fünftel konnte zumindest noch eine weitere Klappe
identifiziert werden. Diskussion, Schlussfolgerung: Die
generelle Annahme, sowohl eine terminale als auch eine
präterminale Klappe seien immer vorhanden, muss aufgrund unserer Daten zurückgewiesen werden.
Contexte : La maladie variqueuse est fréquente. Les valves
veineuses étant habituellement impliquées dans ce processus pathologique, de nombreux auteurs les ont étudiées.
La topographie précise des valves pose de nombreux
problèmes. Matériel et méthode : Étude macroscopique
de la topographie précise des valves de la grande saphène
allant de la jonction saphéno-fémorale, jusqu’à 25cm de
son extrémité distale. 140 veines ont été étudiées in situ sur
72 sujets post-mortem. Résultats : La jonction saphénofémorale montre la présence d’une valve dans 88,5% des
cas située entre 0 et 1,4cm de l’embouchure et dans 89,2
des cas une autre valve est présente, située entre 1,4 et
8,2cm de l’embouchure. Dans 1/5ème des cas, une
troisième valve a pu être identifiée. Conclusion : La présence d’une valve de l’embouchure de la veine grande
saphène et d’une autre valve pré-terminale associée n’est
pas toujours avérée.
Häufigkeit und exakte Postition der Venenklappen
der saphenofemoralen Mündung
Topographie précise des valves veineuses de la
jonction saphéno-fémorale
In all probability a combination of both factors could be the solution (12). The role of
arteriovenous blood flow is discussed controversially, too (10).
The number of valves does not coincidence with the length of the greater saphenous
vein (9). Valves are blood flow modulators
(18), which open when blood passes and close
by the decreasing flow velocities rather than
by a reflux into the sinuses of the valve (17).
According to Trendelenburg's theory, valves
of the greater saphenous vein prevent both reflux from the femoral vein and from the deep
venous system (3, 13, 30), as perforating veins
present valves in nearly 75% (13).
Somjen reported a reflux at the saphenofemoral junction in patients with saphenous vein incompetence in 66%; in the other
34% he could identify at least a regional incompetence (28). One the other side Fassiadis stated that the valves at the saphenofemoral junction do not play a decisive role
because „reflux in the greater saphenous
vein starts distally and progress proximally”
(10). Nevertheless, a reflux can also occur
from those superficial veins discharging
into the great saphenous vein (1, 28). Therefore, the exact position and distribution of
the valves gain importance.
Several studies are dealing with the frequency or the total number of valves but not
* Study design: DM, EB; data collection: DM, LM;
statistical analysis: DM, EB; data interpretation:
DM, EB; manuscript preparation: DM, LM, EB;
literature search: DM, EB; funds collection: DM
Downloaded from www.phlebologieonline.de on 2017-06-15 | IP: 88.99.165.207
Received: July 5, 2006; accepted in revised form: For
October
17, 2006
personal or educational use only. No other uses without permission. All rights reserved.
Phlebologie 1/2007
4
Mühlberger, Morandini, Brenner
with their exact position. They state that
there are more valves in the greater saphenous vein in the tight than in the calf (15, 21,
27). The number of valves in the greater saphenous vein can vary from 3 to 13 (9, 16).
However, except for three studies (2, 22,
27), no description of the exact position of
valves is available.
Cotton describes a terminal valve (4, 8,
13). Hach denotes this valve as „Mündungsklappe” and defined its position within a range of 0.5 cm to 1.5 cm distally to the
entrance of the greater saphenous vein into
the femoral vein (14). This valve prevents
reflux from the femoral vein (6). According
to some authors, there is always a valve directly at the junction (19, 21, 27). Other
studies record fairly constant positions (15,
16, 26). Pang published an existence of 85%
of the terminal valve (22), and Shinohara et
al. reported that it was consistently present
(27). Banjo published a 100% likelihood for
a valve in the terminal 3.0 cm of the greater
saphenous vein for Caucasians and 98% for
Africans (2).
Cotton also describes a preterminal
valve, named „Schleusenklappe” by Hach
(8, 14). On the mind of Hach there are two
preterminal valves 3.0 cm distally (14).
Others reported only one, 3-5 cm (19) or
2-5 cm (26) distally to the saphenofemoral
junction. Such an preterminal valve should
prevent reflux from the other branches of
the confluence of the superficial inguinal
veins (1, 5, 6). The insufficiency of the preterminal valve can cause most of the varicose veins (23).
On the basis of the data published we
suppose in contrast to the general agreement
(7, 20) that a terminal valve directly at the
saphenofemoral junction is not present in all
cases. Furthermore, we are convinced that
mostly there is a valve directly distally from
the entrances of the veins of the saphenofemoral junction (5), which may be called a
preterminal valve. Moreover, it is absolutely
necessary to define the distance limits in
which it is possible to classify a terminal and
a preterminal valve.
The aim of our morphological study was
to find out both,
● the exact position and the frequency of
the terminal valve and
● the preterminal valve including the location of potential other valves.
Material, methods
From September until December 2005 we
(D.M., L.M.) dissected the greater saphenous veins from 72 formalin fixed bodies in a
range of 25 centimetres from the saphenofe-
a)
b)
Phlebologie 1/2007
Fig. 1
Right (a) and left (b)
saphenofemoral junction
TV: terminal valve,
PTV: preterminal valve,
gsv: greater saphenous
vein, fa: femoral artery,
fv: femoral vein
a) in situ of a man
(age: 61 years);
b) man (age: 76 years)
moral junction during the regular dissection
course. All cadavers derived from the Division for clinical-functional Anatomy of
Innsbruck Medical University assigned to a
specific use for the anatomical dissection
course of students in the second year. They
were bequested to den Division by informed
constent.
All bodies were Caucasians. From those
72 specimens there were 41 female and 31
male. The mean age of all was 78.4 years
and the mean height 168 cm. Due to the fact
that three veins were dissected inadvertently
by students and one cadaver status after amputation of the right lower extremity we had
a total of 140 legs (71 left and 69 right) from
72 bodies to dissect. After locating the
greater saphenous vein and the other trunks
of the confluence of the superficial inguinal
veins (external pudendal vein, superficial
epigastric vein, superficial circumflex iliac
vein, anterior and superficial accessory
great saphenous vein) we carefully exposed
the greater saphenous vein, the saphenofemoral junction and the adjacent parts of the
femoral vein. Then we opened the greater
saphenous vein longitudinally towards the
saphenofemoral junction in order to treat
eventual valves with care and the adjoining
parts of the femoral vein to identify exactly
the terminal valve. We cleaned the lumen of
the vein with diluted formaldehyde, and
identified the valves macroscopically. The
measurement was performed in situ with a
tape measure from the opened confluence of
the great saphenous vein into the femoral
vein to the nodule of the valve. We documented this photographically with a Nikon
D100 (Nikon Corporation, Japan) and by
means of a distinct protocol.
As veins are in vivo very dynamic
vessels, which alter their diameter in relation both to volume and pressure, cadaveric measurement of their diameters would
result in data of extremely limited value.
Therefore, diameters were not measured.
The analysis of data (D.M., E.B.) was
performed by SPSS 12.0 (SPSS Inc., Chicago, USA) and Excel 2003 (Microsoft Inc.
Redmont, USA).
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5
Valves in the saphenofemoral junction
Results
None of the investigated valves showed
macroscopically deformations or changes,
which might be due to a previous thrombosis. We could find a 1st left valve in all 71
legs in the range of 0.0 cm to a maximum of
7.2 cm distally to the saphenofemoral junction. The mean distance value was 0.79 cm
(SD ±1.24 cm) and the median was 0.5 cm.
The 1st right valve was present in all 69 legs
in the range of 0.0 cm to a maximum of
5.8 cm distally to the entrance of the greater
saphenous vein into the femoral vein. The
mean distance value was 0.85 cm (SD
± 1.13 cm) and the median was also 0.5 cm.
A 2nd left valve exists in 59 cases with a
mean distance value of 3,88 cm (SD
±3.60 cm) and a 2nd right valve was present
in 56 legs with a mean distance value of 4.38
cm (SD ±2.0 cm). We could find the earliest
2nd right valve 1.5 cm and the earliest 2nd left
valve 1.4 cm distally to the saphenofemoral
junction.
In a total of 34 cases (24.4%) we have
identified a 3rd valve, in five veins a 4th, and
in two veins an additional 5th valve.
Because of the enormous range, we
found the 1st valves (0-7.2 cm, 0-5.8 cm),
and the great deviation of the mean distance
value to the median (0.79 cm, 0.85 cm to
0.5 cm), we suppose, that all 1st valves,
which are located more than 1.4 cm distally
to the saphenofemoral junction, in truth are
valves at the 2nd place. This concerns eight
left and eight right 1st valves. Due to this
step we got following new results:
Left valves
The left valves I (terminal valves) were
present in the defined range of 0.0 cm to 1.4
cm in a total of 63 cases; this is 88.7%
(63/71). The mean distance value was 0.45
cm (SD ±0.25 cm). The median was 0.4 cm.
The left valves II (preterminal valves)
were available in a total of 65 legs with a
mean distance value of 3.76 cm (SD ±1.49
cm) in the range of 1.4 cm to 7.8 cm distally
to the saphenofemoral junction. One valve
a)
b)
Fig. 2 Distribution of valves at the left (a) and right (b) side
TV: terminal valves, PTV: preterminal valves, AV: additional valves
was outside the double standard deviation of
the left valves II, but inside the double standard deviation of the right valves II.
Right valves
The right valves I (terminal valves) existed in
a total of 61 legs with a mean distance value
of 0.51 cm (SD ±0.35 cm) and with a median
of 0.4 cm. These corresponds to 88.4%
(61/69) in the defined range of 0.0 to 1.4 cm.
The right valves II (preterminal valves)
were present in a total of 62 cases in the
range of 1.4 cm to 11.8 cm. The mean distance was 4.21 cm (SD ±1.97 cm). Because
of the fact that two of those right valves II
were outside the double standard deviation
(8.2 cm) we think that only a total of 60
valves were preterminal ones.
Furthermore, we could not find any significant differences in the total number of
valves in respect to sex, side, and age.
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Phlebologie 1/2007
6
Mühlberger, Morandini, Brenner
Discussion
Conclusion
It is absolutely necessary to define the distance limits in which it is possible to classify
the terminal valve and the preterminal
valve. Due to our data, we are convinced that
our defined range of 0.0 cm to 1.4 cm distally to the entrance of the greater saphenous
vein into the femoral vein is correct for a
classification of a terminal valve. Nevertheless, the general agreement that there always
exists a terminal valve near the saphenofemoral junction has to be disproved. However, in a total of 88.5% (124/140) we did
find one. The valve seems to be constant,
but it is not. This corresponds with our hypothesis presented in the introduction.
Furthermore, we suppose that the minimum distance limit for the correct identification of a preterminal valve starts at 1.4 cm
distally to the saphenofemoral junction. The
definition of the maximal distance limit is
difficult, because the physiological function
of the preterminal valve is the prevention of
reflux from the superficial trunks of the
confluence of the superficial inguinal veins
(1, 8, 9). Thus, a preterminal valve has to
exist distally to the last entrance of the
superficial inguinal veins which discharge
into the greater saphenous vein. But there is
a great variability of those veins, because
the normal case exists in only 37% (24).
To our opinion all valves located distally
to the double standard deviation certainly
are not preterminal valves. Based to our results we suppose that all valves in the range
of 1.4 cm to 8.2 cm are preterminal valves.
This concerns 89.2% (124/140), and 62.8%
(88/140) of the preterminal valves are in the
area about the mean distance value within
one standard deviation between 2.3 cm and
5.3 cm on the left and between 2.3 cm and
6.2 cm on the right side. It appears that the
range of 2.0 cm till 6.0 cm may be the area in
which we can identify a preterminal valve
definitely. But we also saw that the preterminal valve seemed to be constant too, but
definitely it is not.
We can state that a terminal valve exists in
88.5% in the range of 0.0 cm to 1.4 cm and
a preterminal valve is present in 89.2% in
the range of 1.4 cm to 8.2 cm distally to the
saphenofemoral junction.
Those findings may be important for the
development of a main trunk varicose of the
great saphenous vein. Hach found this form
of varices (C2EpAS2,3PR) in an insufficiency
of the terminal or preterminal valve with the
beginning of a descending reflux (14). He
called this sign in radiographic and sonographic diagnostics Hach-Teleskop Zeichen
(14). This is in contrast to Fassiadis (10)
who turned the terminal valve from „gate
keeper into rear guard” because of an ascending reflux. We disagree with Fassiadis
because a nearly 90% existence of a terminal valve, in respect, is an indication for
an important role as a blood flow regulator.
Other studies stated that venous hypertension can shift valves in a pathological way
(29).
Due to the fact, that a terminal valve does
not exist in 10% of the cases and its nonexistence need not to be accompagnied by
varicosis, we believe that insufficient valves
near the saphenofemoral junction cannot be
the only reason for varicosis. This does not
mean that they play no role, but other morphologic and haemodynamic factors have to
be considered. Therefore, further studies
about the position of venous valves both in
the femoral vein and in perforating veins as
well as haemodynamics in the venous system of the inferior extremity will be necessary.
Phlebologie 1/2007
Acknowledgement
Special thanks go to Mrs. Sonja Huber, company officer with statutory authority, from Bandagist Heindl
GmbH in Linz, Austria, for their great financial support.
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Correspondence to:
Dominic Mühlberger
Department of Anatomy, Embryology and Histology
Innsbruck Medical University
Müllerstrasse 59, 6020 Innsbruck, Austria
Fax +43/(0)5 12/9 00 37 31 12
E-mail: [email protected]
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