European Journal of Cardiovascular Medicine

Varicose veins of the lower limb remain one of the most prevalent venous disorders, affecting up to 25–30% of the adult population worldwide [1,2]. The great saphenous vein (GSV) and its termination at the saphenofemoral junction (SFJ) play a pivotal role in venous reflux and recurrence after surgery. Inadequate understanding of SFJ anatomy or failure to identify accessory tributaries during surgery often leads to residual reflux or neovascularization [3–5].

The great saphenous vein typically receives the superficial circumflex iliac vein, superficial epigastric vein, superficial external pudendal vein, anterior accessory vein, posteromedial thigh vein along with some additional veins that are not named. However, literature reveals wide individual variations in the number and pattern of tributaries [6,7]. Chronic venous insufficiency (CVI) alters venous wall elasticity and calibre, potentially affecting SFJ topography.

Cadaveric and radiological studies form the anatomical baseline for surgical reference, but postmortem changes may modify tissue relationships. Conversely, surgical exploration during varicose vein procedures offers real-time insight into SFJ anatomy in pathological states. Few studies have directly compared the SFJ between cadavers and surgical patients in the same regional population [8–10].

Therefore, this study was designed to provide a detailed comparison of the SFJ’s morphometry, SEPA relationship, and tributary pattern in normal cadavers and patients with CVI in a tertiary care setup in North India

Study Design and Ethical Considerations

An ambispective comparative observational study was conducted at a tertiary care teaching hospital between January 2023 and March 2024. Institutional Ethics Committee approval was obtained (IEC/23/SURG/221). Written informed consent was taken from all living subjects prior to surgery.

Inclusion criteria:

1. All consecutive cadavers undergoing dissection in Dissection Hall, AIIMS Raebareli, due to academic purposes during study period.
2. All consecutive patients more than 18 years of age undergoing Trendelenberg procedure in CTVS Operating Theatre, AIIMS Raebareli, as part of their standard medical care, during study period, who gave consent to be included in the study.

Study Groups

1. Group C (Cadaveric group): 46 lower limbs dissected from 23 formalin-fixed cadavers (16 males, 7 females) aged 45–80 years.
2. Group S (Surgical group): 40 limbs from 40 patients undergoing high ligation and stripping for CEAP classification C4–C6 varicose veins as part of their treatment as per standard clinical guidelines.

Data Collection

In both groups, the following parameters were recorded:

• Demographic details
• Length between greater trochanter and lateral condyle of femur
• Length between pubic tubercle and anterior superior iliac spine (inguinal ligament)
• Vertical distance between inguinal ligament and upper margin of SFJ
• The junction of inguinal ligament below which SFJ was located
• SEPA’s relation to the SFJ (anterior, posterior, duplicate, or absent)
• Number and type of SFJ tributaries (superficial epigastric vein, superficial circumflex iliac vein, superficial pudendal vein, anterior accessory vein, posteromedial thigh vein, or additional veins)

Figure 1: Schematic showing SFJ in relation to the inguinal ligament, femoral vein, and pubic tubercle. ASIS- anterior superior iliac spine, PT- pubic tubercle, SFJ- sapheno-femoral junction

In cadavers, dissection was performed through a standard groin incision, exposing the femoral vein and GSV confluence. In surgical patients, intraoperative findings during high ligation and stripping were documented after surgical exposure under anaesthesia. The findings were documented in a Data Collection Form.

Statistical Analysis

All data were entered into Microsoft Excel and analyzed using IBM SPSS version 25. Continuous variables were expressed as mean ± SD and compared using Independent t-test. Categorical variables were compared using Chi-square test. Pearson correlation and linear regression were applied to assess relationships between thigh length and SFJ distance. p ≤ 0.05 was considered statistically significant.

Table 1: Demographic and Morphometric Comparison between Cadaveric (Group C) and Surgical (Group S) Subjects

In both groups, the SFJ was consistently situated below the junction of the medial one-third and lateral two-thirds of the inguinal ligament. The mean perpendicular distance from the inguinal ligament was 3.1±0.5 cm (cadaveric) versus 2.8±0.8 cm (surgical). SFJ was situated caudally in cadavers (p=0.006). The SFJ distance showed a moderate positive correlation with thigh length in both groups:

• r = 0.580 (cadaveric), p < 0.05
• r = 0.583 (surgical), p < 0.05

Linear regression confirmed a predictable increase of 0.08 cm in SFJ distance for every 1 cm increase in thigh length

SEPA Relationship

Table 2: Comparison of SEPA Position in Relation to the Saphenofemoral Junction

There was no significant difference between the two groups (p>0.05). Location of SEPA posterior to great saphenous vein, at its junction to SFJ marks an important surgical landmark. However, in our study, it was found missing in approximately 35% of subjects in both groups.

Tributary Patterns

Table 3: Comparative Distribution of Saphenofemoral Junction Tributaries

No significant difference was noted in tributary numbers and pattern in both groups.

The SFJ is a critical surgical landmark for high ligation in varicose vein surgery. There are various ways to identify the SFJ during dissection. The SEPA is located just behind the junction of great saphenous vein and femoral vein. The great saphenous vein dips into the deep fascia at SFJ. The femoral arterial pulsation may be over the SFJ, lateral to the palpating finger.

 In our study, the SEPA was posterior to the SFJ in nearly 65% of both groups, corroborating findings by Glass et al. [11] Manjunath et al. [12] noted SEPA absence in 12%, comparable to our 15%. Manirekar et al [19] reported posterior SEPA in 56%, anterior SEPA in 28% and absent SEPA in 4% of patients. While absent in a significant portion of our population, its presence nonetheless serves as an important landmark and the surgeon must be keep an eye out for it. In approximately one fourth of population, SEPA shall run anterior to SFJ, and poses a danger of troublesome bleeding for unsuspecting surgeon.

While classical teaching emphasizes on the presence of three tributaries, i.e. superficial pudendal vein, superficial epigastric vein and superficial circumflex iliac vein, we did not find all of them in our study in each patient.  On the other hand, there is no significant difference in the cadaveric population and patients suffering from varicose veins, highlighting that CVI merely affects pre-existing tributaries. Tributary analysis revealed that the superficial pudendal vein was the most consistent, followed by the superficial epigastric and superficial circumflex iliac veins. Manirekar et al [19] reported highest incidence of superficial epigastric vein (98%) in Central Indian population. Riju et al. [13] reported additional tributaries in 43% of CVI patients, similar to our 47.5%.

Table 4. Location of SFJ as per multiple reference anatomy and surgical textbooks

Most of the standard reference textbooks, of anatomy and surgery, describe location of SFJ/saphenous opening in relation to pubic tubercle in terms of absolute values (Table 4). We have found it to be approximately 3cm below junction of medial one-third and lateral two-thirds of inguinal ligament. Moreover, the position of SFJ varies with length of femur, and therefore, by height of person. To the best of authors’ knowledge, SFJ has not been described in relation of inguinal ligament earlier. We believe our description is more accurate and takes into account that absolute anatomical positions would change with change in stature of person.

Riju et al has performed a similar study in South Indian population in 80 patients undergoing Trendelenberg procedure and concluded that location of SFJ was higher and medial as compared to western counterparts, while the number of tributaries were lower[13]. Our findings are similar.

Limitations of our study include limited sample size and lack of multicentric study. Multicentric studies in future with a larger sample size, and also involving diverse geographic areas, may shed additional light on the venous anatomy, and the regional variations therein. 

Conflicts of Interest

None declared.

Funding

No external funding received.

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