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The Giacomini vein as an autologous conduit in infrainguinal arterial reconstruction

2004; Elsevier BV; Volume: 40; Issue: 3 Linguagem: Inglês

10.1016/j.jvs.2004.06.038

1097-6809

Konstantinos T. Delis, Mark Swan, Jeremy Crane, Nicholas Cheshire,

Coronary Interventions and Diagnostics

The standard conduit in infrainguinal arterial bypass grafting, the great saphenous vein, is often unavailable. Arm and small saphenous veins are used as alternative conduits; yet both are deficient in length to accommodate femorocrural bypasses as a single conduit. In light of its high prevalence, the Giacomini vein harvested in continuity with the small saphenous vein may offer the latter extra length, promoting their combination into a single conduit able to meet the needs of infrainguinal reconstruction, particularly in lengthy infrainguinal bypass grafting. The Giacomini vein merits consideration when arterial reconstruction is performed in proximity to its anatomic course. The standard conduit in infrainguinal arterial bypass grafting, the great saphenous vein, is often unavailable. Arm and small saphenous veins are used as alternative conduits; yet both are deficient in length to accommodate femorocrural bypasses as a single conduit. In light of its high prevalence, the Giacomini vein harvested in continuity with the small saphenous vein may offer the latter extra length, promoting their combination into a single conduit able to meet the needs of infrainguinal reconstruction, particularly in lengthy infrainguinal bypass grafting. The Giacomini vein merits consideration when arterial reconstruction is performed in proximity to its anatomic course. The type of conduit, run-off, and smoking are the major determinants of long-term patency in infrainguinal arterial bypass grafting.1Rutherford R.B. Jones D.N. Bergentz S.E. Berqgvist D. Comerota A.J. Dardik H et al.Factors affecting the patency of infrainguinal bypass.J Vasc Surg. 1988; 8: 236-246PubMed Scopus (188) Google Scholar, 2Myers K.A. Fuller J.A. Scott D.F. Devine T.J. Denton M.J. Chan A. Multivariate Cox regression analysis of covariates for patency rates after femorodistal vein bypass grafting.Ann Vasc Surg. 1993; 7: 262-269Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 3Gonzalez-Fajardo J.A. Vaquero C. Femorocrural bypass for limb salvage real indications and results.in: Branchereau A. Jacobs M. Critical limb ischaemia. Futura, Armonk (NY)1999: 165-182Google Scholar The great saphenous vein (GSV) is the vein conduit of choice,4TransAtlantic Inter-Society Consensus (TASC)Management of peripheral arterial disease.Eur J Vasc Endovasc Surg. 2000; 19: S97-200Google Scholar yet it may be unusable, previously stripped, or harvested. As autologous vein conduits in femorodistal bypass grafting for severe ischemia (>50% critical) offer cumulative primary patency (85%, 1 year; 80%, 3 years; 70%, 5 years) superior to prosthetic material (72%, 38%, 27%, respectively),4TransAtlantic Inter-Society Consensus (TASC)Management of peripheral arterial disease.Eur J Vasc Endovasc Surg. 2000; 19: S97-200Google Scholar their implementation is an ever increasing priority.4TransAtlantic Inter-Society Consensus (TASC)Management of peripheral arterial disease.Eur J Vasc Endovasc Surg. 2000; 19: S97-200Google Scholar The use of the small saphenous vein (SSV) in infrainguinal bypass grafting, reported initially by Weaver et al5Weaver F.A. Barlow C.R. Edward W.H. Mujlherin J.L. Jenkins J.M. The lesser saphenous vein: autogenous tissue for lower extremity revascularizarion.J Vasc Surg. 1987; 5: 687-692PubMed Scopus (37) Google Scholar and Shandall et al6Shandall A.A. Leather R.P. Corson J.D. Kupinski A.M. Shah D.M. The use of the short saphenous vein in situ for popliteal to distal artery bypass.Am J Surg. 1987; 154: 240-244Abstract Full Text PDF PubMed Scopus (22) Google Scholar, has since been followed by others,7Chang B.B. Party P.S.K. Shah D.M. Leather R.P. The lesser saphenous vein: an underappreciated source of autogenous vein.J Vasc Surg. 1992; 15: 152-157Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 8Calligaro K.D. Syrek J.R. Dougherty M.J. Rua I. Raviola C.A. DeLaurentis D.A. Use of arm and lesser saphenous vein compared with prosthetic grafts for infrapopliteal arterial bypass: are they worth the effort?.J Vasc Surg. 1997; 26: 919-927Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar to substantiate a primary patency similar to that of arm veins (Table I). Yet, its length limitation restricts SSV as a conduit to short bypasses if used alone, or as part of composite grafts. Coursing the posterior thigh as a large tributary or trunk projection of the SSV, the Giacomini vein may increase the effective length of the SSV as a bypass conduit, with wide-reaching vascular implications in light of Giacomini vein's occurrence reported in 56% to over 86% of limbs (Table II).9Giacomini C. Osservazioni anatomiche per servire allo studio della circolazione venosa delle estremita inferiori Parte I: Delle vene superficiali dell'arto addominale e principalmente della saphena esterna.Giornale della Reale Accademia di Medicina di Torino. 1873; 14: 109-215Google Scholar, 10Kosinski C. Observations on the superficial venous system of the lower extremity.J Anat. 1926; 60: 131-142PubMed Google Scholar, 11Moosman D.A. Hartwell S.W. The surgical significance of the subfascial course of the lesser saphenous vein.Surg Gyn Obst. 1964; 118: 761-766PubMed Google Scholar, 12Mercier R. Anatomie chirgicale de la veine saphene externe Consequences chirurgicale dans le traitement radical des varices du membre inferieur.J Chir (Paris). 1967; 93: 59-70PubMed Google Scholar, 13Stolic E. La veine sous-aponevrotique posterieure de la cuise.C R Ass Anat. 1970; 149: 1016-1026PubMed Google Scholar, 14Engel A.F. Davies G. Keeman J.N. von Dorp T.A. Colour flow imaging of the normal short saphenous vein.Eur J Vasc Surg. 1994; 8: 179-181Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 15Georgiev M. Myers K.A. Belcaro G. Giacomini's observations on the superficial veins of the abdominal limb and principally the external saphenous.Int Angiol. 2001; 20: 225-233PubMed Google Scholar, 16Caggiati A. Fascial relationships of the short saphenous vein.J Vasc Surg. 2001; 34: 241-246Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 17Georgiev M. Myers K.A. Belcaro G. The thigh extension of the lesser saphenous vein: from Giacomini's observations to ultrasound scan imaging.J Vasc Surg. 2003; 37: 558-563Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 18Delis KT. Perforating veins in chronic venous disease [thesis]. London: University of London, Imperial College; 2003.Google Scholar The Giacomini vein's applicability as a conduit in infrainguinal arterial reconstruction, in continuity with the SSV, is presented in this article.Table IIPrevalence of the Giacomini vein (thigh extension of the small saphenous vein), expressed as percentage amongst the total of investigated limbsAuthorYearJournalInvestigationGiacomini vein prevalence (%)Giacomini9Giacomini C. Osservazioni anatomiche per servire allo studio della circolazione venosa delle estremita inferiori Parte I: Delle vene superficiali dell'arto addominale e principalmente della saphena esterna.Giornale della Reale Accademia di Medicina di Torino. 1873; 14: 109-215Google Scholar1873G Realle Accad Med TorPostmortem86.3Kosinski10Kosinski C. Observations on the superficial venous system of the lower extremity.J Anat. 1926; 60: 131-142PubMed Google Scholar1926J AnatPostmortem82.2Moosman and Hartwell11Moosman D.A. Hartwell S.W. The surgical significance of the subfascial course of the lesser saphenous vein.Surg Gyn Obst. 1964; 118: 761-766PubMed Google Scholar1964Surg Gyn ObsPostmortem56Mercier12Mercier R. Anatomie chirgicale de la veine saphene externe Consequences chirurgicale dans le traitement radical des varices du membre inferieur.J Chir (Paris). 1967; 93: 59-70PubMed Google Scholar1967J Chir (Paris)Postmortem85Stolic13Stolic E. La veine sous-aponevrotique posterieure de la cuise.C R Ass Anat. 1970; 149: 1016-1026PubMed Google Scholar1968C R Ass AnatPostmortem95Engel et al14Engel A.F. Davies G. Keeman J.N. von Dorp T.A. Colour flow imaging of the normal short saphenous vein.Eur J Vasc Surg. 1994; 8: 179-181Abstract Full Text PDF PubMed Scopus (15) Google Scholar1994Eur J Vasc Endovasc SurgColor duplex63.2Georgiev et al15Georgiev M. Myers K.A. Belcaro G. Giacomini's observations on the superficial veins of the abdominal limb and principally the external saphenous.Int Angiol. 2001; 20: 225-233PubMed Google Scholar2001Int AngiolGiacomini's observations86.3*References reporting on the original data of Giacomini.9Caggiati16Caggiati A. Fascial relationships of the short saphenous vein.J Vasc Surg. 2001; 34: 241-246Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar2001J Vasc SurgPostmortem and duplex65Georgiev et al17Georgiev M. Myers K.A. Belcaro G. The thigh extension of the lesser saphenous vein: from Giacomini's observations to ultrasound scan imaging.J Vasc Surg. 2003; 37: 558-563Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar2003J Vasc SurgGiacomini's observations86.3*References reporting on the original data of Giacomini.9Delis18Delis KT. Perforating veins in chronic venous disease [thesis]. London: University of London, Imperial College; 2003.Google Scholar2004MS thesis, LondonColor duplex70.4* References reporting on the original data of Giacomini.9Giacomini C. Osservazioni anatomiche per servire allo studio della circolazione venosa delle estremita inferiori Parte I: Delle vene superficiali dell'arto addominale e principalmente della saphena esterna.Giornale della Reale Accademia di Medicina di Torino. 1873; 14: 109-215Google Scholar Open table in a new tab An otherwise fit and well 94-year-old Caucasian woman, with no previous significant medical history other than essential thrombocytosis, presented with a 10-day history of rest pain in her right foot, on a background of ipsilateral short distance claudication on 20-yards exertion over the preceding 6 months. She had no palpable pulses below the right common femoral artery, no associated bruits, and an ankle brachial pressure index of 0.4. A 2 × 1-cm dry superficial ulcer was present at the posterolateral heel. The right GSV was varicose through its course, yet this was not associated with other stigmata of chronic venous disease (CVD). Intra-arterial digital subtraction angiography (IADSA) revealed a severely atheromatous distal superficial femoral artery (SFA), popliteal artery obliteration, and a single-vessel run-off via the anterior tibial artery (ATA). An SFA-to-ATA bypass was required, with anastomoses at the middle of the thigh and the lower calf. Preoperative vein mapping with duplex confirmed varicose GSVs (bilaterally) unsuitable for grafting. The right SSV was competent, with a satisfactory diameter, yet deficient in length for the intended procedure. Before its termination at the popliteal fossa, however, it gave off a large tributary, a Giacomini vein, coursing the posterior thigh subfascially to the groin. This offered an effective extension of the SSV length by over 25 cm and featured a luminal diameter of 43 mm in the lower half of thigh, proving adequate as a bypass conduit. Under general anesthesia, with the patient supine, the SSV and Giacomini veins were harvested in continuity from the ankle to mid thigh, thus providing a 50-cm-long conduit. The saphenopopliteal junction was flush ligated (Fig 1, A). With the SFA medially exposed at midthigh, an end-to-end anastomosis between the SFA and distal SSV end was fashioned with 6/0-prolene after heparin infusion (5000 IU). The reversed graft was tunneled to the popliteal fossa and through the interosseous membrane into the anterior compartment, enabling an end-to-side anastomosis between the Giacomini-graft end and the ATA at the lower calf (7/0-prolene). Pulse was palpated at the dorsalis pedis artery on limb perfusion, and triphasic flow signals were obtained on handheld Doppler evaluation of the ATA distal to the graft. The patient was extubated within 12 hours, while on heparin. On day 3 she developed left basal pneumonia and supraventricular tachycardia, without compromising her blood pressure. By day 6 the patient was making a good recovery. On day 4, warfarin was started, replaced by clopidogrel (75 mg/d)on week 4. Graft surveillance on day 12 was unremarkable, remaining so until the patient's eventual demise from gastrointestinal bleeding, over a year later. A 73-year-old gentleman was admitted for a right total knee replacement for osteoarthritis and on preoperative assessment was found to have an asymptomatic popliteal artery aneurysm ipsilaterally. He was otherwise well, with an unremarkable medical history and no concomitant aneurysmal disease. He had a full complement of pulses, a prominent right popliteal pulse, without evidence of distal embolization.Duplex imaging revealed a tortuous 3-cm popliteal aneurysm. On IADSA the distal popliteal artery, the trifurcation, and 3 run-off vessels were intact. The contralateral popliteal was unaffected. Elective aneurysm repair was performed using a reversed 10-cm-long vein conduit, composed of the distal Giacomini and proximal SSV, through a posterior exposure with a typical S-shaped incision crossing the knee skin crease. The vein was harvested via the same incision of popliteal exposure, with the patient prone (Fig 1, B). Flow control and longitudinal incision of the aneurysm were followed by interposition of the conduit reversed (6/0 prolene), with the sac finally wrapped over the graft (3/0 vicryl).Upon reperfusion pedal pulses returned and triphasic signals were obtained from the popliteal artery below the graft on handheld Doppler. The patient had an unremarkable recovery and was discharged on day 7. Graft surveillance before discharge and at 6 weeks was unremarkable, remaining so to date. Dissection studies conducted over the past 1.5 centuries reported a Giacomini vein, a thigh extension of the SSV, in 2 thirds (or more) of limbs,9Giacomini C. Osservazioni anatomiche per servire allo studio della circolazione venosa delle estremita inferiori Parte I: Delle vene superficiali dell'arto addominale e principalmente della saphena esterna.Giornale della Reale Accademia di Medicina di Torino. 1873; 14: 109-215Google Scholar, 10Kosinski C. Observations on the superficial venous system of the lower extremity.J Anat. 1926; 60: 131-142PubMed Google Scholar, 12Mercier R. Anatomie chirgicale de la veine saphene externe Consequences chirurgicale dans le traitement radical des varices du membre inferieur.J Chir (Paris). 1967; 93: 59-70PubMed Google Scholar, 13Stolic E. La veine sous-aponevrotique posterieure de la cuise.C R Ass Anat. 1970; 149: 1016-1026PubMed Google Scholar, 15Georgiev M. Myers K.A. Belcaro G. Giacomini's observations on the superficial veins of the abdominal limb and principally the external saphenous.Int Angiol. 2001; 20: 225-233PubMed Google Scholar, 17Georgiev M. Myers K.A. Belcaro G. The thigh extension of the lesser saphenous vein: from Giacomini's observations to ultrasound scan imaging.J Vasc Surg. 2003; 37: 558-563Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar an occurrence confirmed in the last decade on duplex imaging.14Engel A.F. Davies G. Keeman J.N. von Dorp T.A. Colour flow imaging of the normal short saphenous vein.Eur J Vasc Surg. 1994; 8: 179-181Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 16Caggiati A. Fascial relationships of the short saphenous vein.J Vasc Surg. 2001; 34: 241-246Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 18Delis KT. Perforating veins in chronic venous disease [thesis]. London: University of London, Imperial College; 2003.Google Scholar Despite our knowledge on its anatomic variants, the functional condition, length, and diameter of the Giacomini vein were unexplored until recently. The Giacomini vein is 10 times less susceptible to valvular incompetence than the GSV and SSV trunks together (P < .01)18Delis KT. Perforating veins in chronic venous disease [thesis]. London: University of London, Imperial College; 2003.Google Scholar; its presence does not affect the distribution and the extent of venous reflux, and its prevalence is even across the CVD spectrum. In 16% of limbs the SSV trunk itself continues in the thigh as a Giacomini vein, whereas in 51% the Giacomini vein is a large tributary of the SSV, the latter terminating at the popliteal fossa.18Delis KT. Perforating veins in chronic venous disease [thesis]. London: University of London, Imperial College; 2003.Google Scholar A third of limbs (31%) feature a Giacomini vein extending to the top of the thigh, and in an additional third (34%) it extends to the middle of thigh.18Delis KT. Perforating veins in chronic venous disease [thesis]. London: University of London, Imperial College; 2003.Google ScholarWith a luminal diameter as large as 7.7 mm in the lower thigh (interquartile range, 1.83-4.3 mm), the Giacomini vein, although smaller on average than the saphenous veins,5Weaver F.A. Barlow C.R. Edward W.H. Mujlherin J.L. Jenkins J.M. The lesser saphenous vein: autogenous tissue for lower extremity revascularizarion.J Vasc Surg. 1987; 5: 687-692PubMed Scopus (37) Google Scholar, 6Shandall A.A. Leather R.P. Corson J.D. Kupinski A.M. Shah D.M. The use of the short saphenous vein in situ for popliteal to distal artery bypass.Am J Surg. 1987; 154: 240-244Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 8Calligaro K.D. Syrek J.R. Dougherty M.J. Rua I. Raviola C.A. DeLaurentis D.A. Use of arm and lesser saphenous vein compared with prosthetic grafts for infrapopliteal arterial bypass: are they worth the effort?.J Vasc Surg. 1997; 26: 919-927Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 18Delis KT. Perforating veins in chronic venous disease [thesis]. London: University of London, Imperial College; 2003.Google Scholar may be an alternative vein conduit. In the first case, the Giacomini vein (Fig 2, A) harvested in continuity with the SSV enabled SFA-to-ATA bypass grafting using a single conduit, made thus sufficiently long, in the absence of a GSV. In the second case the Giacomini vein (Fig 2, B), harvested in continuity with the most proximal SSV through the S-shaped incision of the posterior popliteal artery exposure, enabled aneurysm repair. Preoperative duplex scanning determined the presence of a Giacomini vein along with its length, diameter, and valvular quality. In both cases the vein was competent, measured 4 to 5 mm in diameter in the lower half of thigh, and was well over 20 cm in length. The slightly smaller Giacomini vein caliber, compared to the SSV, optimized the geometrical compatibility of the inverted graft with the anastomotic sites. In the second case the Giacomini vein was used because of its anatomic relationship with the popliteal aneurysm for repair, lying alongside the S-shaped incision, although alternative autologous conduits could have been used to spare the ipsilateral GSV. In the first case, the varicose GSV degeneration rendered the SSV/Giacomini conduit a sound option in our 95-year-old patient with critical ischemia. Arm veins could have been used at the cost of a composite conduit, a more demanding harvest, and the associated upper extremity morbidity. Infrainguinal bypass grafts using the SSV as a conduit (Table I) have a 55% to 60% cumulative 3-year patency,5Weaver F.A. Barlow C.R. Edward W.H. Mujlherin J.L. Jenkins J.M. The lesser saphenous vein: autogenous tissue for lower extremity revascularizarion.J Vasc Surg. 1987; 5: 687-692PubMed Scopus (37) Google Scholar, 6Shandall A.A. Leather R.P. Corson J.D. Kupinski A.M. Shah D.M. The use of the short saphenous vein in situ for popliteal to distal artery bypass.Am J Surg. 1987; 154: 240-244Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 7Chang B.B. Party P.S.K. Shah D.M. Leather R.P. The lesser saphenous vein: an underappreciated source of autogenous vein.J Vasc Surg. 1992; 15: 152-157Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar nearing that of the GSV.4TransAtlantic Inter-Society Consensus (TASC)Management of peripheral arterial disease.Eur J Vasc Endovasc Surg. 2000; 19: S97-200Google Scholar The lower assisted patency of 23.5%, reported in a single study, was still similar to that of grafts using arm vein.8Calligaro K.D. Syrek J.R. Dougherty M.J. Rua I. Raviola C.A. DeLaurentis D.A. Use of arm and lesser saphenous vein compared with prosthetic grafts for infrapopliteal arterial bypass: are they worth the effort?.J Vasc Surg. 1997; 26: 919-927Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar The additional length that the Giacomini vein provides to the SSV permits a significant conduit extension, with the synergy of the 2 veins meeting the needs of infrainguinal reconstruction, particularly when lengthy as in femorocrural bypass grafting. The procedure may thus be performed without resort to composite conduits, eliminating the potential of veno-anastomotic stenoses.4TransAtlantic Inter-Society Consensus (TASC)Management of peripheral arterial disease.Eur J Vasc Endovasc Surg. 2000; 19: S97-200Google ScholarTable ITabulated literature review on the use of the small saphenous vein (SSV) as a conduit in infrainguinal bypass grafting and the reported patencyAuthorsYearLimbsSSV graftsAnastomoses% failures (within 30 days) (n)Cumulative patency (%)ProximalDistal1 year2 years3 yearsWeaver et al5Weaver F.A. Barlow C.R. Edward W.H. Mujlherin J.L. Jenkins J.M. The lesser saphenous vein: autogenous tissue for lower extremity revascularizarion.J Vasc Surg. 1987; 5: 687-692PubMed Scopus (37) Google Scholar198729SSV onlyFemoralPopliteal, peroneal, tibial072606014SSV + autologous veinsFemoral Existing graftPeroneal, tibial Peroneal, tibial21.4 (2/14)47383813SSV + PTFEFemoral Existing graftPopliteal, peroneal, tibial Peroneal, tibial35.7 (5/13)3221-Shandall et al6Shandall A.A. Leather R.P. Corson J.D. Kupinski A.M. Shah D.M. The use of the short saphenous vein in situ for popliteal to distal artery bypass.Am J Surg. 1987; 154: 240-244Abstract Full Text PDF PubMed Scopus (22) Google Scholar19875SSV in situInfrapoplitealTibial20 (1/5)nanana31Free vein graftN/AN/AN/AN/AN/AN/AChang et al7Chang B.B. Party P.S.K. Shah D.M. Leather R.P. The lesser saphenous vein: an underappreciated source of autogenous vein.J Vasc Surg. 1992; 15: 152-157Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar199210 30SSV in situ Excised vein bypassPopliteal Popliteal/femoralTibial Tibial, popliteal0 (0/10)77.177.155.15Composite SSVExisting PTFE graftPopliteal10.2 (6/59)24Composite SSVFemoral/poplitealDorsalis pedis, tibialCalligaro et al8Calligaro K.D. Syrek J.R. Dougherty M.J. Rua I. Raviola C.A. DeLaurentis D.A. Use of arm and lesser saphenous vein compared with prosthetic grafts for infrapopliteal arterial bypass: are they worth the effort?.J Vasc Surg. 1997; 26: 919-927Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar199717SSV onlyInfrapoplitealCrural, dorsalis pedis0na23.5naSSV, Small saphenous vein; PTFE, polytetrafluoroethylene; na, not available; N/A, not applicable. Open table in a new tab SSV, Small saphenous vein; PTFE, polytetrafluoroethylene; na, not available; N/A, not applicable. In light of its anatomic and functional features that may meet the needs of arterial bypass surgery, particularly in continuity with the SSV, as exemplified in the reported cases,9Giacomini C. Osservazioni anatomiche per servire allo studio della circolazione venosa delle estremita inferiori Parte I: Delle vene superficiali dell'arto addominale e principalmente della saphena esterna.Giornale della Reale Accademia di Medicina di Torino. 1873; 14: 109-215Google Scholar, 10Kosinski C. Observations on the superficial venous system of the lower extremity.J Anat. 1926; 60: 131-142PubMed Google Scholar, 11Moosman D.A. Hartwell S.W. The surgical significance of the subfascial course of the lesser saphenous vein.Surg Gyn Obst. 1964; 118: 761-766PubMed Google Scholar, 12Mercier R. Anatomie chirgicale de la veine saphene externe Consequences chirurgicale dans le traitement radical des varices du membre inferieur.J Chir (Paris). 1967; 93: 59-70PubMed Google Scholar, 13Stolic E. La veine sous-aponevrotique posterieure de la cuise.C R Ass Anat. 1970; 149: 1016-1026PubMed Google Scholar, 14Engel A.F. Davies G. Keeman J.N. von Dorp T.A. Colour flow imaging of the normal short saphenous vein.Eur J Vasc Surg. 1994; 8: 179-181Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 15Georgiev M. Myers K.A. Belcaro G. Giacomini's observations on the superficial veins of the abdominal limb and principally the external saphenous.Int Angiol. 2001; 20: 225-233PubMed Google Scholar, 16Caggiati A. Fascial relationships of the short saphenous vein.J Vasc Surg. 2001; 34: 241-246Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 17Georgiev M. Myers K.A. Belcaro G. The thigh extension of the lesser saphenous vein: from Giacomini's observations to ultrasound scan imaging.J Vasc Surg. 2003; 37: 558-563Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 18Delis KT. Perforating veins in chronic venous disease [thesis]. London: University of London, Imperial College; 2003.Google Scholar the prevalent Giacomini vein is worth considering in infrainguinal reconstruction when the GSV is unavailable. Use of the Giacomini vein may offer technical merits when arterial reconstruction is considered in proximity to its anatomic course.