Figure 105.

The sites of proximal reflux associated with the saphenopopliteal junction also constitute a frequent source of postoperative recurrence.

These sites can be suprafascial: Giacomini veins derived from the long saphenous vein. perineal veins, and branches of the lateral and anterior aspects of the thigh. The therapeutic management of these recurrences is easier when they have been previously identified by ultrasound mapping.

Associated proximal reflux can also be derived from perforating veins with a longitudinal, subfascial, and intramuscular course, related to the vena profunda femoris. These are much more difficult to treat, as surgical access to the vessels requires muscle dissection causing an unsightly and disabling scar. Their deep course also makes sclerosis of these vessels more difficult. However, they can be treated surgically with a guide introduced into the popliteal fossa (Figure 105) or, preferably, by ultrasound-guided catheterization or endoscopy.