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Letters to the Editor |
Department of Radiology, University of Ottawa, Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, Canada K1J 7V6. e-mail: ihammond@ottawahospital.on.ca
Editor:
I wish to remind the readership of Radiology that with the exception of vascular surgeons and radiologists, many physicians, possibly the majority of primary care physicians, are unaware that the superficial femoral vein is actually a deep vein (1). This ambiguity may result in patients with thrombosis of this vein being denied anticoagulant therapy because the referring physician mistakenly assumes that the thrombus is in a superficial vein (2). After encountering such a situation myself several years ago, I abandoned the name superficial femoral vein in favor of femoral vein, which is used by anatomists (3–5). I also advise our residents to do the same, but many seem to ignore my plea.
Vascular surgeons define the superficial femoral vein as being the continuation of the popliteal vein, and the common femoral vein as being formed by the confluence of the superficial femoral and the deep femoral veins (6), while acknowledging that these are not absolutely accurate anatomic terms (7). In the interest of patient safety, I move that "superficial femoral vein" be banished from radiology reports and replaced with "femoral vein." Will someone kindly second the motion?
REFERENCES
Department of Radiology, Duke University Medical Center, Room 1502, Durham, NC 27710. e-mail: smith146@mc.duke.edu
I read with keen interest the letter from Dr Hammond, who moves that "superficial femoral vein" be banished from radiology reports and replaced with "femoral vein." Dr Hammond is certainly not the first to have concerns regarding the nomenclature of the superficial femoral vein. Bundens et al (1) published the results of a survey of anatomy department chairpersons, multispeciality groups, and vascular laboratory directors in 1995. The survey was meant to assess the potential for errors in interpretation of venous sonography reports in which the term superficial femoral vein is used. Their survey revealed that fewer than 10% of anatomists teach the term to medical students, and only 3% believe it is correct, while 93% of vascular laboratory staff use the term superficial femoral vein in their reports.
Most important, only 24% of the respondents from multispeciality groups would have administered anticoagulants for treatment of a patient described as having leg pain and acute thrombosis of the superficial femoral vein. The results of this survey sparked numerous letters regarding whether the term indeed posed potential hazard to a patient who did not receive anticoagulant therapy for deep venous thrombosis on the basis of the belief that the superficial femoral vein is a superficial rather than a deep venous structure (2–4). To that end, an International Interdisciplinary Consensus Committee on Venous Anatomical Terminology convened on September 8–9, 2001, and concluded that the term superficial femoral vein should not be used (5).
How did we get into this mess in the first place? It is certainly not from anatomists, as Dr Hammond observes. The initial reference to the superficial femoral vein was made in 1941 by Homans (6), who discussed surgical exploration of the confluence of the femoral veins in the groin. Although one can only speculate why he chose this term, most likely it was to match the accompanying superficial femoral artery. Interestingly, although the latter has been used for more than a century, it is also not recognized as a legitimate anatomic term (7).
Why, then, is no one concerned with the term superficial femoral artery? Probably because abnormalities of the superficial femoral artery are most often treated by specialists who are very familiar with the terminology and do not for a moment believe that the superficial femoral artery lies just beneath the subcutaneous tissues. Alternatively, venous thrombosis is treated by a wide variety of clinicians, many of whom are unfamiliar with the specific venous anatomic terminology, as noted in the survey of Bundens et al (1).
Finally, regardless of the vessel name, it is the duty of the radiologist to state clearly within the imaging report that the patient has deep venous thrombosis. Although some would like things to stay as they are or even believe that new terms should be invented, I agree that it is less confusing and, more important, safer if we avoid using the term superficial femoral vein and instead use the more anatomically accepted term femoral vein. Yes, Dr Hammond, I second your motion.
REFERENCES
Department of Radiology, Jefferson Medical College, Thomas Jefferson University, 111 South 11th Street, Suite 4200, Gibbon, Philadelphia, PA 19107. e-mail: joseph.bonn@jefferson.edu
In his enthusiastic letter, Dr Hammond raises the topic of misleading medical nomenclature that in recent years has been more in the realm of the pharmaceutical industry, which contends with homonymous trade names for drugs, than in the relatively sedate world of anatomic terminology. His concerns have not been expressed in vain, however, for perhaps unbeknownst to him, they were addressed in a formal manner less than a year ago in a report by the International Interdisciplinary Consensus Committee on Venous Anatomical Terminology, which was published in the August 2002 issue of the Journal of Vascular Surgery (1).
Under the auspices of the Fourteenth World Congress of the International Union of Phlebology in September 2001, members of a precongress meeting gathered to update the official anatomic terminology of the lower extremity venous system and to address four problems identified in clinical use and in publications. These problems included (a) a deficiency in the nomenclature of the veins of the lower limbs, which has been clarified by recent advances in knowledge of their physiology and pathophysiology (many the result of ultrasonographic discoveries), (b) the introduction and use of names of veins not present in the existing official anatomic document, the Terminologica Anatomica, (c) incorrect interpretation of these names, which leads to confusion and inappropriate treatment of venous disease (the source of Dr Hammond’s concern in his letter), and (d) inadequate listing, specifically of perforating veins, saphenous vein collateral vessels, tributary veins, and some of the deep veins.
The faculty of this meeting set out to modify the official venous terminology to satisfy not only anatomists but clinicians as well, and to "avoid any confusion for the clinical practitioner" (1). Their efforts were conducted under the watchful eye of a remarkably comprehensive gathering of venous anatomic specialists, who represented the International Union of Phlebology, the International Federation of Associations of Anatomists, and the Federative International Committee on Anatomical Terminology. In addition, input was solicited prior to the meeting from 20 other experts who could not attend.
As a testimony to its international representation, the committee’s reach extended beyond simply the correction of misleading terminology and its usage but to the globalization of medicine, such as when they concluded, "Such a common language is important for investigation of the venous system and for accurate diagnosis and correct treatment of venous disorders. Universally accepted new terminology will facilitate effective international exchange of information" (1).
In their report, the consensus committee addressed the entirety of the superficial and deep venous terminology of the lower extremities in encyclopedic detail, and they did not shy from confronting misleading terminology and setting it straight. More specifically, in anticipation of Dr Hammond’s issue, they officially established "femoral vein" as the vein that originates from the popliteal vein and courses in the femoral canal and bluntly discarded "superficial femoral vein" as an "unauthorized term ... because it is a deep vein and is not in the official Terminologica Anatomica" (1). To clarify this further, as does Dr Hammond, they noted that the correct term for the other major vein in the thigh is the "profunda femoris vein, or deep femoral vein," rather than "deep vein of thigh," which they labeled "non-specific and misleading" (1).
While we are clearing the fog of venous terminology, we should also note that among the many clarifications offered in their report was an important revision of the nomenclature of the superficial veins of the lower extremity, specifically the saphenous venous system. While addressing confusion over whether "LSV" refers to the "long saphenous vein" or the very different "lesser saphenous vein," the committee stated that adoption of the terms great saphenous vein, or GSV, and small saphenous vein, or SSV, should restore order from anatomic anarchy.
Dr Hammond’s letter provides us with the opportunity to illuminate the work of this consensus committee and reminds us of the value of a common language in medicine, especially when accurate communication can have far-reaching and critical implications. Knowledge may be power, but the everyday habits of experienced clinicians may be more powerful still; undoing the ingrained language of a culture takes time, repetition, and the dedicated efforts of those in positions of influence, such as journal editors, medical school professors, and academic clinicians on the front lines of graduate medical education.
Radiologists, who are some of the most prolific everyday users of medical terminology, should readily adopt the terms femoral vein, deep femoral vein, great saphenous vein, and small saphenous vein, and in their best evangelical mode, they should take the lead role in spreading the word, so to speak.
REFERENCES
Department of Radiology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210-2399. e-mail: cardellj@mailbox.hscsyr.edu
As chairman of the Society of Interventional Radiology Standards of Practice Committee, I have reviewed the responses to Dr Hammond’s letter to the editor submitted by Drs Smith and Bonn. I agree with their comments and in particular agree that the term superficial femoral vein should not be used because (a) it is not acknowledged by anatomists, and (b) it likely will result in some patients not receiving anticoagulant or thrombolytic therapy from providers who mistakenly believe it is not part of the deep venous system of the lower extremity.
The Society of Interventional Radiology appreciates the opportunity to respond to this letter to the editor and endorses the comments submitted by Drs Smith and Bonn.
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