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Chapter
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1
Anatomy
• Type D: The GSV is not visible for a certain distance
from the distal thigh down below the knee, but
pierces the superficial fascia to become a
subcutaneous CV that distally, usually at the mid-leg,
enters again into the saphenous compartment. This
arrangement corresponds to the ‘S’ type in Figure 1.23
and was found in 14% = 72/500 of cases. In 58% of
these the GSV and the CV were incompetent and the
latter visible (Fig. 1.29D).
• Type E: Same as the previous but the absent portion
of the GSV was very short and, from just below the
knee down along the leg; 14% = 72/500. In 53% of
these the GSV was incompetent and with varicose
collaterals just distal to the knee (Fig. 1.29E).
In 3% of cases (15/500) the classification according to the
criteria described above was not possible.
These data show that in one-third of subjects the middle
portion of the GSV is absent (or hypoplastic) for a variable
length (types D and E). In subjects with this pattern, varicose
veins were present in 56% of cases, while in subjects where
the GSV is present in its entire length (types A, B and C) varicose veins were present in 34% of cases. This may indicate that
the subcutaneous vein which assumes the role of a saphenous
vein becomes more readily varicose, probably because it is not
protected by the superficial fascia. In such cases the anatomical pattern classified as types D and E might be a predisposing
factor for varicose veins.
42
41% both GSV and AASV were present. In these cases the
AASV was invariably thinner than the GSV (average 2.4 vs
4.0 mm). Proximally, the ASV joined the GSV close to the SFJ
and only rarely (in 3% of cases) terminated directly into the
femoral vein. Following the vein backwards, the AASV pierced
the superficial fascia and exited the saphenous compartment
at a distance of 7–30 cm (average 16 cm), continuing distally
as a subcutaneous collateral in an anterolateral direction in
72% of cases, in a medial or anterior direction in 11%, and
as more branches and in more directions in 11%. In 6% of
cases the AASV joined the GSV without leaving the saphenous
compartment (Fig. 1.31).
38
In the remaining 11% of the 172 observed limbs only one
vein was observed in the proximal part of the saphenous
compartment, but according to the ‘alignment’ sign this vein
was the AASV, while there was no GSV in the expected position
(saphenous aplasia) (Fig. 1.19C)
distally from the SFJ the AASV curved medially and continued
downwards along the typical course of the GSV.
. In these cases, 18–20 cm
38
The AASV is of clinical importance because in patients with
varicose veins it may be the only proximal reflux source while
the GSV remains competent
3,46
(Fig. 1.32), or alternatively,
both GSV and ASV may be incompetent. In a retrospective
study of 1450 varicose limbs the AASV was involved in 14%
(203/1450) of cases (M. Cappelli, personal communication,
2000). The possible patterns of GSV and/or AASV incompetence at the SFJ are described elsewhere.
33
T vein
A very constant tributary vein (known as the T vein), has been
described.
leg just distal to the knee and joins the GSV at the same level
in a right-angle fashion (see Fig. 1.7), running inside the
fascial compartment for a long distance (Fig. 1.30). It is consistently fed by reflux varicose veins, which are clinically
visible in the paratibial region and/or in the lateral aspect of
the leg.
48
It runs horizontally from the lateral aspect of the
The anterior accessory saphenous vein
When two veins are present in the proximal third of the great
saphenous compartment, the medially situated vein is the
GSV while the laterally placed vein is the AASV.
AASV is recognized and distinguished from the GSV by
the ‘alignment’ sign
own ‘eye’ (see Fig. 1.19B).
37
(see Fig. 1.19A), and may also have its
3
The anatomy of the AASV was studied by transverse DUS
of the saphenous compartment of the thigh in 172 consecutive limbs. In 48% of cases only the GSV was present while in
“T” Vein
33,38–41
The
Small Saphenous Vein
The SSV begins behind the lateral malleolus as a continuation
of the lateral marginal foot vein. It ascends up the posterior
aspect of the calf to empty into the popliteal vein. The SSV lies
for its entire length in an intrafascial compartment delimited
deeply by the aponeurotic (muscular) fascia and superficially
by the superficial fascia. The distal part of this compartment
appears on transverse scan, especially in fat legs, as an ‘eye’
similar to that of the GSV in the thigh. The proximal part of
the compartment is typically of a triangular shape and is
delimited by the medial and lateral heads of the gastrocnemius muscle and the superficial fascia that stretches over the
Figure 1.30 A vein can be seen running horizontally from the lateral
aspect of the leg just distal to the knee and joining the great saphenous
vein (GSV) at the same level in a right-angle fashion. What is peculiar is that
it runs inside the fascial compartment for a long tract.
The
‘T’ vein of the leg. EJVES 2003;25:313–18.)
14
GSV
(From Zamboni P et al:
A
Figure 1.31 Anterior accessory saphenous vein (AASV) patterns: Following
the vein backwards, the AASV pierces the superficial fascia of the
saphenous compartment at a distance of 7–30 cm. It continues distally as
subcutaneous collateral in an anterolateral direction in 72% of cases (A); in a
medial or anterior direction in 11%, and as more branches and in more
directions in 11% (B). In 6% of cases the AASV joins the GSV without leaving
the saphenous compartment (C).
la veine saph
Phl
ène accessoire antérieure et de son role dans la maladie variqueuse.
ébologie 57:135–140, 2004).
B C
(From Ricci S, Georgiev M, Cappelli M: Définition de
SE
60
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SI
TV
AASV
SP
PTV
PASV
Figure 1.32 The anterior accessory saphenous vein (AASV) may be the
only proximal reflux source while the great saphenous vein is competent: in
these cases the terminal valve (TV) is incompetent while the preterminal
valve (PTV) is normally competent. PASV, posterior accessory saphenous
vein; SE, superficial epigastric vein; SI, superficial iliac vein; SP, superficial
pudendal vein.
(Original sketch courtesy of A Pieri)
SSV
3129
16 13 12 19
Figure 1.34 In about 50% of normal subjects the small saphenous vein has
no popliteal junction at all or is just a tiny communicating vessel (right), the
classical junction (the first on the left) being not the most frequent.
der Stricht J. La petite veine saph
GSV
ène existe-t-elle, Phlébologie 3:309–15, 2001).
(From Van
Small Saphenous Vein
GCV
PV
PA
Figure 1.33 In 26% of cases the small saphenous vein merges with the
gastrocnemius vein before joining the popliteal vein.
3,36
intermuscular groove (Figs 1.12B, 1.21).
The SSV may occasionally be duplicated, with two (or even three) veins of
various lengths running into the saphenous compartment.
Saphenopopliteal junction
The saphenopopliteal junction (SPJ) is situated, typically,
within 5 cm proximal to the popliteal crease. In some cases
the SSV merges with the gastrocnemius vein before joining the
popliteal vein (Fig. 1.33). This has been found in 26% of cases
in a series of 83 consecutive limbs with incompetent and
dilated SSV.
may join the popliteal vein at different sites on its circumference. In the above-mentioned series the SPJ was lateral in
42%, posteromedial in 30%, posterior in 15%, posterolateral
in 12% and even anterolateral in 1% of cases.
in normal subjects it has been observed that in about 50% of
cases the SSV has no popliteal junction at all (see next paragraph), or is just a tiny vessel (Fig. 1.34).
SSV may be hypoplasic or absent.
49
Another point of surgical interest is that the SSV
49
Astonishingly,
50
In some cases, the
Giac
TE
Figure 1.35 Proximally the thigh extension may join the great saphenous
vein as intersaphenous thigh anastomosis (the ‘true’ Giacomini vein);
continue straight up into the gluteal area as a single vein or be divided into
many deep and superficial branches; join the deep femoral veins as a
posterior or posterolateral thigh perforator; or divide into many muscular or
subcutaneous branches of the posterior thigh.
Bourgery, Anatomie descriptive. In Delaunay CA, editor, [no title available] Paris, 1835.
Courtesy M. Georgiev, MD)
Musc
Perf
SPJ
(From a design taken from
Thigh extension of the SSV
In 1873 Giacomini described in detail the thigh extension
(TE) of the SSV (Fig. 1.35).
confirmed that the SSV extends into the thigh in about 50%
of cases; in a third of these the SSV joins the popliteal vein
(Fig. 1.36A) and then continues up into the thigh, while in the
remaining two-thirds of cases the SSV continues into the thigh
without any connection with the popliteal vein53 (Figs 1.34,
1.36B). The anatomy of the TE of the SSV (also known as vein
of Giacomini or femoropopliteal vein) has been confirmed by
USI. The distal portion of the TE is recognized on DUS by its
intrafascial position into a triangle-shaped compartment that
resembles the GSV compartment and is delimited by the semi-
51,52
Further anatomical dissections
15
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1
Anatomy
TE
SSV
SSV
TE
PV
A
Figure 1.36 Ultrasound imaging aspects of small saphenous vein (SSV)–popliteal arrangement. A, The SSV extends into the thigh in about 50% of cases; in
one-third of these the SSV joins the popliteal vein and then continues up into the thigh (B), while in the remaining two-thirds of cases the SSV continues
into the thigh without any connection with the popliteal vein (PV) (TE, thigh extension).
A
Figure 1.37 The thigh extension may transmit reflux from the incompetent
saphenopopliteal junction up to the great saphenous vein and/or varicose
veins of the thigh (A), or vice versa, from the incompetent saphenofemoral
junction and/or groin, to the small saphenous vein (SSV) (B).
B
B
L
SPJ
A
M
PV
FP
G
P
S
PA
PP
PA
M
GV
tendinous muscle (medially), the long head of the biceps
muscle (laterally) and the superficial fascia that stretches over
the intermuscular groove (see Figs 1.9, 1.16, 1.21A). Proximally, the TE may join the GSV at various distance from the
SFJ as intersaphenous thigh anastomosis (the ‘true’ Giacomini
vein); continue straight up into the gluteal area as a single vein
or be divided into many deep and superficial branches; join
the deep femoral veins as a posterior or posterolateral thigh
perforator; or divide into many muscular or subcutaneous
branches of the posterior thigh. In many cases the proximal
ending of the TE is a combination of the above-mentioned
terminations. The possible variants of proximal termination
of the TE are presented in Figure 1.35. The TE may transmit
reflux from the incompetent SFJ and/or groin, gluteal and
thigh perforators and/or collaterals to the SSV, or, vice versa,
from the incompetent SPJ up to the GSV and/or varicose veins
of the posterior thigh (Fig. 1.37A, B).
3,33
Arrangement of the SSV and its collaterals
As with the GSV the subcutaneous collaterals of the SSV/TE
are recognized because they pierce the superficial fascia to
enter the saphenous compartment. One particular superficial
collateral of the SSV deserves separate description. It is the
so-called ‘popliteal area vein’ and was described by Dodd.54
This vein runs subcutaneously along the posterior aspect of
16
Figure 1.38 The so-called ‘popliteal area vein’ runs subcutaneously along
the posterior aspect of popliteal area, calf and leg, sometimes parallel to the
small saphenous vein, and typically has a separate junction with the popliteal
vein, usually lateral to the saphenopopliteal junction (SPJ).
S, Georgiev M, Goldman MP: Anatomical bases of ambulatory phlebectomy. In: Goldman
MP, Georgiev M, Ricci S, Ambulatory phlebectomy, Boca Raton, 2005, Taylor
(Adapted from Ricci
& Francis)
popliteal area, calf and leg, sometimes parallel to the SSV, and
typically has a separate junction with the popliteal vein,
usually lateral to the SPJ (Fig. 1.38).
3,55
Foot Veins
The arrangement of the superficial veins in two layers separated by the superficial fascia is also present in the foot and
collat.V
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fascia
V.Marg
Figure 1.39 The dorsal venous arch and the medial and lateral marginal
veins – V. Marg – (anatomic origin of the great and small saphenous veins)
are similarly placed under the superficial fascia while the tributaries run
more superficially – collat. V.
collat.V
Arch Vein
MI:1.3
2DG
Figure 1.41 Perforating veins connect the superficial veins to the deep
veins; they ‘perforate’ the aponeurotic fascia, giving them their name. The
fascial point of perforation is always visible with ultrasound. Also, valves are
visible, usually at the level of the fascial hole (arrow).
9.8
0
9.8
cm/s
11L5
T8.4
CF 4.4
21 fps
1
2
2DG
PRF
16.5K
Filter
90
DR
75
CG
50
3
90
DR
75
Foot Veins
Figure 1.40 The collateral veins on dorsum of foot are the continuation of
the subcutaneous collaterals of the leg and are also subcutaneous,
overcoming the deeper arch vein.
can be demonstrated by DUS. The dorsal venous arch and the
medial and lateral marginal veins are the anatomical origin of
the great and small saphenous veins, respectively, and are
similarly placed under the superficial fascia (Fig. 1.39). The
collateral veins on the dorsum of the foot are the continuation of the subcutaneous collaterals of the leg and are also
subcutaneous (Fig. 1.40).
56
Perforating veins
Perforating veins were first described in 1803 by Van Loder.
They occur from the ankle to the groin, connecting the
superficial veins to the deep veins; they ‘perforate’ the aponeurotic fascia, giving them their name. The fascial point of perforation is always visible with USI (Fig. 1.41).
The average number of perforating veins per leg has been
found to be as great as 155
59
or as few as 64.60 They are not
distributed regularly along the limb’s surface but increase in
density from proximal to distal in a 1 : 2 : 8 proportion between
the thigh, the leg, and the foot.
61
Sixty percent of perforating veins, always the ones that are
more important and named, are accompanied by an artery
(Fig. 1.42)
; and usually contain one to three one-way valves,
depending on their length (see Fig. 1.41). These one-way
valves can be thought of as check valves, which serve to
prevent high venous pressure (from muscle contraction) from
being transmitted to the superficial veins. Normally, perforat-
57,58
59
Figure 1.42 Perforators are usually accompanied by an artery easily visible
by duplex and color ultrasound.
0
2
11L5
4
T8.4
28 fps
Figure 1.43 The ‘S’ shape of normal perforators is a mechanism helping to
achieve competence.
ing veins are thin walled, varying in diameter from less than
1 mm to 2 mm.62 They may also be valveless, especially when
less than 1 mm in diameter.63 In such cases, their competence
is maintained by their oblique orientation through muscle, or
by the ‘S’ shape that they display (Fig. 1.43).
With muscular contraction, the deep fascia is tightened and
the S curves are compressed. This puts the perforator veins
under tension, closes the vein and prevents blood from escaping from the deep veins of the calf muscle pump into the
2DG
90
DR
75
17
Chapter
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1
Anatomy
18
Table 1.2 Distribution of incompetent perforator veins on 901
lower limbs
Percentage of Limbs with
Incompetent Veins
Perforator Veins Right Limbs Left Limbs
Saphenofemoral junction 100.00 100.00
Saphenopopliteal junction 15.0 15.5
Mid-Hunterian perforator 7.0 6.7
Genicular perforator 2.9 1.6
Lateral thigh perforators 1.8 1.3
13.5-cm midcalf Cockett 15.9 17.3
18.5-cm midcalf Cockett 34.3 35.2
24-cm midcalf Cockett 20.0 19.6
30-cm midcalf Cockett 13.0 12.7
35-cm midcalf Cockett 6.6 7.0
40-cm midcalf Cockett 4.2 3.1
Calf perforators (other) 12.0 11.2
Gastrocnemius/peroneal muscle
perforator
Anterior tibialis/peroneal perforator 3.1 2.9
Lateral tibial perforators 0.02 0.04
Lateral foot perforators 2.0 2.4
Medial foot perforators 3.5 2.9
Modified from Sherman RS: Ann Surg 130:218, 1949.
25.0 24.0
superficial veins. Although variable in location, a number of
perforating veins occur with marked regularity (Table 1.2).
Paratibial perforators connect the main trunk or tributaries
of the GSV with the posterior tibial veins and course close to
the medial surface of the tibia. These correspond to the
so-called Sherman PV (at the lower and mid leg) and Boyd PV
(at the upper leg). Posterior tibial perforators connect the
posterior accessory GSV with the posterior tibial veins. These
correspond to the so-called Cockett PV, named first, second,
and third. As described by Frank Cockett, they can be indicated topographically as upper, middle and lower.
The most important perforators in the thigh are known as
the Hunterian and the Dodd perforator(s), which are located
in the medial thigh. These connect the GSV to the femoral vein
in the middle third of the medial thigh (Hunterian) and the
lower third of the thigh (Dodd).
64
Incompetence of the
midthigh (Hunterian) perforator is a common cause for
medial thigh varicose veins in patients with a competent SFJ.
Perforating veins have also been described in the foot.
65
Raivio
has documented more than 40. One is situated about
2.5 cm below the inferior tip of the medial malleolus. A
second occurs approximately 3.5 cm below and anterior to the
medial malleolus. The other two are on an arc approximately
3 cm anterior to and below the medial malleolus. Perforating
veins in the foot are valveless or have one-way valves that are
reversed to allow blood to flow from the deep to the superficial veins.
66
The great number of perforating veins and venous
anastomoses of the foot allows for their safe removal.
Venous valvular system
Fabricius of Aquapendente (1533–1620) is credited with being
the first to detail the anatomy of veins and their valves, in
Padua in 1579. He suggested that valves ‘… insure a fair distribution of the blood … prevent distention … and stop blood
from flooding into the limb …’.
67
However, a more recent
historical review credits the Parisian Charles Estienne with
mentioning venous valves in 1545 and Lusitanus and Cannano
publicly demonstrating valves in Ferrera, Italy in 1555.
68
The valves appear as translucent, thin structures that vibrate
with blood flow. Numerous bicuspid valves appear down to
vein diameters less than 100 micrometers (µm).
studies demonstrate valves in venules as small as 40 µm in
diameter.
70,71
69
Recent
Studies of the embryologic development of veins show that
the number of venous valves decreases in utero with fetal
maturity. It has been suggested that this disappearance continues, albeit at a reduced but variable rate, during childhood,
adolescence and adult life.
72,73
A morphologic study of normal saphenous veins removed
from cadavers has revealed an average of 8.7 valves, with 6.3
of these appearing above the knee and 2.4 below the knee.
74
Aging in itself does not appear to decrease the number of
venous valves of the leg, nor does the number of venous valves
appear to differ between men and women.
75
The number of venous valves has been found to be fewer
in varicose veins than in normal veins. Valvular insufficiency
occurs in undamaged valves as well as damaged valves. Competent venous valves withstand pressures of up to 3 atmos-
76
pheres.
Therefore, for incompetence to occur, the valve
annulus dilates to render the valves incompetent. This observation is supported by investigations that reveal no difference
in viscoelastic behavior in perivalvular vein wall tissue.
Chronic venous dilation may lead to sclerosis. It is postulated
that this is caused by turbulent blood flow.
78
However, sinus
wall and valvular defects have been found in autopsy studies
in up to 90% of adults without apparent varicosities.
79
There-
77
fore, valve and valvular sinus abnormalities, at best, comprise
only one factor in the development of varicose veins. A full
explanation of the pathophysiologic significance of valvular
deficiency and dysfunction is addressed in Chapter 3.
Nerves of the Leg of Phlebologic Interest
The sural nerve (SuN) and the saphenous nerve (SaN) are
interesting in VV treatment because of their proximity to the
SSV and the GSV at the leg, respectively.
The SuN, running along the SSV, is formed by two different
branches merging at different leg levels to form the definitive
nerve. The tibial branch (nervus cutaneus medialis surae –
NCMS) branches from the tibial nerve at the popliteal fossa
and runs parallel to the SSV in the groove of the gastrocnemius
muscles, ventrally and outside the SSV compartment. Generally at the middle third of the calf (but with large variations)
it meets the peroneal branch of the SuN and enters the saphenous compartment, coming in straight contact with the SSV,
extending down to the foot.
The peroneal branch of the SuN (nervus cutaneus lateralis
surae – NCLS) originates from the common peroneal nerve.
This nerve comes down laterally to the popliteal fossa along
the biceps femoris muscle to the head of peroneus. During
this course it sends a ‘communicating branch’, the NCLS,
directed distally and medially, to join the NCMS to complete
the SuN (Fig. 1.44).
This typical anatomical arrangement (Fig. 1.45), has great
variations. The two branches can run independently.
point of contact with the SSV may be found by DUS at different levels of the calf. This point has been called the ‘risk point’
because possible nerve injury during VV treatments
probable from this point distally.
82
The SaN takes origin from the femoral nerve 2 cm below
the inguinal ligament, comes down along the adductor
80
The
81
is more
canal following the femoral artery, continues behind the sar-
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torius muscle, becoming superficial at the knee where it runs
between the sartorius and gracilis muscle tendons. At this
point the nerve is visible by DUS behind the GSV and in
deeper position. Progressively the SaN becomes superficial
and runs anterior to the GSV, coming in close contact with the
vein (Fig. 1.46)
at about 2–3 cm below and medial to the tibial
tuberosity. From this point down the nerve follows the GSV
extending to the foot. It is also possible to identify the ‘risk
point’ for the SaN (Fig. 1.47).
83–86
Histology
Vein walls
The first part of the venous system consists of the venule,
which serves as a collecting tube for capillaries. The cutaneous
Great saphenous vein
Figure 1.44 The sural nerve is formed by two branches, one coming from
the tibial nerve (TN), the medial sural cutaneous nerve (Med SCN), the other
coming from the common peroneal nerve, the lateral sural cutaneous nerve
(Lat SCN). Both form the sural nerve that runs in close contact with the
distal small saphenous vein.
Small saphenous vein
Common peroneal nerve
Lateral SCN
Medial SCN
Sural nerve
Point of contact
‘Risk point’
microcirculation is organized as two horizontal plexuses. One
is situated 1–1.5 mm below the skin surface. The other is at
the dermal subcutaneous junction. Arterioles ascending into
these layers and venules descending are paired while they
connect the two plexuses. The arterial capillaries form dermal
papillary loops and at the dermal subcutaneous junction collecting veins contain bicuspid valves oriented to prevent retrograde flow of blood.
87
The venule is approximately 20 µm
in diameter and consists of an endothelium surrounded by a
fibrous tissue composed of a thin layer of collagenous fibers.
The venule increases in diameter, with smooth muscle cells
appearing within the fibrous sheath when the diameter is
approximately 45 µm. At a diameter of 200 µm, the muscular
layer becomes better defined. At a clinically recognizable
diameter consistent with small phlebectasia (venectasia), the
vessels are composed of a thick media with myocytes. Collagenous fibers are clearly organized into bundles, and elastic
fibers can be observed.
88
Larger diameters contain elastic fibers
and a more organized structure.
Telangiectasias commonly seen in the skin of lower
extremities can be explained by abnormalities in the organization and ultrastructure of the cutaneous microvasculature
rather than by neovascularization. The telangiectasias seen in
essential telangiectasia and in scleroderma are clearly a dilation of the postcapillary venules of the upper horizontal
89
plexus.
Microscopically, the normal young internal saphenous vein
is a musculofibrous conduit with both passive and active functions. The normal vein is slightly oval, with the short axis
perpendicular to the skin. In response to an increase in intraluminal pressure, the diameter increases and the vein loses its
oval appearance. Veins tend to assume an elliptical shape,
particularly at low transmural pressures. These qualities of
shape deformability allow veins to change volume with very
little force, thus aiding their role as a high-capacitance
90,91
system.
With continued increases in venous pressure or
progression of varicose disease, the vein increases in both
length and diameter and becomes tortuous. Whether normal
or varicose, the saphenous vein is composed of three tunics:
intima, media and adventitia.
The intima is a thin structure consisting of a layer of
endothelial cells and a deep fenestrated basement membrane
bounded by a thin, fragmented elastic lamina.
92
The central
portion of the cell containing the nucleus bulges into the
lumen and, on its free surface, exhibits multiple small microvilli. Although endothelial cells are easily destroyed by chemical and physical insults, they demonstrate a marked capacity
for regeneration.
93
The media is composed of three layers of muscle bundles.
The inner layer consists of small bundles of longitudinally
Histology
Risk point
V.S.E.
N.S.T.
N.S.E.
A
N.S.T. N.S.T. N.S.T. N.S.T.
B C D E
V.S.E. V.S.E. V.S.E. V.S.E.
N.S.P.N.S.P.N.S.P.
N.S.P.
N.S.P.
Figure 1.45 Different anatomical combinations of
the two branches of the sural nerve and different
levels of nerve-to-vein contact (‘risk point’). (NSE,
sural nerve; NSP, lateral sural cutaneous nerve;
NST, medial sural cutaneous nerve; VSE = SSV)
(Adapted from Payen B: Rappel anatomique de la veine
saph
ène externe, Phlébologie 38:453, 1985)
19
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1
Anatomy
0
GSV
1
2
3
Figure 1.46 The saphenous nerve, initially in a deeper position, becomes
superficial and anterior to the GSV, coming in close contact with the vein
(‘risk point’) at about 2–3 cm below and medially to the tibial tuberosity. The
nerve is visible using ultrasound with a high frequency probe (12–18 Mhz).
most cells of the longitudinal layer to improve contractile
efficiency.
94
The amount of muscle within the vein wall is not uniform
throughout the venous system. There is an increasing smooth
muscle content from the proximal to the distal and the deep
to the superficial veins.
95
The obvious functional importance
is to counteract hydrostatic pressure. In addition, the greatest
extent of circular muscle occurs at the level of insertion of the
valve leaflets. This composition helps to prevent valvular dilatation and incompetence and is the last region to dilate in a
varicose vein.
96
This area is known to be dilated in primary
valvular insufficiency.
The adventitia is the thickest portion of the vein wall. It is
primarily composed of collagen, with interlacing fibers oriented in longitudinal, spiral, and circular fashions.
vessels of the thigh, a considerable network of elastic fibers
occurs and stretches from valve to valve.
merges with the perivenous connective tissue and contains the
vasa vasorum and adrenergic nerve fibers.
97
The collagen layer
98,99
93
In larger
The vasa vasorum
provides the arteriovenous circulation in the wall of the blood
vessel. These vessels arise as branches from arterioles present
in perivenous connective tissue that are fed by neighboring
arteries.
100
Venous capillaries of the vasa vasorum form venules
that empty into veins running in the loose perivenous connective tissue. As discussed in Chapter 3, alterations of the
vasa vasorum may lead to the development of arteriovenous
fistulas.
Great saphenous
vein
Saphenous
nerve
Point of contact
‘Risk point’
Figure 1.47 Intimate association of the saphenous nerve with the great
saphenous vein below the knee joint. The saphenous nerve originates
from the femoral nerve, follows the femoral artery in the adductor canal,
becomes superficial at the knee passing between the sartorius and gracilis
muscle tendons, getting in close contact with the great saphenous vein
(GSV). From this point down the nerve follows the GSV until it reaches the
foot. It is also possible to identify the ‘risk point’ for the saphenous nerve.
arranged muscle fibers. Loose connective tissue and small
elastic fibrils separate the muscle bundles.
92
The middle layer
is composed of wide bundles of smooth muscle in a circular
orientation. The muscle bundles may be separated by thin
or thick layers of elastic fibrils.
92
In addition, the outer layer
is quite variable, being composed of longitudinal muscle
bundles spread out through thick fibrous tissue. The outermost cells of the circular layer interdigitate with the inner-
20
Venous valves
Venous valves are composed of a thin layer of collagen and a
variable amount of smooth muscle covered on both surfaces
by endothelium.
101
An increase in muscle fibers is found at the
base of the valve cusp running circumferentially and longitudinally for a variable distance along the length of the valve
97,102
cusp.
Elastic fibers extend along the whole length of the
cusp and lie close to the endothelium. Collagen fibers are
concentrated at the base, thinning out toward the free edge of
the cusp. The valve is avascular and thus dependent on
humeral blood for its oxygen supply.
103,104
Fegan97 proposes that the muscle fibers play an active role
in regulating blood flow. Through an evaluation of anatomical dissection of multiple valves, he believes that contraction
of the circular muscles at the base of the valve reduces the vein
diameter, and contraction of the longitudinal fibers shortens
and thickens the cusp. This type of coordinated muscle action
maintains tone in the vein wall in the face of increased pressure from retrograde blood flow.
The valve cusp changes with age.
105
In the parietal layer,
collagen becomes thicker and denser with an increase in the
elastic lamellae. The luminalis develops deep, narrow depressions. The vein wall at the valve sinus thickens with an increase
in adipose tissue, muscle cells and connective tissue. These
changes produce less flexibility of the valve cusp, which may
produce abnormal blood flow currents and eddies that could
lead to valvular incompetence.
Vein wall variation
The composition of vein walls varies with the type and location of the veins. Depending on their location, veins assume
many different functions, and the muscular content of the
vein wall varies accordingly. They are used as pumps and
reservoirs and must withstand variations in gravitational and
intravascular pressure demands. The percentage of smooth
muscle increases with distal locations. Veins in the lower
extremities are the only veins that are composed of more than
40% smooth muscle, with veins in the foot having 60–80%
smooth muscle compared with 5% in axillary veins.
the hydrostatic pressure within the vein also correlates with
95
However,
smooth muscle content and superficial veins have more
https://t.me/med1917
smooth muscle than deep veins.
106
The differences in vein wall
content may affect sclerotherapy treatment, as described in
Chapter 7.
The function of the vein wall collagen is to prevent overdistension, whereas elastin produces elastic recoil. With advancing age, multiple changes may occur in the vessel wall. The
intima thickens, increasing and disorienting elastic fibers.
92
The media develops a more disorganized arrangement of
muscle bundles and hypertrophy of the outer muscular layer.
Elastic fibers become more irregular and dystrophic and the
elastic lamina becomes more fragmented, atrophic, thin and
irregular.
92
The adventitia becomes increasingly fibrous. Thus
the lack of an organized elastic support and smooth muscle
degeneration in an aged vein render it more susceptible to
pressure-induced distension.
Some histologic studies demonstrate that fibrotic wall
changes are a common finding in the GSV in all age groups
without venous disorders.
106
The incidence of fibrotic change
increases from 25% to 50% in the population under 40 years
of age to 100% in those over 70 years of age.
Other studies have confirmed the fact that varicose saphenous veins have significantly larger wall areas and larger
amounts of collagen. This is true more so in the proximal GSV
compared with the distal GSV. Also there is excess smooth
muscle and elastin in varicose veins proximally compared
with distally. This has suggested to some that varicose veins
are a dynamic response to venous hypertension. Others believe
that the vein wall in varicose disease is thinned rather than
dynamically responsive.
107
In saphenous veins subjected to biopsy during arterial
bypass surgery, intimal thickening has been found to be
common. Smooth muscle hyperplasia, elastosis and fibrosis
contribute to this intimal thickening. In addition, medial
longitudinal muscle hypertrophy is seen.
108
Venules
Venules in the upper and mid dermis usually run in a horizontal orientation. The diameter of the postcapillary venule
ranges from 12 mm to 35 mm. Collecting venules range from
40 mm to 60 mm in the upper and mid dermis and enlarge
to become 100 to 400 mm in diameter in the deeper tissues.
109
One-way valves are found at the subcutis (dermis)–adipose
junction on the venous side of the circulation.70 Valves are
usually found in the area of anastomosis of small to large
venules and also within larger venules unassociated with
branching points. The free edges of the valves are always
directed away from the smaller vessel and toward the larger
and serve to direct blood flow towards the deeper venous
system. The structure of these valves is identical to that of the
valves found in deep and larger veins.
Postcapillary venules are composed of endothelial cells
covered by a basement membrane, some collagen fibers, and,
rarely, smooth muscle cells. Collecting veins in the deep
dermis gradually receive more muscle cells until they become
veins with a continuous muscle coat (see Fig. 1.48).
110,111
Telangiectasias
Histologic examination of simple telangiectasias demonstrates
dilated blood channels in a normal dermal stroma with a
single endothelial cell lining, limited muscularis, and adven-
112
titia.
Therefore, such vessels probably evolve from capillaries
or early venules.
Blue-to-red arborizing telangiectasias of the lower extremities are probably dilated venules, possibly with intimate and
direct connections to underlying larger veins of which they are
direct tributaries.
113–115
Electron microscopic examination of
‘sunburst’ varicosities of the leg has demonstrated that these
vessels are widened cutaneous veins.88 They are found 175 to
382 µm below the stratum granulosum. The thickened vessel
walls are composed of endothelial cells covered with collagen
and muscle fibers. Elastic fibers are also present. Electron
microscopy reveals an intercellular collagenous dysplasia,
lattice collagen and some matrix vesicles. These findings
suggest that telangiectatic leg veins, like varicose veins, have
an alteration of collagen metabolism of their walls. Therefore,
like varicose veins, these veins are dysplastic.
Alternatively, arteriovenous anastomoses may result in the
pathogenesis of telangiectasias. These were demonstrated by
de Faria and Moraes
115
in 1 of 26 biopsy specimens of leg
telangiectasias.
Skin biopsy of more unusual forms of telangiectasia, such
as unilateral nevoid telangiectasia, may show an accumulation
of mast cells.
induced by the chronic release of one or more products of
mast cells, particularly heparin.
116
In these cases permanent vasodilation may be
117,118
Innervation
Innervation of the vein plays an important part in the regulation of venous tone. Different stimuli are known to produce
venous constriction: pain, emotion, hyperventilation, deep
breathing, Valsalva’s maneuver, standing and muscular exer-
119
cise.
Although muscular veins have little or no sympathetic
innervation, cutaneous veins are under hypothalamic thermoregulatory control and have both α
receptors.
120
Because the outermost media and adventitia
contain the nerve endings, myogenic conduction contributes
to the neurogenic activation by coordinating venous contrac-
102,121
tion.
of muscle cells from nerve endings is rarely less than 1000 Å
(0.1 nm).
Even in the outer layers of the media, the separation
122
Therefore, an intact smooth muscle layer is important in vein physiology.
Venous constriction and dilation occur through both
central and local nervous stimuli.
123
when veins are used as arterial conduits. One report describes
spasms of a vein graft 14 months after operation, causing
anginal symptoms.
124
Localized cooling provides both a
potentiation of adrenergic stimulation and a direct stimulus
for venous smooth muscle contraction;
is reduced by warming.
126
Venoconstriction also occurs with
infusions of norepinephrine (noradrenaline),
(adrenaline), phenylephrine, serotonin and histamine.
Veins dilate in response to phenoxybenzamine, phentolamine,
reserpine, guanethidine, barbiturates and many anesthetic
129
agents.
Therefore, circulating adrenergic and pharmacologic
substances influence vein diameter and this may explain why
central mechanisms may also be responsible for venous tone.
Evidence for a central sympathetic control of venoconstriction
has been demonstrated by the failure of such venoconstriction
to occur with the tilting of sympathectomized patients.
the stress of mental arithmetic or unpleasant thoughts has
been shown to activate adrenergic nerves connected to cutaneous veins.
because of a change in either respiration or nerve stimulation.
119
Veins may become more distensible during sleep
131
This is one reason for recommending continuous compression of sclerotherapy-treated veins during the endosclerotic
stages after treatment (see Chapter 8).
Local chemical changes produced through exercise also
provide for the distribution of blood flow in accordance with
local metabolic needs. Venous smooth muscle is also sensitive
to endothelium-derived vasoconstrictor substances and peptides such as endothelin.
124
Finally, the increasing smooth
muscle content from proximal to distal veins, and a thicker
muscular media in superficial veins compared with muscular
deep veins, supports the physiologic concept of increasing
venous contractility in the distal venous system.
- and β-adrenergic
This may be problematic
125,126
venoconstriction
127
epinephrine
130
128
Even
Histology
21
Chapter
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