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32 Chapter 3/Epidemiology of Chronic Peripheral Venous Disease
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50
40
MEN WOMEN
30
% Prevalance
20
10
Normal
TSV
VV
TCS
0
Achin
g
Itchin
ines
v
ea
H
d
e
p
Tir
m
a
r
C
s
g
g
g
n
i
elli
w
S
s
s
n
e
l
t
es
R
SYMPTOM
FIGURE 3.3 Symptoms by visible disease status, San Diego, California, 1994–1998.
Escalating rates of symptoms were also found across
categories of visible venous disease.13 Figure 3.3 shows the
prevalence rates by symptom and visible category for each
sex. Symptom prevalence in subjects with TSV, the most
common category of visible disease, was only marginally
greater than in normal participants. Symptoms were generally about twice as common when VV was present. Rates
were further increased in the presence of TCS. Again, with
the exception of restless legs (p = 0.06), these differences
were highly statistically signifi cant (p < 0.01). Similar to
functional disease, symptom prevalence in association with
visible disease was uniformly greater in women although
trends were similar in both sexes.
SYMPTOMS BY VISIBLE AND
FUNCTIONAL DISEASE
To estimate the relative importance of each symptom to
the clinical picture of venous disease we evaluated the odds
ratios (OR) for each symptom in each of the 12 categories
of venous status formed by crossing the three categories of
functional disease with the four categories of visible disease
g
H
eavines
s
ire
T
g
d
m
Cra
pin
i
ll
e
w
S
g
n
i
ch
Itchin
A
s
g
n
stles
e
R
using logistic regression adjusted for age, sex, BMI, education, and racial/ethnic group (see Table 3.4). Aching (OR
2.20) and swelling (OR 2.99) were signifi cantly associated
with DFD even in subjects without visible disease. These
two symptoms were signifi cantly associated with DFD
across all categories of visible disease, with the strongest
association in subjects with TCS. Aching was signifi cantly
associated with VV regardless of venous functional status
and was associated with TCS except in those with normal
functional examinations. Itching followed a similar pattern
being signifi cantly associated with varicose veins regardless
of functional status, and with TCS except in those with
normal functional exams. However, the OR for itching with
varicose veins and DFD was twice the level of the parallel
ratio for aching (5.31 and 2.82, respectively). Swelling had
associations very similar to itching for varicose veins, but
was associated with much higher rates when TCS was
present (ORs 11.61, 6.94, and 6.17 for swelling, itching, and
aching, respectively, in subjects with DFD and TCS). Heaviness, tired legs, and cramping each had modest associations
with disease in the presence of both functional and visible
abnormalities. Although the symptom of restless legs was
associated with disease for subjects with both DFD and
QOL and CPVD 33
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TABLE 3.4 Odds Ratios for Symptoms by Functional
Disease Status Adjusted for Age, Sex, Ethnicity, Education,
and Body Mass Index, San Diego California, 1994–1998
Normal TSV VV TCS
N
Normal 1024 2519 184 58
SFD 5 22 591 117
DFD 39 87 107 55
Aching
Normal ref 1.11 2.05* 0.85
SFD 0.03 1.56 2.29* 3.90*
DFD 2.20* 1.93* 2.82* 6.17*
Itching
Normal ref 1.11 1.98* 2.63
SFD 0.04 5.88* 2.33* 4.81*
DFD 1.10 0.32 5.31* 6.94*
Heaviness
Normal ref 1.33 1.60 0.02
SFD 0.01 1.44 2.69* 5.68*
DFD 0.59 1.65 2.82* 5.27*
Tired
Normal ref 1.09 1.63* 0.42
SFD 0.01 0.30 2.07* 3.80*
DFD 1.52 1.04 2.95* 4.79*
Cramping
Normal ref 0.95 1.45 0.46
SFD 0.03 1.36 1.41* 1.82*
DFD 1.53 1.57 1.44 3.82*
Swelling
Normal ref 1.15 1.91* 5.41*
SFD 0.02 4.13* 2.31* 6.73*
DFD 2.99* 2.57* 5.82* 11.61*
Restless
Normal ref 1.44* 2.36* 1.13
SFD 0.03 1.50 1.64* 0.95
DFD 2.32 0.82 1.18 3.78*
*p < 0.05.
TSV = Telangiectasias and spider veins, VV = Varicose veins, TCS =
Trophic changes, SFD = Superfi cial functional disease, DFD = Deep
functional disease.
it. Swelling was a more specifi c marker for prevalent disease
with less than 10% of normal subjects reporting this symptom
and at least a two-fold higher rate associated with functional
disease or any visible disease besides TSV. Likewise, heaviness and itching were reported in legs with functional or
visible fi ndings at more than twice the rate reported in
normal legs. Tired legs and cramping were also increased in
legs with functional or visible fi ndings but the contrasts with
normal legs were not as strong. The joint occurrence of
aching and swelling, or aching and tired legs was useful in
distinguishing diseased legs.
13
Our fi nding that swelling is a strong predictor is concordant with several other reports. A study of patients attending
a vascular clinic found an association between vascular
endothelial growth factor (VEGF) and CEAP classifi cation,
and between VEGF and swelling.14 The Edinburgh Study,
conducted in patients from clinical practices, evaluated associations by leg as in the present report. Disease was defi ned
by the presence of superfi cial and deep refl ux. For isolated
superfi cial refl ux, associations were found for heaviness and
itching in women; there were no signifi cant associations in
men. For venous disease defi ned as combined superfi cial
and deep refl ux, associations were found between swelling,
cramps, and itching for men, and between aching and cramps
in women.15 A study of a large employed population found
swelling and nocturnal cramps to be the most common
symptoms.16 Surprisingly, in that population the strongest
association was found for people with small cutaneous
veins, the equivalent of TSV in our study. In a clinical
population evaluated by color-fl ow duplex, the strongest
associations were found for aching and swelling that were
associated with below-knee refl ux.
17
Women were more likely to report symptoms than men.
Similar results have been reported by other investigators.
16,18
This is not simply an artifact of the greater prevalence of
visible disease and superfi cial functional disease in women3
since it was evident on a percentage basis for each category
and was also found for deep functional disease, which was
more prevalent in men.
TCS, it did not consistently distinguish disease as rates were
elevated in subjects with normal functional examinations
who had either TSV or VV. In general, a combination of
visible and functional fi ndings tended to increase ORs
compared with only a visible or functional fi nding.
SYMPTOM SPECIFICITY AND CPVD
In this population-based study, aching was the most commonly reported symptom related to venous disease. However,
it was relatively nonspecifi c as about 15% of normal subjects (assessed by either functional or visible status) reported
QOL AND CPVD
Despite the high prevalence of venous disease, the impact
13
upon daily functioning and quality of life is still poorly
documented. Venous disease has been considered as a cosmetic problem that might affect emotional well-being.
Several studies have shown that venous disease affects
selected aspects of daily functioning (reviewed in Reference
19). An ad hoc committee of the SVS/ISCVS recommended
the expansion of outcome measures in studies of venous
disease to include patient reported functioning and quality
20
of life measures.
In their review, the ad hoc committee
noted that comprehensive evaluation of venous disease must
34 Chapter 3/Epidemiology of Chronic Peripheral Venous Disease
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54
54
52
50
48
46
52
50
48
46
44
NL TSV VV TCS
Physical
Functioning
Role
Physical
Pain Index
General
Health
tions
Perce
Vitality
Social
Functioning
Role
Emotional
Mental Health
44
NL TSV VV TCS
FIGURE 3.4 SF-36 scores by visible disease status for physical (top) and mental (bottom) health scores, San Diego,
California, 1994–1998.
include assessment of clinical outcomes and quality of life.20
However, only a limited number of studies have measured
quality of life in patients with venous disease. At least six
previous studies have used the Medical Outcomes Study 36
Item Short Form (SF-36) for patients with varicose veins.
With some exceptions
21,22
patients in these studies were not
well described in terms of disease status.
SF-36 AND CPVD
The SF-36 includes eight subscales. These subscales
have been factor analyzed and clustered into two groups:
physical and mental health.23 Physical health components
are regarded as measures of functioning, whereas mental
health components are thought of as indicators of wellbeing. Functioning describes what people are able to do
while well-being characterizes how people feel, particularly
on mental health or emotional dimensions.
Scores for the four physical health components of SF-36,
broken down by visible disease categories in the SDPS, are
summarized in the top portion of Figure 3.4.
19
The mental
health components of the SF-36 are shown in the bottom
portion of the fi gure. The differences between visible categories of disease were highly signifi cant with a strong linear
component for the physical health subscales of the SF-36.
In particular, there were strong linear effects for the Physical
Functioning (F
(F
= 41.98, p < 0.0001), Pain (F
1/2245
and General Health Perception scales (F
= 52.20, p < 0.0001), Role-physical
1/2245
= 25.43, p < 0.0001),
1/2245
= 8.45,
1/2245
SF-36 and CPVD 35
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54
52
Physical
Functioning
50
48
46
Role
Physical
Pain Index
General
Health
Perceptions
44
NL SFD DFD
54
52
50
48
46
44
NL SFD DFD
FIGURE 3.5 SF-36 scores by functional disease status for physical (top) and mental (bottom) health scores, San
Diego, California, 1994–1998.
p < 0.001). The only signifi cant effect for the mental health
or well-being scales was for Vitality, and this effect was
relatively weak in relation to the other SF-36 functional
scales (F
= 5.28, p < 0.03).
1/2244
19
Similar trends were observed for the functional categories based on the duplex ultrasound evaluations. However,
these trends were not as strong as for the visible categories
(see Figure 3.5). The overall F scores were statistically signifi cant and there were strong linear trends for all four SF-36
physical health scales (df for all tests 1/2253; Physical Functioning F = 9.74, p < 0.01; Role-Physical, F = 23.18, p <
0.001; Pain F = 6.85, p < 0.01; General Health Perceptions,
F = 9.34, p < 0.001). Similar trends were not observed for
Vitality
Social
Functioning
Role
Emotional
Mental
Health
any of the mental health scores and all tests of differences
between groups and linear trends were nonsignifi cant.
19
After adjustment for sex and ethnicity, age was signifi cantly inversely correlated with the physical but positively
correlated with the mental summary component scores
(PCS, r = −0.26; MCS, r = 0.18). This suggests that older
participants had lower physical health scores but slightly
higher mental health scores. Men scored signifi cantly higher
on the PCS summary score than women (p < 0.01) and
marginally higher on the MCS summary dimensions
(p < 0.10). There were also signifi cant differences in SF-36
summary scores by ethnicity with the Asian group scoring
highest on both the PCS and MCS components. For the
36 Chapter 3/Epidemiology of Chronic Peripheral Venous Disease
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MCS component, the non-Hispanic White group obtained
the lowest mean score. Despite the univariate effects of age,
gender, and ethnicity, adjustments for these variables did not
affect the results for either visible category or functional
category. This suggests that differences in quality of life are
explained primarily by disease category. Ethnicity, age, and
gender contribute to the prediction of quality of life, but do
so independently of disease category.
19
A fi nal set of analyses examined the effect of visible
category adjusting for functional category and the effect of
functional category adjusting for visible category. These
analyses focused on the PCS and MCS summary scores.
Using a general linear model, we observed very strong
differences in PCS by visible category (F
= 35.15,
1/2211
p < .001). However, once visible category was entered,
functional category did not explain additional variance
(p = .74). The model entering the functional categories with
the visible category as a covariate still favored the visible
category. These fi ndings suggest that the visible categories
explain most of the variance in the SF-36 physical component scores. In the MCS model, differences between both
the visible and functional categories were nonsignifi cant and
adjustments did not have signifi cant effects.
19
Evidence from this study suggests that venous disease
affects the functional scales (what people can do) but does
not appear to affect the well-being aspects (how people feel).
Very similar results were reported in a recent European
study. Kurz and colleagues also found signifi cant gradations
in SF-36 PCS scores by disease severity, but found few
differences for the MCS components.22 In addition to evidence suggesting that quality of life measures are associated
with disease severity, some evidence suggests that the measures are also responsive to changes following therapeutic
intervention.
24
In summary, even modest venous disease is associated
with signifi cant limitations on the physical functioning
scales of the SF-36. Venous disease did not appear to affect
emotional aspects of health-related quality of life.
CONCLUSIONS
Our major fi ndings in the SDPS for the epidemiology of
CPVD are summarized as follows.
Overall Characteristics of CPVD
were discordant, the presence of one condition did not
necessarily imply the other. In addition, fully onefourth of limbs with TCS did not have functional
venous disease.
4. 26.4% of legs with edema were normal functionally
and without VV or TCS. This provides a populationbased estimate of the proportion of edematous legs of
nonvenous etiology.
5. Legs with both TCS and DFD had prevalences of
edema, superfi cial events, and deep events of 48.2,
11.3, and 24.6%, respectively, compared with 1.7, 0.6,
and 1.3% for legs visibly and functionally normal.
Thus, although edema and venous thrombotic events
were increased dramatically with TCS and DFD, they
also occurred in their absence as well as in the absence
of milder forms of CPVD.
Risk Factors for CPVD
1. The most consistent risk factor across all defi nitions of
venous disease was family history, suggesting the
importance of a genetic link.
2. Age was a strong risk factor, but somewhat more so for
visible than functional disease.
3. Hormonal factors and ligamentous laxity were
consistent risk factors for both visible and functional
disease in women.
4. Sitting, standing, and walking were consistent risk
factors for visible disease and SFD.
5. Physical anthropometric factors were risk factors in
women for VV, TCS, SFD, and DFD, and for VV,
TCS, and DFD in men.
6. Cardiovascular diseases tended to be inversely
associated with venous disease.
7. Ethnicity associations were attenuated in multivariate
analysis, although still present for TSV and VV.
8. Key risk factors for venous thrombosis, older age,
obesity, and hormonal factors were also risk factors for
visible and functional venous disease.
9. Other risk factors including measured heart rate;
measured systolic and diastolic blood pressure; alcohol
consumption; dietary fat, carbohydrate, and protein;
history of diabetes; high heel use in women; history of
previous or current cancer; vasectomy in men; and
history of allergic disease showed at best weak
associations.
1. Venous disease increased with age, and NHW had
more disease than Hispanics, African-Americans, or
Asians.
2. TSV, VV, and SFD were more common in women, and
TCS and DFD more common in men.
3. Visible and functional disease were closely linked, with
92% of legs concordant. However, since 8% of legs
Symptoms of CPVD
1. Symptoms are signifi cantly more common in legs with
visible venous disease compared to legs without, and
are greater the more severe the visible disease.
2. Symptoms are signifi cantly more common in legs
with functional venous disease compared to legs
References 37
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without, and are greater the more severe the functional
disease.
3. The combination of visible and functional venous
disease is associated with the most symptomatology,
and again symptoms are a function of severity.
4. Aching is the most common symptom, and is related to
both visible and functional disease.
5. Swelling shows the highest odds ratios of the seven
symptoms, and is related to both visible and functional
disease.
6. Nighttime restless legs and cramping are less specifi c
symptoms for venous disease, but still show statistically
signifi cant associations.
Quality of Life in CPVD
1. QOL as defi ned by physical health measures is
impaired by visible disease, with the impairment
proportional to the severity of disease. Visible venous
disease is far more than a cosmetic problem.
2. QOL as defi ned by physical health measures is
impaired by functional disease, but much of this effect
can be explained by overlap with visible disease. This
is in contrast to symptoms (see earlier), where if
anything, associations are somewhat stronger for
functional disease.
3. QOL as defi ned by mental health measures did not
show strong or consistent associations with either
visible or functional venous disease.
Thus, CPVD is commonplace and is a major cause of
morbidity in populations, including measurable effects on
QOL.
References
1. Eklof B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P,
Kistner RL et al. American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classifi cation. Revision of the CEAP
classifi cation for chronic venous disorders: Consensus statement,
J Vasc Surg. 2004. 40: 1248–1252.
2. Evans CJ, Allan PL, Lee AJ, Bradbury AW, Ruckley CV, Fowkes FG.
Prevalence of venous refl ux in the general population on duplex scanning: The Edinburgh vein study, J Vasc Surg. 1998. 28: 767–776.
3. Criqui MH, Jamosmos M, Fronek A, Denenberg JO, Langer RD,
Bergan J et al. Chronic venous disease in an ethnically diverse population: The San Diego Population Study, Am J Epidemiol. 2003. 158:
448–456.
4. Adhikari A, Criqui MH, Wooll V, Denenberg JO, Fronek A, Langer
RD et al. The epidemiology of chronic venous diseases, Phlebology.
2000. 15: 2–18.
5. Saarinen J, Laurikka J, Sisto T, Tarkka M, Hakama M. The incidence
and cardiovascular risk indicators of deep venous thrombosis, Vasa.
1999. 28: 195–198.
6. McColl MD, Ramsay JE, Tait RC, Walker ID, McCall F, Conkie JA
et al. Superfi cial vein thrombosis: Incidence in association with pregnancy and prevalence of thrombophilic defects, Thromb Haemost.
1998. 79: 741–742.
7. Helmerhorst FM, Bloemenkamp KW, Rosendaal FR, Vandenbroucke
JP. Oral contraceptives and thrombotic disease: Risk of venous thromboembolism, Thromb Haemost. 1997. 78: 327–333.
8. Denenberg JO, Criqui MH, Langer RD, Fronek A, Bergan J. Risk
Factors for Chronic Venous Disease: The San Diego Population Study.
Under revision.
9. Komsuoglu B, Goldeli O, Kulan K, Cetinarslan B, Komsuoglu SS.
Prevalence and risk factors of varicose veins in an elderly population,
Gerontology. 1994. 40: 25–31.
10. Gourgou S, Dedieu F, Sancho-Carnier H. Lower limb venous insuffi ciency and tobacco smoking: A case-control study, Am J Epidemiol.
2002. 155: 1007–1015.
11. Coughlin LB, Gandy R, Rosser S, de Cossart L. Factors associated
with varicose veins in pregnant women, Phlebology. 2001. 16: 41–50.
12. Fowkes FG, Lee AJ, Evans CJ, Allan PL, Bradbury AW, Ruckley CV.
Lifestyle risk factors for lower limb venous refl ux in the general population: Edinburgh Vein Study, Int J Epidemiol. 2001. 30: 846–852.
13. Langer RD, Ho E, Denenberg JO, Fronek A, Allison M, Criqui MH.
Relationships between symptoms and venous disease: The San Diego
population study, Arch Intern Med. 2005. 165: 1420–1424.
14. Howlader MH, Smith PD. Symptoms of chronic venous disease and
association with systemic infl ammatory markers, J Vasc Surg. 2003.
38: 950–954.
15. Bradbury A, Evans CJ, Allan P, Lee AJ, Ruckley CV, Fowkes FG. The
relationship between lower limb symptoms and superfi cial and deep
venous refl ux on duplex ultrasonography: The Edinburgh Vein Study,
J Vasc Surg. 2000; 32: 921–931.
16. Kroger K, Ose C, Rudofsky G, Roesener J, Hirche H. Symptoms in
individuals with small cutaneous veins, Vasc Med. 2002. 7: 13–17.
17. Labropoulos N, Leon M, Nicolaides AN, Giannoukas AD, Volteas N,
Chan P. Superfi cial venous insuffi ciency: Correlation of anatomic
extent of refl ux with clinical symptoms and signs, J Vasc Surg. 1994.
20: 953–958.
18. Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What
are the symptoms of varicose veins? Edinburgh vein study cross
sectional population survey, BMJ. 1999. 318: 353–356.
19. Kaplan RM, Criqui MH, Denenberg JO, Bergan J, Fronek A. Quality
of life in patients with chronic venous disease: San Diego population
study. J Vasc Surg. 2003. 37: 1047–1053.
20. McDaniel MD, Nehler MR, Santilli SM, Hiatt WR, Regensteiner JG,
Goldstone J et al. Extended outcome assessment in the care of vascular diseases: Revising the paradigm for the 21st century, J Vasc Surg.
2000. 32: 1239–1250.
21. Smith JJ, Guest MG, Greenhalgh RM, Davies AH. Measuring the
quality of life in patients with venous ulcers, J Vasc Surg. 2000. 31:
642–649.
22. Kurz X, Lamping DL, Kahn SR, Baccaglini U, Zuccarelli F, Spreafi co
G, Abenhaim L, VEINES Study Group. Do varicose veins affect
quality of life? Results of an international population-based study, J
Vasc Surg. 2001. 34: 641–648.
23. Ware JE, Jr., Gandek B. Overview of the SF-36 Health Survey and the
International Quality of Life Assessment (IQOLA) Project, J Clin
Epidemiol. 1998. 51: 903–912.
24. Baker DM, Turnbull NB, Pearson JCG, Makin GS. How successful is
varicose vein surgery—A patient outcome study following varicose
vein surgery using the SF-36 health assessment questionnaire, Eur J
Vasc Endovasc Surg. 1995. 9: 299–304.
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CHAPTER
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4
Venous Anatomy, Physiology,
and Pathophysiology
JOHN BERGAN and LUIGI PASCARELLA
In order to understand treatment of various venous disorders, it is necessary to know the normal anatomy of the
venous system of the lower extremities as well as the normal
functioning of its elements and the mechanisms that cause
derangements in its normal functioning.
In 2001, an International Interdisciplinary Committee
was designated by the Presidents of the International Union
of Phlebology and the International Federation of Anatomical Associations to update the offi cial Terminologia
Anatomica, regarding the veins of the lower limbs. The
relative defi ciency of the offi cial Terminologia Anatomica1
with regard to the veins of the lower limbs was responsible
for a nonuniform anatomical nomenclature in clinical literature and this caused diffi culty in international exchange of
information and inappropriate treatment of venous disease.2
The Committee with the participation of Members of the
Federative International Committee for Anatomical Nomenclature (FICAT) outlined a Consensus Document at a
meeting held in Rome on the occasion of the 14th World
Congress of the IUP. Terminological recommendations of
the Committee were published
unfamiliar, terms are used in the following exposition.
3
and these new, possibly
ANATOMY
The venous system in the lower extremities can be
divided, for purposes of understanding, into three systems:
the deep system, which parallels the tibia and femur; the
superfi cial venous system, which resides in the superfi cial
tissue compartment between the deep muscular fascia and
the skin; and the perforating or connecting veins, which join
the superfi cial to the deep systems. It is because these latter
veins penetrate anatomic barriers, they are called perforating
veins.
Although the superfi cial veins are the targets of most
therapy, the principal return of blood fl ow from the lower
extremities is through the deep veins. In the calf, these deep
veins are paired and named for their accompanying arteries.
Therefore, the anterior tibial, posterior tibial, and peroneal
arteries are accompanied by their paired veins, which are
interconnected. These crural veins join and form the popliteal vein. Occasionally the popliteal veins as well as more
proximal deep veins are also paired like the calf veins.
As the popliteal vein ascends, it becomes the femoral
vein. Formerly, this was called the superfi cial femoral vein,
but that term has been abandoned.
femoral vein is joined by the deep femoral vein, and the two
become the common femoral vein, which ascends to become
the external iliac vein proximal to the inguinal ligament.
Ultrasound imaging has shown that the superfi cial compartment of the lower extremities consists of two compartments, one enclosing all the structures between the muscular
fascia and the skin, and the other, within the superfi cial
compartment enclosing the saphenous vein and bounded by
the muscular fascia inferiorly and the superfi cial fascia superiorly, is termed the saphenous compartment (see Figure
4.1). The importance of this anatomic structure is underscored by its being targeted during percutaneous placement
of endovenous catheters and the instillation of tumescent
anesthesia.
The main superfi cial veins are the great saphenous vein
and the small saphenous vein. These receive many interconnecting tributaries, and these tributaries may be referred to
as communicating veins. They are correctly called tributaries rather than branches of the main superfi cial veins. The
great saphenous vein has its origin on the dorsum of the foot.
4,5
3
Near the groin the
The Vein Book
39
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Copyright © 2006, Elsevier Inc.
40 Chapter 4/Venous Anatomy, Physiology, and Pathophysiology
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FIGURE 4.1 This diagram of the Saphenous Compartment shows its relationships with the Superfi cial and Deep
compartments as well as the Saphenous Vein (SV) and Nerve and their relationships to the Medial, Anterior, and Lateral
Accessory Saphenous Veins (ASV). (Redrawn from Reference 3.)
It ascends anterior to the medial malleolus of the ankle and
further on the anteromedial aspect of the tibia. At the knee,
the great saphenous vein is found in the medial aspect of the
popliteal space. It then ascends through the anteromedial
thigh to join the common femoral vein, just below the inguinal ligament. Throughout its course, it lies within the saphenous compartment. The small saphenous vein originates
laterally from the dorsal venous arch of the foot and travels
subcutaneously behind the lateral malleolus at the ankle. As
it ascends in the calf, it enters the deep fascia and ascends
between the heads of the gastrocnemius muscle to join the
popliteal vein behind the knee (see Figure 4.2). In fact, there
are many variations of the small saphenous vein as it connects both to the popliteal vein and to cranial extensions of
the saphenous vein, as well as connections to the posteromedial circumfl ex vein (vein of Giacomini).
The third system of veins is called the perforating vein
system. As indicated earlier, they connect the superfi cial and
deep systems of veins. There is a fundamental fact, which
confuses understanding of perforating veins. This relates to
fl ow direction. Some perforating veins produce normal fl ow
from the superfi cial to the deep circulation, others conduct
abnormal outfl ow from the deep circulation to the superfi cial
circulation. This is termed perforating vein refl ux. Any of
these perforating veins may demonstrate bidirectional fl ow
(see Table 4.1).
In the leg, the principal clinically important perforating
veins are on the medial aspect of the ankle and leg, and are
found anatomically at approximately 6 cm intervals from the
base of the heel through the upper portion of the leg. They
are therefore at roughly 6, 12, 18, and 24 cm from the fl oor
(see Figure 4.3). These medial perforating veins may become
targets for treatment of severe chronic venous insuffi ciency.
Smaller perforating veins can be found along intermuscular
septa and these allow direct drainage of blood from surface
veins into the deep venous system.
6
Conversely, when they
are dysfunctional, they allow muscular compartment pres-
TABLE 4.1 Summary of Important Changes in
Nomenclature of Lower Extremity Veins
Old terminology New terminology
Femoral Vein Common Femoral Vein
Superfi cial Femoral Vein Femoral Vein
Sural Veins Sural Veins
Soleal Veins
Gastrocnemius Veins
(Medial and Lateral)
Huntarian Perforator Mid Thigh Perforator
Cockett’s Perforators Paratibial Perforator
Posterior Tibial Perforators
May’s Perforator
Gastrocnemius Point Intergemellar Perforator
sure to be transmitted directly to unsupported cutaneous and
subcutaneous veins and venules.
VENOUS PHYSIOLOGY
It is estimated that 60 to 75% of the blood in the body is
to be found in the veins. Of this total volume, about 80% is
contained in the veins that are less than 200 μm in diameter.
It is important to understand this reservoir function as it is
related to the major components. The splanchnic venous
circulation and the veins of the skin are richly supplied by
the sympathetic nervous system fi bers, but muscular veins
have little or none of these. The veins in skeletal muscle, on
the other hand, are responsive to catecholamines.
Although arterial pressures are generated by muscular
contractions of the heart, pressures in the venous system
largely are determined by gravity. In the horizontal position,
pressures in the veins of the lower extremity are similar to
the pressures in the abdomen, chest, and extended arm.
However, with the assumption of the upright position, there
Venous Physiology 41
https://t.me/med1917
FIGURE 4.2 This diagrammatic representation of the Great Saphenous
Vein emphasizes it relationship to perforating veins and the Posterior Arch
Vein. (Redrawn from Mózes G, Gloviczki P, Kádár A, Carmichael SW.
Chapter 2, Anatomy of the Perforating Veins in Gloviczki, P, and Bergan,
JJ, eds. Atlas of Endoscopic Perforating Vein Surgery. Springer, London.
1998.)
are dramatic changes in venous pressure. The only point in
which the pressure remains constant is the hydrostatic indifferent point just below the diaphragm. All pressures distal
to this point are increased due to the weight of the blood
column from the right atrium. When assuming the upright
position, there is an accumulation of approximately 500 ml
of blood in the lower extremities, largely due to refl ux
through the valveless vena cava and iliac veins. There is
some loss of fl uid into the tissues, and this is collected by
the lymphatic system and returned to the venous system.
Venous valves play an important role in transporting
blood from the lower extremities to the heart. In order for
valve closure to occur, there must be a reversal of the normal
FIGURE 4.3 Deep connections of the main thigh and leg perforating
veins are shown in this diagram of the deep veins of the lower extremity.
(Redrawn from Mózes G, Gloviczki P, Kádár A, Carmichael SW. Chapter
2, Anatomy of the Perforating Veins in Gloviczki, P, and Bergan, JJ, eds.
Atlas of Endoscopic Perforating Vein Surgery. Springer, London. 1998.)
transvalvular pressure gradient. A pressure and generated
velocity fl ow exceeding 30 cm/second leads to valve closure.
Direct observation of human venous valves has been made
7
possible by specialized ultrasound techniques.
Venous fl ow
is not in a steady state but is normally pulsatile, and venous
valves undergo regular opening and closing cycles. Even
when fully opened, the cross-sectional area between the
leafl ets is 35% smaller than that of the vein distal to the
valve. Flow through the valve separates into a proximally
directed jet and vortical fl ow into the sinus pocket proximal
to the valve cusp. The vortical fl ow prevents stasis and
ensures that all surfaces of the valve are exposed to sheer
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