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14 Chapter 2 Development and anatomy of the venous system
(a) (b)(c) (d)
n
Median sacral v.
l
(a) (b)
(a)
(b)
(c)
d)
.
L
a
R
y
vv.
y
sinus
a
a
a
.
.
ada
.
Aorta
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Sinus venosus
Vitelline
and
umbilical
vv.
Ant. cardinal
v.
Common
cardinal
v.
Subcardinal
v.
Subcardinal
anastomosis
Post
cardinal
v.
Sub-
supracardinal
anastomosis
(Renal collar)
IIiac anastomosis
of postcardinal vv.
Subclavian
v.
Supracardinal
v.
Prerenal
segment
(Subcardinal)
Renal segment
(Sub-
supracardinal
anastomosis)
Postrenal
segment
(Supracardinal)
Hypogastric v.
Ant. cardinal
v.
Hepatic
segment
of
Inf. vena
cava
R. ext.
jugular
v.
Subclavian
v.
Azygos
Post.
cardinal
v.
R. suprarenal
Renal v.
R. spermatic
Gonadal v.
Inf. vena cava
External iliac v.
vena
cava
R. renal
or ovarian
R. int. jugular v.
L. brachiocephalic v.
Sup.
v.
v.
v.
v.
Int. iliac v.
2.1 (a–d) Stages in development of the major veins.
Source: (Redrawn from Avery LB. Developmental Anatomy, revised 7th edition. Philadelphia, PA: W.B. Saunders Co., 1974.)
Oblique
v.
Inf.
vena
cava
Hemiazygos
v.
L.
suprarena
v.
L. renal
v.
L.
spermatic
or ovarian
v.
L. commo
iliac v.
The left anterior cardinal vein is connected with the
right anterior cardinal vein. This left-to-right channel
becomes the left brachiocephalic vein. The portion of the
left anterior cardinal vein that is caudal to this anastomosis regresses but does not disappear; it forms the oblique
vein of the left atrium (vein of Marshall) and the coronary
sinus. The persistence of the left caudal anterior cardinal
vein results in a double superior vena cava (SVC) (Figure2.2a). In the absence of the right proximal SVC, the
blood from the right upper body is drained into a left SVC
(Figure2.2b).
2.1.1.2 Inferior vena cava and tributaries
The inferior vena cava (IVC) develops from multiple
segments. The paired posterior cardinal veins originally
extend into the region that will become the pelvis and are
joined together at the iliac anastomosis (Figure2.1). Most
of the posterior cardinal veins disappear; the most cranial
portion on the right persists as the arch of the azygos. The
very caudal portion of the posterior cardinal veins and iliac
anastomosis form the common, external, and internal iliac
veins and the median sacral vein. The posterior cardinal
veins are mostly replaced by the ventral subcardinal and
the dorsal supracardinal veins. Drainage of the more cranial region of the abdomen goes mostly into the subcardinal veins and that of the more caudal portion goes into the
supracardinal veins. Most of the azygos system develops
from the supracardinal veins. Lastly, the veins of the left
side generally regress, resulting in a right-sided IVC.
The most inferior portion of the IVC—the postrenal
segment—develops from the right supracardinal vein;
therefore, it is relatively posterior in position. This is
demonstrated by the conuence of the common iliac veins
2.2 Anomalies of the vena cava. (a) Double SVC. (b) Left SVC.
(c) Double inferior vena cava. (d) Left inferior vena cava (a and
b: posterior views; c and d: anterior views).
(c)
R. brachiocephalic v.
R. brachiocephalic v
L. sup. vena cava
. sup. vena cav
R. sup. vena cava
. sup. vena cava
Pulmonary
Pulmonar
vv.
Coronary
Coronar
sinus
Inf.
Inf.
vena
ven
cava
cav
Inf. vena cava
Inf. vena cav
L. renal v.
L. renal v
R. renal v.
R. renal v
Gonadal vv.
Gon
l vv
Aorta
L. inf. vena cava
L. inf. vena cav
(d)
(
tic
Sup. mesenteric a.
G
oa
a
L.
c
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Sup. mesenteri
renal
L. renal v.
Retr
Retroaor
L. renal v.
L. ren
Gonadal v.
ona
2.3 Circumaortic renal collar.
forming behind the common iliac arteries. At the level of
the kidneys, the IVC is formed from the right sub-supracardinal anastomosis (renal segment), thereby becoming more
anterior in position. Above the kidneys, the IVC is formed
from the right subcardinal vein (prerenal segment), which
is still more anterior, as is demonstrated by the IVC diverging anterior to the aorta. The hepatic segment of the IVC is
formed directly by hepatic sinusoids.
Since the IVC develops from bilateral veins, with the
right veins usually persisting, variations are to be expected,
although they are unusual. If the right subcardinal vein fails
to make a connection with the liver, absence of the suprarenal IVC occurs, such that the IVC drains into the arch
of the azygos and the hepatic veins drain independently
through the diaphragm to the right atrium. Double IVC
(0.2%–3%) usually occur in the infrarenal portion due to
bilateral persistence of both the right and left supracardinal
veins (Figure2.2c).
14
Aleft IVC (0.2%–0.5%) results from
caudal regression of the right supracardinal vein with persistence of the left supracardinal vein (Figure2.2d). Renal
vein anomalies include the persistent (circumaortic) renal
collar (1.6%–14%) and the posterior (retroaortic) left
renal vein (3.2%)
15
(Figure2.3).
Congenital absence of the IVC is a rare but important anomaly, since it is a cause of deep vein thrombosis in
young patients, especially in those without risk factors for
thrombosis.
laterals have been observed, rupture has been reported,
and some patients have presented with severe backache
due to venous congestion.
16
Aneurysmal changes of retroperitoneal col-
18
17
2.1.2 Veins of the limbs
The general pattern for the development of the vasculature
of the limbs begins as a ne capillary network arising from
several segmental branches of the aorta. As the limb begins
to extend from the body, a channel from within this network predominates as the axial or central artery. The blood
returning to the body from capillary networks is rst collected in a marginal sinus that extends around the apex of
the limb bud, just deep enough to reach the apical ectodermal ridge. The capillary networks and the marginal sinus
itself send out new vascular sprouts in response to growth of
the limbs. Early on, blood drains from the marginal sinuses
of the limbs into the supercial venous plexuses of the body,
2.2 Anatomy 15
but the blood is progressively shunted into deeper channels as development progresses and deep veins—frequently
paired—develop along major arteries. Valves form in the
veins relatively early. It is thought that the denitive number
of valves is reached by the sixth month of fetal life.
The development of the veins of the limb is likely preceded by the development of major nerves. Gillot and Uhl
proposed that venous development is induced by major
nerves; in the embryo, these angio-guiding nerves are the
femoral, the sciatic, and the posterior femoral cutaneous
3
nerves.
Many of the embryonic veins regress during development; their persistence (of the sciatic vein, lateral marginal vein, etc.) is, however, frequently seen in patients with
venous malformations.
19–21
The axial artery of the upper limb forms the brachial
artery in the arm and the interosseous artery in the forearm, with the ulnar and radial arteries forming later. As the
digits are forming, the apical marginal sinus regresses, but
the proximal marginal channels persist as the cephalic and
basilic veins.
2.2 ANATOMY
2.2.1 Veins of the lower extremities
The veins of the lower extremities are composed of the
supercial, the deep, and the perforating veins (PVs). PVs
connect the supercial to the deep venous system. They
pass through the deep fascia, which separates the supercial compartment from the deep. Communicating veins
connect veins within the same system. The recent development of the evaluation of the veins with duplex scanning
resulted in the recognition of the saphenous subcompartment and the saphenous fascia.
covers the saphenous subcompartment and separates the
great saphenous vein (GSV) from other veins in the supercial compartment. Bicuspid valves are important structures
in the leg veins, assisting unidirectional ow in the normal
venous system.
2.2.1.1 Cutaneous microcirculation
The cutaneous branches of arteries reach the skin either
directly or following the penetration of skeletal muscles. In
the skin, the arterioles form a reticular and a more supercial subpapillary dermal plexus.
dermal papillae emerge from the latter plexus and drain
through venules into the subpapillary venous plexus, which
drain into the dermal or middle plexus, and those veins
drain into the deeper, subdermal reticular venous plexus at
the dermal-subcutaneous junction (Figure2.4).
oriented, small-valved veins connect the reticular venous
plexus to the supercial veins.
2.2.1.2 Superficial veins of the lower extremity
Few veins of the human body have more variability in
their gross anatomy than the supercial veins of the leg.
Supercial veins—the GSV and the small saphenous vein
(SSV) and their tributaries—course in the subcutaneous fat
outside the deep fascia and drain blood from the skin and
subcutaneous tissues (Figures2.5 and 2.6, Table2.1).
22,23
The saphenous fascia
24
Capillary loops of the
25
Vertically
2
26,27
16 Chapter 2 Development and anatomy of the venous system
s
s
Saphenous
Supe
venous arch
v.
Great
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Epidermis
Dermis
Supercial
compartment
c
c
Deep veins
Subpapillary
venous plexu
Reticular
venous plexu
Saphenous
fascia
Great
saphenous
vein
compartment
Deep
compartment
Subcutis
Fascia
Muscle
DISTAL
a
a
b
PROXIMAL
b
2.4 Venous networks in the lower extremity. Capillaries of dermal papillae are drained by the subpapillary venous plexus, which in
turn joins to the reticular venous plexus. Supercial veins
(a) drain dermal veins and empty into the deep axial veins through direct
perforating veins (b). Perforating veins communicate with each other through small branches. Muscular venous sinuses ll from the
supercial veins or from the reticular venous plexus through indirect perforating veins (c), and they are drained into the deep axial
veins.
rf. peroneal n.
Small
saphenous v.
Lateral
perforating vv.
saphenous v.
Saphenous n.
Medial
perforating vv.
Sural n.
Lateral
marginal v.
Dorsal
Medial marginal
Deep peroneal n.
2.5 Supercial and perforating veins of the foot.
The supercial venous system of the foot is divided
into the dorsal and plantar subcutaneous venous networks
(Figure2.5). Supercial vein tributaries drain blood into
the dorsal venous arch on the dorsum of the foot at the
level of the proximal head of the metatarsal bones. The
medial and lateral ends of this arch continue through the
medial and lateral marginal vein into the GSV and SSV,
respectively.
The GSV begins just anterior to the medial ankle,
crosses in front of the tibia, and ascends medially to the
knee (Figure2.6.). Proximal to the knee, the GSV ascends
on the medial side of the thigh and enters the fossa ovalis (the saphenous opening in the femoral fascia, at 3cm
inferior and 3cm lateral to the pubic tubercle). The GSV
2.6 Medial supercial and perforating veins of the leg.
is doubled in the calf in 25% of the population and in the
thigh in 8%.
The GSV lies in the saphenous compartment, between
the muscular fascia and overlying saphenous fascia.
26
22
This
space also includes the accompanying arteries, nerves, and
2.2 Anatomy 17
Great saphenous v.
(a) (b)
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TABLE 2.1 New terminology of lower extremity veins
Old, historic terms or eponyms “New” terms
Supercial femoral vein Femoral vein
Greater or long saphenous vein Great saphenous vein
Lesser or short saphenous vein Small saphenous vein
Giacomini’s vein Intersaphenous vein
Posterior arch vein or Leonardo’s vein Posterior accessory great saphenous vein
(at the calf level)
Cockett perforators (I, II, and III) Posterior tibial perforators (lower, middle, and upper)
Boyd’s perforator Paratibial perforator (proximal)
Sherman’s perforators Paratibial perforators
“24-cm” perforators Paratibial perforators
Hunter’s and Dodd’s perforators Perforators of the femoral canal
May’s or Kuster’s perforators Ankle perforators
2
lymphatics. Tributaries of the GSV can become dilated and
varicose, and they are supercial to the saphenous compartment.
27
The saphenous nerve runs near the GSV in the
distal two-thirds of the calf.
The accessory GSVs are frequently present and run
parallel to the GSV in both the thigh and the leg. These
veins lie either anterior, posterior, or supercial to the main
trunk.
At the calf level, the posterior accessory GSV (PAGSV)
(previously called Leonardo’s vein or posterior arch vein)
begins posterior to the medial malleolus and ascends on the
posteromedial aspect of the calf, and it can join the GSV
distal to the knee or continue upward to the thigh, posterior to the GSV (Figure2.6). The vein also drains through
the posterior tibial perforators into the deep system, usually into the posterior tibial vein.
GSV (AAGSV) at the calf level drains the anterior aspect of
the leg, below the knee.
At the thigh level, the PAGSV drains the medial and
posterior aspect of the thigh. The PAGSV courses vertically,
parallel but posterior to the GSV, and it is devoid of any
fascial coverage. It can anastomose with an oblique epifascial vein coming from the SSV or from its thigh extension
(SSV-TE). This interfascial vein (the SSV-TE) was designated as the posterior thigh circumex vein. Giacomini
described several possible connections between the SSV,
the SSV-TE, the posterior thigh circumex veins, and the
PA-GSV or, directly, with the GSV. The term “Giacomini
vein” is probably incorrect since Giacomini described one
or several possible intersaphenous vein(s) or anastomoses
between the SSV and the GSV.
The AAGSV, also called the anterior saphenous vein
(ASV), since proximally it runs in a saphenous subcompartment, or anterior accessory saphenous vein (AASV),
collects blood from the anterior and lateral side of the thigh
(Figure2.6). The AAGSV courses deep in the subcutaneous
layer of the anteromedial thigh, parallel to the GSV, and
the most proximal segment runs in its own, proper interfascial compartment.
11
The AAGSV and PAGSV join the
GSV just before the conuence of supercial inguinal veins
(saphenofemoral junction) (Figure 2.7). The supercial
epigastric, the supercial circumex iliac, the supercial
28
The anterior accessory
Common femoral v.
Superf.
epigastric v.
Superf.
circumex
iliac v.
External
pudendal v.
Anterior accessory
great saphenous v.
Great saphenous v.
(c) (d)
Common femoral v.
Superf.
epigastric v.
Superf.
circumex
iliac v.
External
pudendal v.
Anterior accessory
great saphenous v.
2.7 The most common anatomic variations of the conu-
ence of supercial inguinal veins (a: 33%; b: 15%; c: 15%;
d: 13%).
external pudendal, the AAGSV, and the PAGSV, together
with the GSV, form the conuence of supercial inguinal
veins (saphenofemoral junction) (Figure2.7). Very rarely,
the GSV terminates high on the lower abdomen or joins
the femoral vein very low, and the supercial inguinal veins
empty individually into the femoral vein. Other tributaries
of the GSV in the groin or lower in the thigh include the
posterior and anterior thigh circumex veins. Anatomical
variations of the saphenofemoral junction are frequent—a
recent review of 13 studies found that in 31%–76% of the
lower extremities enrolled in the studies, three or fewer
18 Chapter 2 Development and anatomy of the venous system
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2.8 Posterior supercial and perforating veins of the leg.
tributaries were present.29 In a cadaveric study of 73 limbs,
the supercial external pudendal vein was the most frequent tributary (94.7%), while the AAGSV was present in
only 21.3%.
ranged from 21.3%–70.1%.
29
The prevalence of AAGSV in four reviews
29–32
The SSV lies lateral to the Achilles tendon in the distal calf (Figure2.8). In the lower two-thirds of the calf,
the SSV runs in the subcutaneous fat and then pierces the
fascia to run between the two heads of the gastrocnemius
muscle.
33
In the popliteal fossa at about 4 to 5cm proximal
to the knee crease, the main trunk of the SSV drains into
the popliteal vein. Asmaller vein—the cranial extension of
the SSV—frequently continues in a cephalad direction (Figure2.8). Uncommonly, the main trunk of the SSV continues without draining into the popliteal vein and eventually
empties into the femoral vein or GSV.
11
The intersaphenous
vein connects the SSV to the GSV in the posterior-medial
thigh in 33%–42%; this vein, which is present in two-thirds
of limbs with venous disease, usually ascends subfascially
and perforates the fascia to join the supercial system.
34
The intersaphenous vein may also turn deep and join the
femoral or profunda femoris vein or posterior thigh muscle
34
As discussed previously, the term Giacomini vein
veins.
probably should not be used, since Giacomini described
multiple anastomoses between the SSV and the GSV.
The sural nerve courses along the SSV in the distal calf.
Adetailed knowledge of the topographical anatomy of the
popliteal fossa is important to avoid nerve injury during
either open ligation and stripping or endovascular ablation
of the SSV. In most cases, the sural nerve (SN) has two
branches: the medial sural cutaneous nerve (MSCN) and
the lateral sural cutaneous nerve (LSCN) (Figures2.9 and
2.10). The MSCN originates from the tibial nerve, and the
2.9 Relation of the small saphenous vein (SSV) and sural nerve
(SN) to fascia layers of the calf. (A) Close to the knee the SSV
runs between the supercial and the deep fascia layers. The
medial sural cutaneous nerve (MSCN) runs under the deep fas-
(B) In the midportion of the calf both the SSV and the MSCN
cia.
run close together, between the fascia layers. (C) In the distal
calf both SSV and SN are supercial to the fascia.
Source: (Kerver AL, van der Ham AC, Theeuwes HP, Eilers PH, Poublon AR,
Kerver AJ, Kleinrensink GJ. The surgical anatomy of the small saphenous
vein and adjacent nerves in relation to endovenous thermal ablation. J Vasc
Surg. 2012 Jul;56(1):181–8, with permission.)
2.2 Anatomy 19
Femoral v.
Pe
.
F
e
l
s
e
A
d
ll
A
.
d
g
t
a
a
https://t.me/med1917
Anastomosis to
deep femoral v.
Small saphenous v.
Sma
Me
Medial and lateral
as
gastrocnemius vv.
Anterior tibial vv
n
Soleal vv.
P
Peroneal vv.
atera
Lateral leg
erfor
perforators
Later
Lateral plantar v.
2
2.10 Anatomic dissection of the veins and nerves of the poste-
rior popliteal fossa. Note the proximity of the SSV to the tibial
nerve, as it dives deep to join the popliteal vein.
Source: (Kerver AL, van der Ham AC, Theeuwes HP, Eilers PH, Poublon
AR, Kerver AJ, Kleinrensink GJ. The surgical anatomy of the small saphenous vein and adjacent nerves in relation to endovenous thermal ablation. J
Vasc Surg. 2012 Jul;56[1]:181–8, with permission.)
rforators of the
femoral canal
Popliteal v.
Posterior tibial vv.
Posterior
perforators
Medial ankle
Medial plantar v.
f th
v.
Soleal v.
.
Paratibial
ia
perforators
ors
.
Soleal v.
ibial vv
tibial
kl
or
perforator
tar v.
l
Upper
Middle
Lower
pper
wer
LSCN originates from the common peroneal nerve. Occasionally, these two branches do not join to form the SN,
and each runs a variable course to the lateral side of the
foot. Sometimes one or the other are not formed. The SN
penetrates the supercial fascia at the same point as the
SSV, about 33.1cm distal from the tibia plateau (range,
25.4–40.4cm).
5
In the distal to third of the calf the SN is near the SSV
and there is a risk of thermal injury. In the proximal third
of the calf the deep fascia separates the SSV from the SN
or the MSCN, and it is a segment with the least chance
of thermal injury (Figure2.9).
5
Thermal injury to the tibial nerve is possible, however, if the tip of the catheter is
pushed deep from the supercial portion of the SSV in an
attempt to ablate the vein close to the saphenopopliteal
junction.
Supercial veins of the lateral leg and thigh form the
lateral venous system. The lateral venous system is drained
through multiple small tributaries into the GSV and SSV or
through PVs into the deep system.
In the supercial veins, bicuspid valves secure unidirectional venous blood ow toward the heart. There are more
constant valves, which are usually located at the termination of the major venous trunks. These valves have strong,
white cusps and marked sinusoid dilatation of the venous
wall at the origin of the valves. Other valves are delicate,
almost transparent, structures. In 20 human cadaveric legs,
Pang identied 4.2 +/– 1.5 (mean +/– SD) valves in the GSV
above the knee.
GSV in 89.4% and a preterminal valve in 90.3%.
35
Muhlberger found a terminal valve in the
36
The frequency of valves is greater below than above the knee. In the
SSV, valves are numerous (median: 7–10, range: 4–13) and
more closely spaced. The highest valve is usually situated
close to the termination of the SSV. Valves in communicating
2.11 Deep veins of the lower extremities.
tributaries between the two saphenous veins are always
oriented to direct blood from the SSV to the GSV.
Small supercial veins and venules, even those with a
diameter of <2mm, may contain valves.
37,38
These valves
likely play an important role in the development of the skin
changes in chronic venous insufciency.
2.2.1.3 Deep veins of the lower extremity
Deep veins accompany their corresponding arteries, frequently in a paired fashion. On the sole, the richly anastomosing deep plantar venous arch collects blood from
the toes and the metatarsals. The deep plantar venous arch
continues into the medial and lateral plantar veins, which
become the posterior tibial veins behind the medial ankle
(Figure2.9). On the dorsum of the foot, the major deep
veins—the dorsalis pedis veins—continue into the anterior
tibial veins.
In the calf, the paired posterior tibial veins run between
the edges of the exor digitorum longus and tibialis posterior muscles and under the fascia of the deep posterior
compartment (Figure 2.11). They drain the muscles of
the deep and supercial posterior compartments and are
connected to the GSV and posterior accessory saphenous
vein by perforators. The posterior tibial veins pierce the
soleus muscle close to its bony adherence (soleal arcade)
and continue into the popliteal vein. The anterior tibial
veins ascend in the anterior compartment. Distally, there
20 Chapter 2 Development and anatomy of the venous system
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is a constant connection between the anterior tibial and
the peroneal veins. The peroneal veins originate in the distal third of the calf and ascend deep to the exor hallucis
longus muscle. They receive the peroneal perforators and
several large veins from the soleus muscle. The anterior tibial and peroneal veins form the short tibio-peroneal trunk,
which joins the posterior tibial veins to form the popliteal
vein.
The popliteal and femoral veins are usually duplicated
in segments of various lengths and form a plexus around
the corresponding arteries similarly to the deep veins of the
calf (Figure2.11). Uhl etal. found a single femoral vein
in 88% and two femoral veins in 12% of the limbs they
studied.
39
The gastrocnemius vein and the SSV are the main
tributaries of the popliteal vein. In the adductor canal, the
popliteal vein becomes the femoral vein and runs initially
lateral and then medial to the femoral artery. The femoral
vein unites with the profunda femoris (deep femoral) vein
at about 9cm below the inguinal ligament. In the adductor canal, or sometimes more distally, there is a consistent
(~84%) anastomosis between the profunda femoris and
the femoral or popliteal veins that provides an important
collateral channel in case of deep venous thrombosis. The
common femoral vein is the continuation of the femoral
vein after it joins the deep femoral vein. The GSV empties into the common femoral vein at the saphenofemoral
junction. Further tributaries of the common femoral vein
are the lateral and medial circumex femoral veins, which
can anastomose with the internal iliac vein. The common
femoral vein is medial to the corresponding artery and ends
at the inguinal ligament, where it continues as the external
iliac vein.
The frequency of valves in deep veins increases in the
proximal-to-distal direction. Deep veins of the foot, the
posterior and anterior tibial, and the peroneal veins are
profusely valved, containing valves at about 2-cm intervals.
The popliteal vein and the most distal part of the femoral
vein usually have one or two valves. There are three or
more additional valves in the femoral vein, up to the junction with the profunda femoris vein. One of these valves is
consistently (~90%) found just distal to this junction.
36
In
the common femoral vein, there is usually only one valve.
It is important to emphasize that in the external iliac and
common femoral veins proximal to the saphenofemoral
junction, there is only one valve or, in 37% of cases, there is
no valve at all. In anatomical dissections of 32 limbs Muhlberger etal. found a common femoral vein valve proximal
to the saphenofemoral junction in 71%.
36
The common
iliac and cava veins are valveless.
2.2.1.4 Perforating veins
There are more than 150 PVs in the lower extremities;
however, the medial PVs are most signicant and have been
in the center of debate for decades.
development of chronic venous insufciency and venous
ulcers is still not well dened. Signicant variation exists
in the location of leg perforators; however, the distribution
of clusters of PVs follows a predictable pattern. Dorsal,
plantar, medial, and lateral foot perforators are the main
groups of PVs in the foot. Alarge PV runs between the rst
and second metatarsal bones and connects the supercial
28,40–42
Their role in the
2.12 Relationship of the medial direct perforating veins to the
deep and supercial posterior fascial compartments. PTV: posterior tibial veins; SPC: supercial posterior fascial compartment.
dorsal venous arch to the pedal vein. The clusters of PVs at
the ankle are the anterior, medial, and lateral ankle perforators. The medial calf perforators exist in two groups: posterior tibial and paratibial PVs. Three groups (lower, middle,
and upper) of posterior tibial PVs connect the posterior
accessory GSV to the posterior tibial veins (Figure2.12).
The paratibial perforators drain the GSV into the posterior
tibial veins.
28
Other perforators of the leg below the knee
are the anterior, lateral, medial, and lateral gastrocnemius,
intergemellar, and Achillean PVs. Infrapatellar and suprapatellar and popliteal fossa PVs are located around the
knee. Perforators of the femoral canal connect tributaries
of the GSV to the femoral vein (Figure2.6). Inguinal perforators drain into the femoral vein in the proximal thigh.
In an ultrasound study of 20 normal adults Hill and
van Rij identied a mean of 14.2 (range, 8–21) perforators
in each limb. Flow was always from supercial to deep.
The paratibial perforators usually drained into the posterior tibial veins, but a formal posterior accessory GSV of
the calf could not be identied in this study.
43
2.2.1.5 Venous sinuses of calf muscles
Venous sinuses are thin-walled, large veins in the calf muscles, which have a capacity to hold great volumes of venous
blood. They are embedded in skeletal muscles, which contract rhythmically during ambulation; therefore, they serve
as “chambers” of the “peripheral heart”: the calf muscle
pump. The soleus muscle is particularly rich in venous
sinuses; it may contain 1 to 18 of such sinuses. They are
less developed in the gastrocnemius muscle. Venous sinuses
are lled from the supercial veins and from the reticular
venous plexus through indirect, muscular perforators and
from the muscles through postcapillary venules and small
muscular veins. Venous sinuses of the soleus muscle are
drained into the posterior tibial and peroneal veins by the
soleal veins (Figure2.11). The soleus veins are large, short,
and tortuous to accommodate the considerable range of
muscular movements. In the lower third of the leg, the
soleus veins frequently join directly into PVs before entering the deep veins. Bilateral gastrocnemius veins draining
the two heads of the gastrocnemius muscle usually empty
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into the popliteal vein, distal to the conuence of the SSV
with the popliteal trunk (Figure2.11). The venous sinuses
themselves are valveless; however, the small intramuscular
veins linking them and the muscular veins draining venous
sinuses into the deep veins contain numerous valves. Indirect PVs feeding venous sinuses are also valved. Valvular
competence plays a critical role in the efcient functioning of the calf muscle pump. Compression of the plantar
venous plexus during ambulation signicantly increases
the ow through the posterior tibial veins into the popliteal veins.
44
2.2.2 Veins of the abdomen and pelvis
The external iliac vein begins at the inguinal ligament,
courses along the pelvic brim, and ends anterior to the
sacroiliac joint by joining the internal iliac to form the
common iliac vein. Its tributaries are the (deep) inferior
epigastric, the deep circumex iliac, and the pubic veins,
which freely anastomose with the corresponding supercial veins and with the obturator vein. The internal iliac
vein is a short trunk that is formed by the union of its
extrapelvic and intrapelvic tributaries. The extrapelvic
tributaries are the gluteal (superior and inferior), the internal pudendal, and the obturator veins. The gluteal veins
anastomose with the medial circumex femoral vein and
receive numerous PVs from the corresponding supercial
veins (Figure2.13). The intrapelvic tributaries of the internal iliac vein, such as the lateral sacral and several visceral
(middle rectal, vesical, uterine, and vaginal) veins, drain
the presacral venous plexus and the pelvic visceral plexuses (rectal, vesical, prostatic, uterine, and vaginal). These
plexuses and the additional supercial (pudendal) plexus
provide free communication for venous ow between the
two sides of the pelvis.
The recently published Symptoms-Varices-Pathophysiology Classication of Pelvic Venous Disorders
four anatomic zones (Figure 59.1). Zone 1 includes the
renal veins and Zone 2 the gonadal, internal iliac, and pelvic veins. Zones 3 and 4 are outside the pelvis—Zone 3
includes pelvic-origin extrapelvic veins, reuxing through
escape points to the genitalia and lower extremity veins,
and Zone 4 comprises veins of the lower extremities.
The common iliac veins begin at the sacroiliac joints
and form a conuence at the right side of the fth lumbar vertebra to form the IVC. The only tributary of the
right common iliac vein is the right ascending lumbar vein,
whereas the left drains the median sacral vein as well. The
ascending lumbar vein runs vertically along the vertebral
column, collects blood from lumbar veins, and proximally
anastomoses with the azygos system.
The IVC ascends on the right side of the vertebral column and terminates in the right atrium very shortly after
passing through the diaphragm (Figure2.13). Its tributaries
are the lumbar veins; the right gonadal vein; the renal veins;
and the right suprarenal, the right inferior phrenic, and the
hepatic veins. The left gonadal and suprarenal veins join
the left renal vein, and the left inferior phrenic vein opens
into the left suprarenal vein. In case of IVC obstruction,
anastomoses between the veins of the chest and abdominal
45
dened
2.2 Anatomy 21
Left innominate v.
Subclavian v.
Sup.
intercostal
v.
Arch of the
azygos v.
Azygos v.
T12
Inf. vena cava
Renal v.
R. gonadal v.
Common
iliac v.
Int. iliac v.
Presacral
plexus
Gluteal v.
Visceral
plexus
Superficial plexus Profunda femoris v.
Great saphenous v.
2.13 Major veins of the pelvis, abdomen, and thorax.
Int. jugular v.
Cephalic v.
Sup.
vena
cava
Accessory
hemiazygos
Hemiazygos v.
L. gonadal v.
Ascending
lumber v.
Lumber vv.
Medial
sacral v.
Lat.
sacral v.
Obturator v.
Ext.
iliac v.
Medical circumex v.
Femoral v.
Axillary v.
v.
Common
femoral
v.
wall (thoraco-epigastric, internal thoracic, and epigastric
veins), the lumbar-azygos connections, and the vertebral
plexuses can provide important collateral avenues.
2.2.3 Veins of the upper extremity and the
thorax
2.2.3.1 Upper extremity veins
Venous return from the arm is mostly maintained by the
functioning of the heart. Valves do not play an important
role in this venous circulation. The deep veins of the arm
are paired and follow their corresponding arteries. Perforators between the deep and supercial veins are less numerous in the arm than in the leg.
2
22 Chapter 2 Development and anatomy of the venous system
.
.
.
C
Cephal
m
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ic v.
Cephalic v.
Basilic v
Basilic v.
Median cubital v.
Median cubital v
ephalic v.
Cephalic v.
2.14 Supercial veins of the upper extremity.
Basicl
v
Basiclic v.
Median v. of forear
Median v. of forearm
The supercial veins of the upper limb are the cephalic
and basilic veins and their tributaries (Figure 2.14). The
dorsal venous plexus of the hand continues into the
cephalic vein on the radial and into the basilica vein on
the ulnar side. The cephalic vein begins at the “anatomical snuff box,” courses over the distal radius to the ventral
aspect of the forearm and ascends on the lateral side of the
arm and in the deltopectoral groove. It enters the infraclavicular fossa, pierces the clavipectoral fascia, and empties
into the axillary vein. The basilic vein ascends on the ulnar
side of the forearm, perforates the deep fascia about midway in the arm, and, after receiving the deep brachial vein,
it continues into the axillary vein. Knowledge of the anatomic variations of the basilic vein are important for those
who perform access procedures for dialysis.
46
The median
cubital vein connects the cephalic and basilic veins in front
of the elbow. Variations are common, including the presence of additional major venous trunks, such as the accessory cephalic or antebrachial veins. The deep veins (radial,
ulnar, brachial, and axillary veins) are usually paired and
follow the course of the main arteries of the arm.
The axillary vein begins at the lower border of the teres
major, which corresponds with the lateral border of the
scapula on an anteroposterior chest roentgenogram. At
the outer border of the rst rib, it becomes the subclavian,
which ends at the medial border of the scalenus anterior
muscle, where it joins the internal jugular vein to form
the brachiocephalic vein. The brachiocephalic (innominate) vein begins behind the sternoclavicular joint. The left
brachiocephalic vein descends obliquely to join the right
one. Constant tributaries of the brachiocephalic vein are
the vertebral, internal thoracic, and inferior thyroid veins.
The superior intercostal vein drains the upper intercostal
veins and opens into the brachiocephalic vein on the left,
whereas on the opposite side it joins the azygos vein.
The SVC is formed behind the rst right costal cartilage
by the union of the brachiocephalic veins. It descends right
of the ascending aorta and opens into the right atrium at
the level of the third right costal cartilage. Halfway along
its length, before it enters the pericardium, it receives the
azygos vein from behind.
2.2.3.2 Azygos veins
The origin of the azygos vein is not constant. It may arise
from the back of the IVC at the level of the renal veins, or
it may be the continuation of the right ascending lumbar
vein (Figure2.13). The azygos vein ascends on the right
side of the body until the fourth thoracic vertebra and then
passes anteriorly to join the SVC. Major tributaries of the
azygos vein are the right superior intercostal, the hemiazygos, and the accessory hemiazygos veins. The hemiazygos
vein courses on the left side of the vertebral column, and
its origin is like that of the azygos vein. At the level of the
eighth thoracic vertebra, it crosses the column and joins
the azygos vein. Often, the left renal vein communicates
with the hemiazygos vein. The accessory hemiazygos vein
descends left to the vertebral column and parallel with
the azygos vein. Proximally, it anastomoses with the left
brachiocephalic vein and ends distally when it joins to the
azygos or the hemiazygos veins at the level of the seventh
thoracic vertebra. The azygos veins drain the intercostal
veins on both sides, receive several visceral tributaries, and
freely anastomose with the vertebral venous plexuses. The
azygos veins and their tributaries provide important collateral circulation in the face of SVC or IVC obstruction.
2.3 HISTOLOGY
The venous wall is three layered: intima, media, and adven-
47
The intima uniformly consists of a single layer of
titia.
endothelial cells resting on scant connective tissue. The
internal elastic lamina, a layer of thick elastic bers at
the base of the intima, is frequently incomplete in medium-sized veins and absent in smaller ones. Venous valves
are bicuspid infoldings of the intima covered by endothelium on both sides, with an intervening connective tissue
skeleton (Figures2.15 and 2.16). At the origin of valves,
the veins may be focally distended, forming a small sinusoid dilation, probably in response to the hemodynamic
consequences of focally reversed ow.
The media is composed of layers of smooth muscle cells
and connective tissue. The relative thickness of the media
and the proportions of the two major components vary
(a)
(b
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)
2.15 Proximal (a) and distal (b) aspects of a venous valve
(stereo microscopy, magnication: ×14).
References 23
2
2.16 Histology of a venous valve (orcein, magnication: ×2.5).
considerably with different sizes and functions. The major
supercial veins, such as the GSV and SSV, have thick muscular media, providing the ability to contract and to resist
the development of varicosities. Tributaries of the saphenous veins have thinner media and can become more easily
varicosed. The media of the deep veins of the calf contain
as much smooth muscle as saphenous veins; however, their
collagen content is higher, resulting in a more rigid wall.
The larger deep veins (femoral, iliac, axillary, subclavian,
and innominate) contain less smooth muscle cell mass. The
adventitia is poorly demarcated and contains loose connective tissue with lymphatics, vessels (vasa vasorum), and
adrenergic nerve bers.
Consensus Statements 2.0 of the American Venous Forum on the development and anatomy of the venous system
No. Consensus Statements
2.1 The main deep vein of the thigh between the popliteal and the common femoral vein is the femoral vein. The old term “supercial femoral vein” should be abandoned.
2.2 The main supercial truncal veins of the lower limbs are the great saphenous vein and the small saphenous vein. The old
terms “long or greater, or short or lesser” should be abandoned.
2.3 The old terms “Cockett” and “Giacomini” veins should be replaced by the new terms “posterior tibial perforating vein” and
“intersaphenous vein,” respectively. The use of eponyms is discouraged.
REFERENCES
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DV, Messing B, Shen O, etal. The fetal
venous system, Part II: Ultrasound evaluation of the fetus with congenital venous
system malformation or developing circulatory compromise. Ultrasound Obstet
Gynecol. 2010;36(1):93–111.
2. Yagel S, Kivilevitch Z, Cohen SM,
Valsky DV, Messing B, Shen O, etal.
The fetal venous system, part I: Normal
embryology, anatomy, hemodynamics,
ultrasound evaluation and Doppler
investigation. Ultrasound Obstet Gynecol.
2010;35(6):741–50.
3. Uhl JF, Gillot C. Embryology and three-dimensional anatomy of the supercial
venous system of the lower limbs. Phlebology. 2007;22(5):194–206.
4. Uhl JF, Verdeille S, Martin-Bouyer Y.
Three-dimensional spiral CT venography
for the pre-operative assessment of varicose patients. Vasa. 2003;32(2):91–4.
5. Kerver AL, van der Ham AC,
Theeuwes HP, Eilers PH, Poublon AR,
Kerver AJ, etal. The surgical anatomy
of the small saphenous vein and adjacent
nerves in relation to endovenous
thermal ablation. J Vasc Surg.
2012;56(1):181–8.
6. Terminologia Anatomica. International
Anatomical Terminology, Federative
Committee on Anatomical Terminology.
Stuttgart; New York: Thieme. 1998.
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