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13 Transcutaneous Laser Vein Ablation . . . . . . . . . . . . . . . . . . . . . 175
Joyce Jackson and Craig F. Feied
Part IV Non-Superfi cial Veins
14 Perforator Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Elna M. Masuda and Darcy M. Kessler
15 Upper Deep Vein Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Sapan S. Desai, Eric Mowatt-Larssen,
and Mitchell Cox
16 Lower Deep Vein Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Jovan N. Markovic and Mitchell Cox
17 Low-Flow Vascular Malformations . . . . . . . . . . . . . . . . . . . . . . 233
Jovan N. Markovic and Cynthia K. Shortell
Part V Thrombosis
18 Ultrasound for Thrombosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Jennifer Heller
19 Superfi cial Venous Thrombophlebitis . . . . . . . . . . . . . . . . . . . . 259
Marlin W. Schul
Contents
20 Deep Vein Thrombosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Sapan S. Desai, Eric Mowatt-Larssen, and Ali Azizzadeh
21 Anticoagulation for Venous Thromboembolism . . . . . . . . . . . . 293
Thomas L. Ortel
22 Thrombophilias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Stephanie M. Dentoni
Part VI Special Topics
23 Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
James Laredo and Byung Boong Lee
24 Venous Leg Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Robert B. McLafferty
25 Biostatistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Elaheh Rahbar, Sapan S. Desai, Eric Mowatt-Larssen,
and Mohammad Hossein Rahbar
26 Vein Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
David O. Joseph, Jessica L. Myers, and Eugene W. Moretti
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Contributors
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Ali Azizzadeh , MD Department of Cardiothoracic and Vascular Surgery ,
University of Texas at Houston Medical School , Houston , TX , USA
Naga Ramesh Chinapuvvula , MD Department of Radiology ,
University of Texas-Houston, Memorial Hermann Hospital , Houston ,
TX , USA
Mitchell Cox , MD Department of Surgery , Duke University Medical
Center , Durham , NC , USA
Stephanie M. Dentoni , MD, FSVM California Vein and Vascular Institute ,
Stockton , CA , USA
Sapan S. Desai , MD, PhD, MBA Department of Surgery , Duke University
Medical Center , Durham , NC , USA
Department of Cardiothoracic and Vascular Surgery, University of Texas at
Houston Medical School , Houston , TX , USA
Craig F. Feied , MD, FACEP, FAAEM, FACPh Department of Emergency
Medicine, Georgetown University School of Medicine , Washington , DC ,
USA
Daniel F. Geersen , MPAP, PA-C Division of Vascular Surgery ,
Duke University Medical Center , Durham , NC , USA
Sergio Gianesini , MD Vascular Disease Center, University of Ferrara ,
Ferrara , Italy
David L. Gillespie , MD, RVT, FACS Division of Vascular Surgery ,
Heart and Vascular Center, Southcoast Health System, Charlton Hospital ,
Fall River , MA , USA
Department of Surgery , Uniformed Services University of the Health
Sciences, F. Edward Hebert School of Medicine , Bethesda , MD , USA
Carlos J. Guevara , MD Division of Vascular and Interventional
Radiology , Department of Radiology, Duke University Medical Center ,
Durham , NC , USA
Jennifer Heller , MD Department of Surgery , Johns Hopkins Vein
Centers, Johns Hopkins University , Baltimore , MD , USA
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Mark N. Isaacs , MD, FACPh, FAAFP, RPhS Vein Specialists
of Northern California , Walnut Creek , CA , USA
Joyce Jackson , RN, MSN, ANP, BC Belmont Aesthetic
and Reconstructive Surgery , Chevy Chase , MD , USA
Berman Skin Institute , Palo Alto , CA , USA
Sean Johnston , MD Department of Radiology , University of TexasHouston, Memorial Hermann Hospital , Houston , TX , USA
David O. Joseph , MD, MS Department of Anesthesia , University of Texas
at Houston Medical School , Houston , TX , USA
Darcy M. Kessler , RVT Division of Vascular Surgery , Straub Clinic and
Hospital, John A. Burns School of Medicine , Honolulu , HI , USA
Charles Y. Kim , MD Division of Vascular and Interventional Radiology ,
Duke University Medical Center , Durham , NC , USA
Brian S. Knipp , MD, MC, USN Division of Vascular Surgery , School of
Medicine and Dentistry, University of Rochester , Rochester , NY , USA
SreyRam Kuy , MD, MHS Division of Vascular Surgery , Medical College
of Wisconsin , Milwaukee , WI , USA
Contributors
James Laredo , MD, PhD, FACS, RVT, RPVI Department of Surgery,
Division of Vascular Surgery, George Washington University Medical
Center , Washington , DC , USA
Byung Boong Lee , MD, PhD, FACS George Washington University
Medical Center , Washington , DC , USA
Jovan N. Markovic , MD Department of Surgery , Duke University Medical
Center , Durham , NC , USA
Elna M. Masuda , MD Division of Vascular Surgery , Straub Clinic and
Hospital, John A. Burns School of Medicine , Honolulu , HI , USA
Robert B. McLafferty , MD, FACS, RVT Division of Vascular Surgery,
Department of Surgery , Southern Illinois University, School of Medicine ,
Springfi eld , IL , USA
Jason McMaster , MD Obstetrics and Gynecology , Medical College
of Wisconsin , Milwaukee , WI , USA
Frank R. Miele , MSEE Pegasus Lectures, Inc. , Forney , TX , USA
Eugene W. Moretti , MD, MHSc. Department of Anesthesiology ,
Duke University Medical Center , Durham , NC , USA
Nick Morrison , MD, FACPh, FACS, RPhS Morrison Vein Institute ,
Scottsdale , AZ , USA
Eric Mowatt-Larssen , MD, FACPh, RPhS Vein Specialists of Monterey ,
Monterey , CA , USA
Contributors
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Cary Munschauer , BA Department of Surgery, The Venous Institute of
Buffalo , Buffalo , NY , USA
Jessica L. Myers , MD Department of Anesthesiology , Duke University
Medical Center , Durham , NC , USA
Diana L. Neuhardt , RVT, RPhS CompuDiagnostics, Inc. , Phoenix ,
AZ , USA
Thomas L. Ortel , MD, PhD Departments of Medicine and Pathology ,
Duke University Medical Center , Durham , NC , USA
Marc A. Passman , MD Section of Vascular Surgery and Endovascular
Therapy , University of Alabama at Birmingham , Birmingham , AL , USA
Elaheh Rahbar , PhD Department of Surgery , Center for Translational
Injury Research, University of Texas Medical School at Houston ,
Houston , TX , USA
Mohammad Hossein Rahbar , PhD Department of Epidemology and
Biostatistics , Human Genetic and Environmental Sciences, University of
Texas School of Public Health at Houston ,
Houston , TX , USA
Marlin W. Schul , MD, MBA, RVT, FACPh Venous and Lymphatic
Medicine, Lafayette Regional Vein and Laser Center, A division of Unity
Healthcare, LLC , Lafayette , IN , USA
Cynthia K. Shortell , MD, FACS Department of Vascular Surgery ,
Duke University Medical Center , Durham , NC , USA
Julianne Stoughton , MD, FACS Department of Vascular Surgery ,
Massachusetts General Hospital , Boston , MA , USA
Michael A. Vasquez , MD, FACS, RVT SUNY Buffalo Department
of Surgery , The Venous Institute of Buffalo , Buffalo , NY , USA
Paolo Zamboni , MD Vascular Disease Center, University of Ferrara ,
Ferrara , Italy
Joseph A. Zygmunt Jr. , RVT, RPhS Covidien Vascular Therapies ,
Global Clinical Education , San Jose , CA , USA
Part I
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Basic Sciences
Anatomy
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Brian S. Knipp and David L. Gillespie
1
Contents
1.1 The Central Venous System ...................... 3
1.2 The Extremity Venous System .................. 5
1.3 Histology of the Vein Wall ......................... 5
1.4 Anatomy of the Lower Extremity
Venous System ............................................ 5
1.4.1 Veins of the Foot .......................................... 5
1.4.2 Great Saphenous System ............................. 7
1.4.3 Small Saphenous System ............................. 10
1.4.4 Auxiliary Superfi cial Venous Systems......... 11
1.4.5 Deep Venous System ................................... 11
1.4.6 Perforators.................................................... 12
1.4.7 Fascial Compartments ................................. 14
1.4.8 Calf Muscle Venous Anatomy ..................... 15
1.4.9 Valves ........................................................... 15
References ............................................................... 16
B. S. Knipp , MD, MC, USN
Division of Vascular Surgery ,
School of Medicine and Dentistry,
University of Rochester , Rochester , NY , USA
e-mail: brian_knipp@urmc.rochester.edu
D. L. Gillespie , MD, RVT, FACS (*)
Division of Vascular Surgery ,
Heart and Vascular Center,
Southcoast Health System,
Charlton Hospital , Fall River , MA 02720 , USA
Department of Surgery, Uniformed Services
University of the Health Sciences ,
F. Edward Hebert School of Medicine ,
Bethesda , MD 20854 , USA
e-mail: david_gillespie@urmc.rochester.edu
Abstract
Embryology and Development of the
Venous System
This chapter focuses on the key embryology,
anatomy, and histology of the venous system.
The embryology and development of the
venous system are intimately related. In normal embryologic development of the central
venous system, venous channels arise within
the fourth week with completion by the seventh to eighth week of development. The
extremity venous system begins with primitive vascular channels developing in the limb
during the third week of gestation. The veins
of the foot along with the great and small
saphenous system, auxiliary superfi cial
venous systems, deep venous system, and perforators constitute the anatomic makeup of the
lower limb.
1.1 The Central Venous System
In normal embryologic development, venous
channels arise within the fourth week. At this
point, paired vascular channels run along the dorsum of the developing embryo and are joined in
the middle forming a rough “H” shape.
The superior-most vessels, known as the anterior cardinal veins, are the precursors of the superior vena caval system. The cranial aspects of
these vessels persist as the internal jugular veins.
Venous buds from the upper extremities develop
E. Mowatt-Larssen et al. (eds.), Phlebology, Vein Surgery and Ultrasonography,
DOI 10.1007/978-3-319-01812-6_1, © Springer International Publishing Switzerland 2014
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B.S. Knipp and D.L. Gillespie
Posterior cardinal veins
Fig. 1.1 In the fourth week of embryologic development,
paired vascular channels, known as the anterior and posterior cardinal veins, arise and join in the midline at the
sinus venosus, the site of development of the cardiac
system
anastomoses to the anterior cardinal system and
give rise to the subclavian and brachiocephalic
veins. The inferior vessels are known as the posterior cardinal veins and serve as the precursors
to the inferior vena cava (IVC) and iliac venous
system. At the midpoint of the channels, there is
a lateral connection known as the sinus venosus,
which represents the developing cardiac system.
The anterior cardinal veins, cranial to the sinus
venosus, are the precursors of the superior vena
cava (SVC) and the venous system draining the
head and upper extremities (Fig. 1.1 ).
Starting in the sixth week of development, the
posterior cardinal veins begin to regress in the
middle, whereas the distal posterior cardinal
veins develop a weblike anastomosis. At the cranial extent of the posterior cardinal veins, just
inferior to the sinus venosus, a new pair of venous
channels arises, known as the subcardinal veins,
lying anteromedial to the posterior cardinal veins.
These vessels join near the mesonephric to form
a midline anastomosis, known as the preaortic
intersubcardinal anastomosis. In addition, at this
point, the primitive hepatic venous system begins
to develop as the vitelline veins, which drain the
yolk sac, coalesce into the portal venous system.
Near the connection with the right subcardinal
vein, this system is interrupted by hepatic sinusoids, the site of the developing liver parenchyma. These sinusoids are in turn drained by the
efferent venae revehentes, which combine to
form the left and right hepatic veins, which drain
into the right atrium. Downward extension of the
venae revehentes anastomoses with the developing inferior vena cava (Fig. 1.2 ).
In the seventh week of embryologic development, the posterior cardinal veins have nearly
completely regressed with the exception of the
cranial and caudal extent, the latter of which
has joined to form the iliac venous bifurcation.
The mesonephric anastomosis of the subcardinal veins develops into the aortic collar; the
usual developmental pattern is regression of the
retroaortic component, leaving a preaortic left
renal vein. The failure of the retroaortic segment to regress leads to a circumaortic or retroaortic left renal vein, depending on the
persistence or regression of the preaortic segment. The subcardinal vein regresses at this
point in all areas except for the suprarenal IVC.
A new pair of venous channels arises at this
time: the supracardinal veins. The right supracardinal vein anastomoses with the right subcardinal vein to become the renal segment of
the vena cava and persists caudally as the
postrenal segment until it anastomoses with the
posterior cardinal vein remnant at the iliac
venous bifurcation (Fig. 1.3 ).
Finally, the cranial components of the supracardinal veins persist as the azygous and hemiazygous
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Superior vena cava
Vena revehens
Tract of developing
aorta
Subcardinal veins
Posterior cardinal veins
(regressing)
Fig. 1.2 In the sixth week of embryologic development,
the posterior cardinal veins begin to regress in their midpoint and join distally to form the future iliac venous
bifurcation. The subcardinal veins develop and anastomose in the perinephric region. The venae revehentes
develop as an outfl ow tract for the portal venous circulation and hepatic sinusoids, draining into the right atrium
and forming an inferior anastomosis with the developing
inferior vena cava
One of the fundamental principles of extremity
vascular development is that the vasculature
tends to parallel major neural structures as the
axons and Schwann cells secrete vascular endothelial growth factor, attracting vascular growth
and encouraging differentiation [ 2 ]. In the leg,
the sciatic nerve induces development of the
deep venous plexus and, below the knee, the
small saphenous vein (SSV). The femoral nerve
guides the development of the great saphenous
vein (GSV). Alterations in the dominance and
reabsorption of primitive venous channels can
lead to venous anomalies such as an axiofemoral
trunk (predominance of the profunda femoris
vein in the thigh and distal anastomosis to the
proximal popliteal vein; the femoral vein is a
small collateral channel) or bifi dity of the femoral vein [ 3 ].
1.3 Histology of the Vein Wall
There are three layers to the vein wall, just as in
the arterial system, namely, intima, media, and
adventitia. However, there is a variance in proportion in the venous system. The intima is generally a single layer of cells lying on a thin
connective tissue skeleton. In the GSV, there is a
relatively thick media which resists dilatation.
However, tributary vessels tend to be quite fragile with minimal media. Deep veins tend to have
fewer smooth muscle cells and a greater proportion of connective tissue.
systems. The completed development of the central venous system is shown in Fig. 1.4 .
1.2 The Extremity Venous
System
Primitive vascular channels occur in the limb
during the third week of gestation. Initially, only
a capillary network is present. This coalesces
into larger plexuses and eventually, by the end of
the third week, into large channels with the
appearance of veins, arteries, and lymphatics [ 1 ].
1.4 Anatomy of the Lower
Extremity Venous System
1.4.1 Veins of the Foot
In the original Terminologia Anatomica descrip-
tion, all the venous structures of the foot were
classifi ed as superfi cial. However, in the latest
interdisciplinary consensus conference on
nomenclature, while the dorsal venous drainage
of the foot is primarily superfi cial in its named
structures, the plantar venous drainage is considered a deep venous system [ 4 ].
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Fig. 1.3 In the seventh week
of embryologic development,
the posterior cardinal veins
have regressed completely
aside from the caudal extent
forming the iliac bifurcation.
The mesonephric anastomosis of the subcardinal veins
develops into the renal
segment of the IVC and the
left and right renal vein; the
cranial extent of the right
subcardinal vein persists as
the suprarenal IVC. The
supracardinal veins develop
and form the infrarenal
segment of the IVC as well
as contribute to the renal
segment
Superior vena cava
Inferior vena cava
B.S. Knipp and D.L. Gillespie
Tract of developing
aorta
Right supracardinal
vein
Right posterior cardinal
vein (regressed)
The venous drainage of the dorsal surface of
the foot can be divided into a well-defi ned superfi cial system and an ill-defi ned deep system. The
superfi cial system is comprised of a discrete dorsal venous arch which gives rise to the medial
and lateral marginal veins, which drain into the
great saphenous vein and the small saphenous
vein, respectively. The dorsal deep venous system of the foot consists of the venae comitantes
of the dorsalis pedis artery, which join to form the
Left supracardinal
vein
Left posterior cardinal
vein (regressed)
Subcardinal veins (regressing)
pedal vein, continuing as the anterior tibial veins.
The anterior tibial veins enter the anterior compartment of the leg and run cephalad along the
course of the anterior tibial artery. Perforating
veins connect these two systems [ 4 , 5 ] (Fig. 1.5 ).
On the plantar surface, the anatomy is deep
system dominant due to the weight-bearing
nature of the foot. The superfi cial veins tend to be
ill-defi ned. The plantar venous network consists
of the deep plantar arch which connects the
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Superior vena cava
Hemiazygos veinAzygos vein
Inferior vena cava
Left renal vein
Inferior vena cava
Fig. 1.4 In the completed central venous system, the
anterior cardinal veins have developed into the SVC and
brachiocephalic venous system. The subcardinal system
has developed into the suprarenal and renal segment of
the IVC as well as the left and right renal vein. The supracardinal system has developed into the infrarenal IVC as
well as the azygous and hemiazygous systems. And the
vitelline veins have coalesced to form the portal venous
system which drains through the developing liver into the
hepatic veins which arise from the venae revehentes
medial and lateral plantar veins. These veins join
to form the posterior tibial veins which then pass
posterior to the medial malleolus and track in a
cephalad direction along the posterior tibial
artery. Perforators exist along the medial and lateral foot, but not appreciably in the plantar
surface. Small accessory veins may drain the surface of the forefoot and fl ow directly into the
peroneal or posterior tibial veins [ 4 , 5 ] (Fig. 1.6 ).
1.4.2 Great Saphenous System
The great saphenous vein (GSV) system begins
in the dorsal venous arch of the foot, which
drains medially through the medial marginal
vein to enter the caudal GSV. This then ascends
anterior to the medial malleolus of the ankle,
crosses the tibia, and continues to ascend the
medial calf. In the distal two-thirds of the calf,
this vein is intimately associated with the saphenous nerve, which supplies cutaneous innervation to the medial calf. The GSV then crosses
the medial surface of the knee and continues
cranially along the medial thigh to enter the
deep system at the saphenofemoral junction,
passing through the fossa ovalis located 3 cm
inferior and 3 cm lateral to the pubic tubercle
(Fig. 1.7 ).
In their study of 1,400 venous studies,
Kupinski et al. documented the following size
ranges for the superfi cial venous system: 2.2–
10.0 mm in the proximal thigh, 1.5–8.8 mm in
the distal thigh, 1.2–7.3 mm in the proximal calf,
and 1.0–5.5 mm in the distal calf [ 6 ].
Several tributaries can enter the vein along its
length. In the calf, both the anterior and posterior
accessory GSV of the calf may be present, draining the lateral and posteromedial calf, respectively. Above the knee, the anterior accessory
GSV of the thigh, if present, drains the lateral
thigh and may provide a communication between
the lateral superfi cial venous plexus and the
GSV system. The posterior accessory GSV of
the thigh drains the medial thigh and runs posterior to the GSV. There may also be an anterior
and/or a posterior thigh circumfl ex vein draining
the lateral and medial thigh, respectively, inferior to the accessory saphenous veins. The key
differentiation between the actual GSV and
accessory or tributary vessels is the saphenous
fascial envelope, which runs along the entire
length of the GSV. This separate saphenous
compartment is bounded superfi cially by
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