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Table2.1 HISTORIC AND NEW ANATOMIC TERMS OF
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LOWER EXTREMITYVEINS
HISTORIC TERM NEW TERM
Greater or long saphenous vein Great saphenous vein (GSV)
Smaller or short saphenous vein Small saphenous vein (SSV)
Saphenofemoral junction Con uence of the super cial
inguinal veins
Giacomini’s vein Intersaphenous vein
Posterior arch vein or
Leonardo’s vein
Posterior accessory great
saphenous vein of the leg
Super cial femoral vein Femoral vein
Cockett perforators (1,11,11) Posterior tibial perforators
(lower, middle, 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
supracardinal vein is associated with regression of the right
7
supracardinal vein (see Figure2.2D).
Developmental variations of the le renal vein include persistent (circumaortic)
renal collar (1–9%) and retroaortic le renal vein (1–2%)
8
(see Figure2.3).
Capillaries of the primitive limb buds initially drain into
the marginal sinuses. In the arm the ulnar portion of the
marginal sinuses dominate over the radial ones, and eventually form the basilic, axillary, and subclavian veins. e subclavian vein drains into the proximal anterior cardinal vein.
e cephalic vein develops secondarily from segments of the
radial marginal sinuses and attaches to the axillary vein later.
In the leg, segments of the primitive marginal sinuses persist
only distally and develop into the peroneal, anterior tibial,
and small saphenous veins (SSV). e great saphenous vein
(GSV) originates from the posterior cardinal vein and later
gives o the femoral, popliteal, and posterior tibialveins.
HISTOLOGY
the liver sinusoids, the suprarenal segment of the IVC will
not develop, consequently the lower part of the body will be
drained through the azygos system and the liver will drain
directly into the heart. Double IVC (0.2–3%) occurs due to
the persistence of the le supracardinal vein, therefore it usually involves only the infrarenal segment (see Figure2.2C).
Le -sided IVC (<0.5%) develops if persistence of the le
e venous wall has three layers:intima, media, and adventitia. e intima is made up by endothelial cells and an
underlying thin connective tissue layer. Valves are formed
by infolding of the intima, therefore they are covered with
endothelium on both sides and have a very thin connective
6
tissue skeleton. Venous valves are bicuspid. e veins are
distended at the base of the valves, probably secondary to
ABCD
Sinus venosus
Viselline
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.
Supradcardinal
v.
Prerenal
segment
(Subcardinal)
Renal segment
(Subsupracardinal
anastomosis)
Postrenal
segment
(Supracardinal)
Hypogastric v.
Ant. cardinal
v.
Hepatic
segment
of
Inf. vina
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.
Sup.
vena
cava
v.
v.
R. renal
or ovarian
R. int. jugular v.
L. brachiocephalic v.
Oblique
v.
Inf.
vena
cava
v.
v.
Int. iliac v. Median sacral v.
Hemiazygos
v.
L.
suprarenal
v.
L. renal
v.
L.
spermatic
of ovarian
v.
L. common
illiac v.
Figure2.1 Embryology of the major veins (adapted with permission from Avery LB. Developmental anatomy , rev. 7e. Philadelphia:Saunders,1974).
18 • BASIC CONSIDERATIONS
A
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R. branchiocephalic v.
L. Sup. vena cava
R. Sup. vena cava
B
in small ones. e media is composed of smooth muscle
cells and connective tissue bers, most of which is collagen.
Larger super cial veins, such as the GSV, have thick muscular media with the ability of signi cant contraction. Smaller
tributaries of the GSV have thinner media, and therefore
are more prone to varicosity. Media of the deep calf veins
Pulmonary
vv.
Coronary
sinus
Inf.
vena
carva
CD
Inf. vena cava
L. renal v.
contain plenty of collagen, providing better wall strength.
More central deep veins, such as femoral, iliac, axillary, and
subclavian veins, contain less and less smooth muscle cell.
e media of the superior and inferior vena cava is built up
almost exclusively from connective tissue. e adventitia is
poorly di erentiated from the media, in particular in larger
veins. It consists of some loose connective tissue with vasa
vasorum and nerve bers.
9,10
A N A T O M Y O F T H E
THORACICVEINS
R. renal v.
Gonadal vv.
Aorta
L. inf. vena cava
Figure2.2 Developmental anomalies of the superior (SVC) and inferior
vena cava (IVC). A) Double SVC (posterior view); B) Le SVC
(posterior view); C) Double IVC; D) Le IVC.
the e ects of local ow reversal. e border of the intima is
marked by the internal elastic lamina:a layer of thick elastic bers. e internal elastic lamina is well developed only
in large veins; it is incomplete in medium-sized and absent
Sup. mesenteric a.
L. renal v.
Retroaortic
L. renal v.
Gonadal v.
Figure2.3 Circumaortic renal collar.
e superior vena cava (SVC) starts at the con uence of the
brachiocephalic veins behind the rst right costal cartilage,
and ends at the level of the third right costal cartilage, where
it drains into the right atrium. e SVC is about 7cm long
and 2cm wide. Halfway along its course, before it enters the
pericardium, the SVC receives the azygos arch. e brachiocephalic veins are formed at the con uence of the subclavian
and internal jugular veins behind the sternoclavicular joints
(see Figure 2.4). e right brachiocephalic vein is short,
about 2–3cm, and lies anterior to the innominate artery.
7
e le one is about 6cm long and courses obliquely behind
the manubrium from le to right, anterior to the le subclavian, common carotid arteries, and superior to the aortic
arch. Major tributaries of the brachiocephalic veins are the
vertebral, internal thoracic, and inferior thyroid veins. e
rst intercostal vein drains into the brachiocephalic veins
on both sides. e le superior intercostal vein is connected
to the le brachiocephalic vein, whereas on the right it joins
the azygos vein. ere are no valves in either the SVC or the
brachiocephalicveins.
e azygos-hemiazygos system forms an H-shaped network in the posterior mediastinum, anterior to the body of
the thoracic vertebrae (see Figure2.4). e azygos vein gives
the entire right arm of the H, the hemiazygos gives the le
lower and the accessory hemiazygos vein the le upper segment. e azygos vein starts at T12 to L2 with the con uence of the right ascending lumbar and subcostal veins. e
azygos vein ascends on the right side up to the level of T4,
then passes anterior to form an arch joining the SVC. Major
tributaries of the azygos vein are the right posterior h to
eleventh intercostal veins and the right superior intercostal
vein draining the second to fourth intercostal veins. e
hemiazygos vein starts similar to the azygos vein but on the
le side of the vertebral column at T12 to L2. It courses cranial and at the level of T8 it crosses over to join the azygos
vein. Major tributaries of the hemiazygos vein are the le
VENOUS EMBRYOLOGY AND ANATOMY • 19
Branchiocephalic v.
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Subclavian v.
Int. Jugular v.
Cephalic v.
azygos-hemiazygos system provides an important collateral
7
pathway in case of IVC or SVC obstruction.
ANATOMY OF THE UPPER
EXTREMITYVEINS
Sup.
intercostal
v.
Arch of the
azygos v.
Azygos v.
Inf. vena cava
Renal v.
R. gonadal v.
Common
iliac v.
Int. iliac v.
Presacral
plexus
Gluteal v.
Visceral
plexus
Supercial plexus
Figure2.4 oracic and retroperitonealveins.
Greater saphenous v.
Medial circumex v.
Sup.
vena
cava
L. gonadal v.
Ascending
lumbar v.
Lumbar vv.
Obturator v.
Supercial femoral v.
Axillary v.
Accessory
hemiazygos
v.
Hemiazygos v.
Medial
sacral v.
Lat.
sacral v.
Ext,
iliac v.
Common
femoral
v.
Profunda femoris v.
posterior eighth to eleventh intercostal veins. e accessory
hemiazygos vein has more variation than the azygos and
hemiazygos veins. Usually it drains the le superior intercostal vein (which in turn drains the le second to fourth
intercostal veins) and the le posterior h to seventh intercostal veins. At the level of T7 it either crosses over to the
right and joins the azygos or stays on the le and joins the
hemiazygos vein. If the connection between the accessory
hemiazygos and the rest of the azygos-hemiazygos system
is not developed, the accessory hemiazygos vein will drain
through the le superior intercostal vein into the le brachiocephalic vein. e azygos-hemiazygos system receives
several small veins from the viscera of the chest and freely
anastomoses with the vertebral venous plexuses as well. e
e dorsal and palmar digital veins join to form the metacarpal veins, which drain into the super cially located dorsal venous network of the hand. e cephalic and basilic
veins arise from this network on the radial and ulnar side
of the wrist, respectively. e super cial veins on the palmar side of the hand are richly anastomosed to the deep
veins. Asuper cial and a more proximal deep venous arch
is formed from the interconnection of the palmar veins and
parallel the corresponding arterial arches.
e cephalic vein originates at the anatomical snu box
from the dorsal venous network. It courses over the distal
radius to the ventral aspect of the forearm and ascends on
the lateral side of the arm. e cephalic vein runs in the deltopectoral groove, it enters the infraclavicular fossa behind
the pectoralis major muscle and pierces the clavipectoral
fascia before empting into the axillary vein (see Figure2.5).
e basilic vein begins on the ulnar side of the wrist, passes
along the ulnar aspect of the forearm, and courses more ventrally at the level of the elbow. Above the elbow the basilic
vein runs medial to the biceps and at about midway in the
upper arm it perforates the deep fascia and joins the brachial vein. A er receiving the brachial vein, the basilic vein
continues in the axillary vein. e median cubital vein connects the cephalic and basilic veins in the antecubital fossa.
e medial antebrachial vein originates from the super cial
palmar venous plexus and runs on the ventral side of the
forearm. It joins either the cephalic or basilic vein or both
in the proximal forearm. e accessory cephalic vein originates from the dorsal venous plexus on the ulnar side and
crosses over dorsally to join the cephalic vein in the forearm. Variations in the anatomy of super cial arm veins are
c o u n t l e s s .
Deep veins of the hand join to form the paired radial,
ulnar, and interosseus veins, which accompany the corresponding arteries. e three pairs of deep veins of the forearm form the brachial veins at the level of the elbow. e
paired brachial veins join the basilic vein to form the axillary vein at the lower border of the teres major muscle (at
the lateral border of the scapula on an anteroposterior chest
X-ray). e axillary vein is located medial and inferior to
the axillary artery and the medial cord of the brachial plexus
lies between the two vessels. e axillary vein ends at the
outer border of the rst rib, where it becomes the subclavian
vein. e subclavian vein runs posterior and superior to the
subclavian artery and receives its only major tributary, the
external jugular vein. e subclavian vein ends at the medial
border of the scalenus anterior muscle, where it joins the
internal jugular vein to form the brachiocephalicvein.
20 • BASIC CONSIDERATIONS
Cephalic v.
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Basilic v.
Median
cubital v.
Cephalic v.
Figure2.5 Upper extremity super cialveins.
Basilic v.
Median v.
of forearm
ere are valves in the super cial and deep veins of
the arm, although they are not so numerous as in the leg.
Valves in the axillary vein usually are located proximal to
the junction with the brachial and cephalic veins. e subclavian vein has a valve just proximal to the con uence of
the external jugular vein. Upper extremity venous return is
maintained mainly by the work of the heart without signi cant contribution of a muscle pump. erefore the valves
are less important from a functional standpoint. Perforators
between the deep and super cial veins are scarce.
ANATOMY OF THE ABDOMINAL
AND PELVICVEINS
and the hepatic veins, additionally on the right side the right
gonadal, suprarenal, and inferior phrenic veins also drain
into the IVC (see Figure2.4). e le gonadal and suprarenal veins join the le renal vein; the le inferior phrenic vein
drains into the le suprarenal vein. In case of IVC obstruction, communication between the veins of the thoracic and
abdominal wall (thoracoepigastric, internal thoracic, and
epigastric veins), the lumbar-azygos anastomosis, and the
vertebral plexuses provide important collateral pathways.
e common iliac veins begin at the sacroiliac joint on
both sides and end at L5, where they form the IVC. e only
tributary of the right common iliac vein is the right ascending lumbar vein; the le common iliac vein drains the le
ascending lumbar and median sacral veins (see Figure2.4).
e right common iliac vein lies posterolateral to the right
common iliac artery. e distal segment of the le common
iliac vein is medial and posterior to the le common iliac
artery, the proximal segment is posterior to the right iliac
artery and distal aorta. Compression of the proximal le
common iliac vein may occur due to the overlying arterial
structures. e external iliac vein starts at the level of the
inguinal ligament, it courses along the pelvic brim and ends
anterior to the sacroiliac joint where the external and internal iliac veins form the common iliac vein. On the right the
distal external iliac vein is medial to the artery; however, as
it ascends, more proximally, it courses posterior to it. e
le external iliac vein remains medial to the artery along its
entire course. Tributaries of the external iliac vein are the
inferior epigastric, deep circum ex iliac, and pubic veins.
e internal iliac vein runs posteromedial to the internal
iliac artery on both sides. e short trunk of internal iliac
vein is formed by the con uence of extra and intrapelvic
venous tributaries. e extrapelvic tributaries include the
gluteal (superior and inferior), internal pudendal, and obturator veins, which drain the pelvic wall and the perineum.
Intrapelvic tributaries of the internal iliac vein are the lateral sacral and visceral (middle rectal, vesical, uterine, and
vaginal) veins, which drain the presacral and pelvic visceral venous plexuses (rectal, vesical, prostatic, uterine, and
vaginal).
Both the IVC and the common iliac veins are valveless.
ere is usually one valve in the external iliac vein, but o en
it is without any valves.
e inferior vena cava (IVC) begins at the con uence of the
common iliac veins and ascends on the right side of the vertebral column, passes through the tendinous portion of the
diaphragm, and a er a short course (approximately 2.5cm)
in the chest it terminates in the right atrium at the level of
T9. In the upper abdomen the IVC is located posterior to
the duodenum, the head and neck of the pancreas, the lesser
sac, and the liver. e intrahepatic portion of the IVC lies
in a groove along the posterior aspect of the caudate lobe.
Tributaries of the IVC are the paired lumbar and renal veins
ANATOMY OF THE LOWER
EXTREMITYVEINS
orough knowledge of the fascial compartments of the leg
is a prerequisite of understanding the relationship between
super cial and deep veins. e fascia surrounding the calf
and thigh muscles separates two compartments:the super cial compartment, consisting of all tissues between the skin
and the fascia, and the deep compartment, which includes
all tissues between the fascia and the bones (see Figure2.6).
VENOUS EMBRYOLOGY AND ANATOMY • 21
11
Epidermis
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Supercial
compartment
Dermis
Deep veins
Subpapillary
venous plexus
Reticular
venous plexus
Saphenous
fascia
Great
saphenous n.
Saphenous n.
Medial
perforating veins
Subcutis
Saphenous
compartment
Deep
Figure2.6 Relationship between the fascia and veins of the lower extremity. e fascia covers the muscle and separates the deep from the super cial
compartment. Super cial veins (a)drain the subpapillary and reticular venous plexuses, and are connected to deep veins through perforating veins
(b). e saphenous fascia invests the saphenous vein. e saphenous compartment is a subcompartment of the super cial compartment.
Fascia
Muscle
compartment
DISTAL
a
a
b
b
PROXIMAL
Super cial veins run in the super cial, deep veins in the deep
compartments. Perforating veins pierce through the fascia
12
and connect the super cial to deep veins.
Communicating
veins connect veins within the same compartment:super-
Superf. peroneal n.
Small
saphenous v.
cial to super cial or deep to deep veins. e saphenous
veins are covered by a brous sheath, the saphenous fascia.
e saphenous fascia is thinner than the deep fascia and
Lateral
perforating veins
it is more pronounced in the upper-mid thigh, than more
1,13
distally.
e space between the saphenous and muscular deep fascia is the saphenous compartment. e saphenous compartment is a subcompartment of the super cial
compartment.
e super cial venous system of the foot is divided into
Sural n.
Lateral
marginal v.
Dorsal
venous arch
Medial marginal v.
Deep peroneal n.
the dorsal and plantar subcutaneous venous network (see
Figure2.7). Super cial 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. e medial and
lateral end of this arch continues through the medial and
Figure2.7 S u p e r cial and perforating veins of the foot andankle.
lateral marginal vein into the GSV and SSV, respectively.
Small super cial veins drain the subpapillary and reticular plexuses of the skin and subcutaneous tissues toform
bigger tributaries, which eventually all connect to the saphe-
14,15
nous veins.
e GSV begins just anterior to the medial
ankle, crosses in front of the tibia, and ascends medial to the
16–18
knee (see Figure2.8).
Proximal to the knee, the GSV
ascends on the medial side of the thigh and enters the fossa
ovalis 3cm inferior and 3cm lateral to the pubic tubercle.
e GSV is doubled in the calf in 25% of the population,
20
in the thigh in 8%.
e saphenous nerve runs in close
proximity to the GSV in the distal two-thirds of the calf.
Accessory GSVs are frequently present, and they run parallel to the GSV both in the thigh and in the leg; they lie
either anterior, posterior, or super cial to the main trunk.
e posterior accessory GSV of the leg (Leonardo’s vein or
posterior arch vein) is a common tributary, it begins posterior to the medial malleolus, ascends on the posteromedial
aspect of the calf, and joins the GSV distal to the knee (see
Figure2.8). e anterior accessory GSV of the leg drains
the anterior aspect of the leg below the knee. e posterior
accessory GCV of the thigh, if present, drains the medial
19
and posterior thigh.
11
e anterior accessory GSV of the
thigh collects blood from the anterior and lateral side of the
thigh (see Figure2.8). e anterior and posterior accessory
GSVs join the GSV just before it ends at the con uence of
super cial inguinal veins (saphenofemoral junction). e
super cial circum ex iliac, super cial epigastric, and external pudendal veins join each other and the distal GSV to
22 • BASIC CONSIDERATIONS
Superf. circumex
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iliac a. & v.
Anterior accessory
great saphenous v.
Superf. epigastric a. & v.
Femoral v.
Pudendal a. & v.
Posterior accessory
great saphenous v.
Great saphenous v.
Great
saphenous v.
Saphenous v.
Intersaphenous v.
Cranial extension of
the small saphenous v.
Popliteal v.
Lat. sural cut. n.
Perforators of the
femoral canal
Anterior accessory
great saphenous v.
Paratibial
perforators
Great saphenous v.
Superf. peroneal n.
Medial ankle perforators
Saphenous v.
Posterior accessory
great saphenous v.
Upper
posterior
Middle
Lower
tibial (Cockett)
perforator
Figure2.8 S u p e r cial and perforating veins of theleg.
form the con uence of super cial inguinal veins (sapheno-
21
femoral junction) (see Figure2.9).
Rarely, the GSV terminates high on the lower abdomen or joins the femoral vein
very low and the super cial inguinal veins empty individu-
22
ally into the femoral vein.
Other occasional tributaries
of the GSV in the groin include the posterior and anterior
thigh circum exveins.
e SSV lies lateral to the Achilles tendon in the distal
23
calf (see Figure2.10).
In the lower two-thirds of the calf
the SSV runs in the subcutaneous fat, then it pierces the fascia and runs between the two heads of the gastrocnemius
A
C
Common femoral v.
Superf.
epigastric v.
Superf.
circumex
iliac v.
External
pudendal v.
Anterior accessory
great saphenous v.
Great saphenous v.
Common femoral v.
Superf.
epigastric v.
Superf.
circumex
iliac v.
External
pudendal v.
Anterior accessory
great saphenous v.
Great saphenous v.
Figure2.9 Common variations (A. 33%, B.15%, C.15%, D.13%) in the
anatomy of the con uence of inguinal veins (saphenofemoral junction).
B
D
Medial
gastrocnemius
perforators
Small
saphenous v.
Lateral
gastrocnemius
perforators
Sural n.
Lateral leg
perforators
Dorsal venous arch
Lateral ankle
perforator
Figure2.10 e SSV and lateral venous system of thecalf.
muscle. In the popliteal fossa at about 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 cephalad direction (see Figure2.10).
24
Uncommonly the main trunk of the SSV continues without
draining into the popliteal vein and eventually empties into
11
the femoral vein or GSV.
e intersaphenous vein (vein of
Giacomini) is a communicating vein connecting the SSV to
the GSV in the posteromedial thigh. e sural nerve courses
along the SSV in the distal calf. Super cial veins of the lateral leg and thigh form the lateral venous system. e lateral
venous system is drained through multiple small tributaries
into the GSV andSSV.
Deep veins of the foot form two divisions:the plantar
and the dorsal veins. e richly anastomosing deep plantar venous arch drains the plantar digital veins through
the plantar metatarsal veins. e deep plantar venous arch
drains into the medial and lateral plantar veins, which
in turn continue in the posterior tibial veins behind the
25
medial ankle (see Figure2.11).
On the dorsum of the foot
the pedal vein drains the deep dorsal digital veins through
the dorsal metatarsal veins. e pedal vein continues in the
anterior tibial veins. Pairs of the posterior and anterior tibial
and peroneal veins accompany the corresponding arteries,
and all drain into the popliteal vein (see Figure2.11). Large
soleal and gastrocnemius (medial, lateral, and intergemellar) veins drain venous sinuses of calf muscles and join the
popliteal vein (Figure 2.12). Venous sinuses are closely
related to deep veins. ey are embedded in the belly of calf
muscles, such as the soleus and gastrocnemius, and are able
to dilate and hold a large amount of blood. With the contraction of calf muscles at walking the blood is pumped to
VENOUS EMBRYOLOGY AND ANATOMY • 23
Perforators of
A
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the femoral canal
Femoral v.
Popliteal v.
Soleal v.
Paratibial
perforators
Soleal v.
Posterior tibial vv.
posterior
tibial
perforator
Medial ankle
perforator
Medial plantar v.
Upper
Middle
Lower
Anastomosis to
deep femoral v.
Small saphenous v.
Medial and lateral
gastrocnemius vv.
Anterior tibial vv.
Soleal vv.
Peroneal vv.
Lateral leg
perforators
Lateral plantar v.
Figure2.11 Deep veins of the foot andcalf.
more proximal deep veins (calf muscle pump). e popliteal vein continues into the femoral vein as it passes through
the adductor canal. e popliteal and femoral veins are fre-
26
quently duplicated.
Distally the femoral vein runs lateral
to the femoral artery; however, more proximally it runs
External iliac v.
Deep femoral v.
Common femoral v.
medial to it. e deep femoral (profunda femoris) vein joins
the femoral vein to form the common femoral vein at about
27
9cm below the inguinal ligament.
e common femoral
vein is medial to the common femoral artery and it becomes
the external iliac vein at the level of the inguinal ligament.
e GSV joins the common femoral vein at the con uence of the super cial inguinal veins. Other tributaries of
the common femoral vein are the circum ex femoral veins
(lateral and medial). In the distal thigh the femoropopliteal
segment frequently communicates through a large collateral
with the deep femoral vein providing an important alternative avenue for venous drainage in case of femoral vein
occlusion. e sciatic vein, the main trunk of the primordial
deep venous system, runs along the sciaticnerve.
ere are as much as 150 perforating veins (PVs) in
the lower extremity; however, only a few of these are clinically important. Signi cant variation exists in the location
of individual PVs; however, distribution of clusters of PVs
follows a predictable pattern. Dorsal, plantar, medial, and
lateral foot perforators are the main groups of PVs in the
28
Alarge PV runs between the rst and second meta-
foot.
tarsal bones and connects the super cial dorsal venous arch
29
to the pedal vein.
rior, medial, and lateral ankle perforators (see Figure2.13).
Clusters of PVs at the ankle are the ante-
30
e medial calf perforators have two groups:posterior tibial
and paratibial PVs. ree groups (lower, middle, upper) of
posterior tibial PVs (Cockett I–III perforators) connect the
posterior accessory GSV to the posterior tibial veins (see
31,32
Figures 2.8, 2.11, 2.12, and 2.13).
forators drain the GSV into the posterior tibial veins.
e paratibial per-
33,34
Other perforators of the leg below the knee are the anterior,
lateral, medial, and lateral gastrocnemius; intergemellar;
and Achillean PVs (see Figure 2.11). Infra- 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 (see Figure2.8). Inguinal perforators drain into the femoral vein in the proximalthigh.
nterior tibial vv.
Figure2.12 Deep veins of theleg.
Femoral v.
Popliteal v.
Gastrocnemius v.
Soleal v.
Posterior tibial vv.
Lower posterior
tibial perforator
Posterior accessory
great saphenous vein
Middle posterior
tibial perforator
Figure2.13 Relationship of the posterior tibial perforators to the deep
and super cial posterior compartments (SPC) of the calf (PTVs,
posterior tibial veins).
24 • BASIC CONSIDERATIONS
Great saphenous vein
SPC
Upper posterior
tibial perforator
Paratibial
perforator
Valves in super cial veins of the lower extremity usually
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are located near the termination of major tributaries. Some
valves are well developed with marked sinusoid dilation
at their base, others are more delicate in their structure. In
the GSV there are about six valves, with more valves located
below than above the knee. Anearly constant valve of GSV
is at 2–3cm distal to its con uence with the femoral vein.
Valves in the SSV are closer to each other than in the GSV.
Valves in communicating branches between the SSV and
GSV are oriented to direct blood from the SSV to the GSV.
Like super cial veins, deep veins have more valves in the calf
than in the thigh. Tibial veins are densely packed with valves,
whereas there are only one or two valves in the popliteal vein.
In the femoral vein there are three to ve valves, with one of
them located just distal to the junction of the deep femoral
vein. ere is usually one valve in the common femoral vein.
Major PVs have one to three valves, all located below the level
of the fascia, that direct ow toward the deep veins. Small PVs
are usually valveless. PVs of the foot are without any valves or
with valves that direct ow toward the super cialveins.
CUTANEOUS NERVES OF THE LOWER
EXTREMITIES
Nerve injury is a potential complication of varicose vein procedures and is the most frequent cause for litigation following
35
varicose vein surgery.
Knowledge of lower extremity nerve
anatomy can minimize adverse outcomes. e most common nerve injury is to the common peroneal nerve where it
36
crosses the neck of the bula.
Other nerves of importance
during varicose vein procedures include the saphenous, tibial, and sural nerves. eir anatomical locations have been
previously described and illustrated in Figures2.8 and2.10.
R E F E R E N C E S
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Baltimore : Urban & Schwarzenberg . 1981 . 13–18 .
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Surg . 2001 . 34 ( 2 ): 241–246 .
14. Negus D , Coleridge Smith P . e blood vessels of the lower
limb: Applied anatomy . In: Negus D , Coleridge Smith P , Bergan
J , e d s . Leg ulcers: Diagnosis and management , 3e. CRC Press .
2005 . 15–24 .
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covery of the venous valves” [comment], J Vasc Surg . 2001 . 33 ( 6 ): 1317 .
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human structure , 5e. Philadelphia : W.B. Saunders . 1986 . 190–196 .
20. omson H . e surgical anatomy of the super cial and perforating
veins of the lower limb, Ann R Coll Surg Engl . 1979 . 61 ( 3 ): 198–205 .
21. Daseler EH , Anson BJ , Reimann AF , Beaton LE . e saphenous
venous tributaries and related structures in relation to the technique
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N M , e d s . Diseases of the veins , 2e. London : Arnold . 1999 . 23–48 .
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lower extremity , J Anat . 1926 . 60 : 131–142 .
24. Bergan JJ . Surgical management of primary and recurrent varicose veins. In: Gloviczki P , Yao J , eds. Handbook of venous disor-
ders:Guidelines of the American Venous Forum . London : Chapman
& Hall Medical . 1996 . 394–415 .
25. White JV , Katz ML , Cisek P , Kreithen J . Venous out ow of the
leg: Anatomy and physiologic mechanism of the plantar venous
plexus , J Vasc Surg. 1996 . 24 ( 5 ): 819–824 .
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M . Blood supply of subcutaneous tissue in the leg and its clinical
application , Clin Anat. 1995 . 8 ( 3 ): 202–207 .
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the lower limb. London : Livingstone . 1956 . 28–64 .
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the foot, Surg Gynecol Obstet . 1968 . 127 ( 4 ): 817–823 .
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Perforating veins . Baltimore : Urban & Schwarzenberg . 1981 . 19–34 .
30. May R . Nomenclature of the surgically most important connecting veins. In: May R , Staubesand J , eds. Perforating veins .
Baltimore : Urban & Schwarzenberg . 1981 . 13–18 .
31. Mozes G , Gloviczki P , Menawat SS , Fisher DR , Carmichael SW ,
Kadar A . Surgical anatomy for endoscopic subfascial division of perforating veins , J Vasc Surg. 1996 . 24 ( 5 ): 800–808 .
ction surrounding the dis-
VENOUS EMBRYOLOGY AND ANATOMY • 25
32. Mozes G , Gloviczki P , Kadar A , Carmichael SW . Surgical anat-
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omy of perforating veins. In: Gloviczki P , Bergan J , eds. Atlas
of endoscopic perforator vein surgery . London : Springer-Verlag .
1998 . 17–28 .
33. Boyd AM . Discussion on primary treatment of varicose veins , Proc R
Soc Med . 1948 . 61 : 633–639 .
34. Sherman RS . Varicose veins: Anatomic ndings and an operative
procedure based upon them , Ann Surg . 1944 . 120 : 772–232 .
35. Campbell WB , France F , Goodwin HM . Medicolegal claims in vascular surgery . Ann R Coll Surg Engl . 2002 . 84181–84184 .
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26 • BASIC CONSIDERATIONS
3 .
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EPIDEMIOLOGY OF CHRONIC PERIPHERAL
VENOUSDISEASE
Michael H. Criqui , Julie O. Denenberg , Robert D. Langer , Robert M. Kaplan , and Arnost F r o n e k
INTRODUCTION
e term “chronic venous disease,” or more speci cally of
interest here, “chronic peripheral venous disease” (CPVD)
has been used more generally to refer to either visible and/
or functional abnormalities in the peripheral venous system.
e most widely used classi cation of such abnormalities
is the CEAP (clinical, etiological, anatomic, pathophysiologic), which employs both anatomic (super cial, deep,
or perforating veins) and pathophysiologic (re ux, obstruction, or both) categories.
ther described in Chapter10 .
e CEAP classi cation re ects the clinical situation in
which patients are typically referred to a vascular specialist
for clinically signi cant venous disease. In contrast to the
clinical situation, population studies of CPVD have typically focused on broader categories determined by visual
inspection only. e three major categories of interest have
been varicose veins (VV), chronic venous insu ciency
(CVI), and venous ulcers. However, there has not been a
standard de nition of these categories. VV has been de ned
at di ering levels of visible disease severity. CVI has typically been de ned by skin changes and/or edema in the distal leg. Venous ulcers, both active and healed, have been
de ned by visible inspection and subjective inference as to
etiologic origin.
Two studies have now reported results on de ned
free-living populations with simultaneous assessment of
both visible abnormalities and functional impairment by
Duplex ultrasound.
Diego Population Study (SDPS) determined both obstruction and re ux, while the Edinburgh study determined
only the latter. e results were revealing in that to some
degree the validity of both the assumptions of earlier population studies and of the CEAP classi cation, at least as
applied to population samples, were brought into question.
Speci cally, the general concept that visible disease necessarily implied underlying functional disease, and vice versa,
was true in the large majority of a ected limbs, but not
universallyso.
1
e CEAP classi cation is fur-
2,3
e Duplex examination for the San
Although these discrepancies occurred in a minority of
cases, they were frequent enough to lead us to separately classify visible and functional CPVD in each limb evaluated in
the SDPS. Speci cally, we classi ed each limb into four visible categories:normal, telangiectasias/spider veins (TSV),
VV, and trophic changes (TCS); the latter category being
one or more of hyperpigmentation, lipodermatosclerosis,
or active or healed ulcer. e presence or absence of edema
was not by itself a criterion for TCS. For functional disease,
we determined the presence of obstruction and re ux separately for the super cial, perforating, and deep systems. e
presence of either re ux or obstruction in super cial or deep
veins was categorized as functional disease, and because of
small numbers, abnormalities of the perforating veins were
considered as deep disease. ree functional categories were
de ned:normal, super cial functional disease (SFD), and
deep functional disease (DFD). Here, the term “functional”
is essentially interchangeable with “anatomic.” Also, in this
population study, obstruction was uncommon and virtually
all legs with obstruction also had re ux, such that SFD and
DFD essentially refer to re ux.
In addition to separately assessing edema, we asked
about a history of super cial venous thrombosis (SVT) and
deep venous thrombosis (DVT), with or without pulmonary embolism.
Table 3.1 shows the prevalence of various manifestations of CPVD in the SDPS by age, gender, and ethnicity.
Speci cally, prevalence rates are given for TSV, VV, TCS,
SFD, DFD, edema on physical examination, and SVT and
D V T b y h i s t o r y .
AGE ANDCVPD
Using mutually exclusive categories for both visible and
functional CVPD, we found a graded relationship with
increasing age for VV, with those aged 70–79years having
nearly twice the prevalence of those aged 40–49years. TSV
also increased with age, but this di erence was obscured by
the mutually exclusive categories, with increasing numbers
27
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