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teacher, UP chapter of ASI; Eminent Surgical Teacher Award, UP ASI; and Best Poster prize at 10th VAICON. His name appears in Asia's Who's Who

reference book, Marquis Who’s Who in the World, Five Hundred Leaders of Inuence, International Directory of Distinguished Leadership, Man of the

Year, American Biographical Institute, International Cultural Diploma of Honor by American Biographical Institute 2000, millennium Medal of Honor by American Biographical Institute, Member of ABIs’ Research Board of Advisors, Twentieth Century Admirable Achievers (Distinguished Who’ Who), Member of the American Association for the Advancement of Science 2002, Marquis Who’s Who in Medicine and Healthcare 2002, Indo-Asian Who’s Who, Asian/American Who’s Who, and International Professional of the Year—2005 by International Biographical Centre, Cambridge, England. He is Fellow of United Writers Association, Fellow of Indian National Science Academy, Fellow of American College of Surgeons, Fellow of International College of Surgeons, Fellow of Association of Colorectal Society of India, Fellow of Royal Society of Tropical Medicine, Fellow of Association of Surgeons of India, Fellow of Union for International Cancer Control, and Fellow of Minimal Access Surgeons of India. Prof. Khanna has delivered more than 100 CME lectures and more than 100 Guest lectures in various national and international conferences in India, USA, Japan, Poland, Egypt, etc. He has more than 350 publications in various national and international journals and 50 chapters in various books to his credit. He is the editor of three books: Current Seminars in Surgery, Manual of Vascular Surgery, and Ulcers of the Lower Extremity. He has attended more than 200 national and international conferences and presented more than 250 presentations. He has guided more than 50 theses for MS course. He is an examiner for MBBS, MS, BDS, DNB, and FNB in minimal access surgery. He is a fellow/member of 33 societies. He is a widely traveled person and has worked in various well-reputed institutes in almost all the major countries of the world. He is a devoted teacher and very active academician and is well praised by all his students. He started the vascular surgery in the department of Surgery at BHU.He is the joint editor of the Indian Journal of Surgery. He has organized more than 25 conferences and workshops. He was the chief inspector for Quality Assurance Review of the Department of Clinical Surgical Sciences, the University of the West Indies, St. Augustine Campus, Trinidad and Tobago, and is in the Expert Selection Committee of UPSC, Uttar Pradesh; BPKIMS, Dharan, Nepal; Aligarh Muslim University, Aligarh; KGMU, Lucknow; Public Service Commission, J & K; MCI Inspector; DNB Inspector; IGIMS, Patna; PGI, Chandigarh; and Indian Institute of Information Technology, Allahabad.

About the Editors

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RavulJindal MS, DNB, FRCS, FAMS,

FIVS is presently director of vascular and

endovascular surgery, Fortis Hospital,

Mohali. He is working in the eld of sur-

gery for the past 21 years and is with

Fortis for 12years. His areas of expertise

include peripheral arterial and venous

interventions. Dr. Ravul Jindal completed

his MBBS from Mahatma Gandhi Institute

of Medical Sciences, Sewagram, and MS

in General Surgery from PGIMER,

Chandigarh. He was awarded a Diplomate

of the National Board in General Surgery,

New Delhi. After completing his senior residency at PGIMER, Chandigarh, he went on to do his Fellowship in Vascular Surgery at St Mary’s Hospital, London, UK.He also completed his FRCS from the Royal College of Surgeons of Edinburgh. St Mary’s hospital is world renowned for vascular surgery and is afliated to Imperial College. Penicillin was discovered by Alexander Fleming in this hospital. Dr. Jindal is actively involved in the national vascular bodies and is a life member of the Vascular Society of India and President of the Venous Association of India (www.venous.in). He is also an executive member of the International Compression Club (ICC) and council member of L’Union Internationale de Phlebologie (UIP). He has vast experience in open and endovascular surgeries, with expertise in endovascular management of aortic aneurysms, revascularization in diabetic foot, and varicose veins. His special interests are the laser treatment of varicose veins where patients are treated as day care without any surgical incisions. He popularized the treatment of diabetic foot, endovascular treatment of aortic aneurysms, and laser ablation of varicose veins in this part of the world. He also introduced the MOCA Technique (mechanico-chemical ablation of varicose veins) and Glue Closure Technique to treat varicose vein for the rst time in the country, which are nonthermal ways of managing varicose veins. Dr. Jindal is involved in research, presentation of papers at national and international meetings, and has a number of publications to his credit. He has written more than 10 book chapters as the rst author in international books in the eld of vascular surgery and is credited with more than 30 publications in various international journals.

Contributors

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Harinder Singh Bedi Cardiovascular Sciences of Ludhiana Mediways Hospital, Ludhiana, Punjab, India

YudhishtarSinghBedi USC, Los Angeles, CA, USA

R� Bootun Section of Vascular Surgery, Charing Cross Hospital, Imperial

College London, London, UK

Piyush Chaudhary Vascular and Endovascular Surgery, Fortis Hospital, Mohali, India

A� H�Davies Section of Vascular Surgery, Charing Cross Hospital, Imperial College London, London, UK

DevendraDekiwadia Dekiwadia Hospital, Rajkot, Gujarat, India

ClaudeGillot URDIA Anatomy Research Unit EA 4465, Paris Descartes

University, Paris, France

MadhuriGore Consultant Surgeon, Former Professor and Chief of Surgery, LTMG Hospital, Mumbai, India

Tarun Grover Division of Vascular and Endovascular Surgery, Medanta Medicity Hospital, Gurugram, Haryana, India

Arjun Jayaraj RANE Center for Venous and Lymphatic Diseases at St. Dominic Hospital, Jackson, MS, USA

RavulJindal Vascular and Endovascular Surgery, Fortis Hospital, Mohali, India

Ajay K� Khanna Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

SoumyaKhanna Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

ArvindKohli Department of CTVS, GMC, Jammu, India

T� R� A�Lane Section of Vascular Surgery, Charing Cross Hospital, Imperial

College London, London, UK

GiovanniMosti Angiology Department, MD Barbantini Clinic, Lucca, Italy

xvi

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WaldemerLechOlszewski Central Clinical Hospital, Ministry of Internal Affairs, Warsaw, Poland

Shoaib F�Padaria Department of Vascular Sciences, Jaslok Hospital and Research Centre, Mumbai, India

BirjuPatel Dekiwadia Hospital, Rajkot, Gujarat, India

ShivanesanPitchai Sree Chitra Tirunal Institute for Medical Sciences and

Technology, Trivandrum, India

SeshadriRaju The Rane Center, Jackson, MS, USA

AjaySavlania Postgraduate Institute of Medical Education and Research,

Trivandrum, India

GurjitSingh Division of CTVS, JK Medicity Hospital, Jammu, India

Karan Thakore Department of Surgery, Karamsad Medical College,

Baroda, Gujarat, India

VijayThakore Angiocare VINS Hospital, Baroda, Gujarat, India

Jean-François Uhl URDIA Anatomy Research Unit EA 4465, Paris

Descartes University, Paris, France

DilipVaghasia Dekiwadia Hospital, Rajkot, Gujarat, India

Contributors

ManbendraVaidya Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

HiralVarnami Angiocare VINS Hospital, Baroda, Gujarat, India

Fernando Vega Rasgado Instituto Mexicano de Flebología, Academia

Mexicana de Flebología y Linfología, Clínica de Várices y Ulceras de México, Mexico City, Mexico

MarkS�Whiteley The Whiteley Clinic, London, UK

The Whiteley Clinic, Guildford, UK

The Whiteley Clinic, Bristol, UK

MarzannaTeresaZaleska Department of Applied Physiology, Mossakowski Medical Research Center, Polish Academy of Sciences, Warsaw, Poland

Anatomy oftheVenous System

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oftheLower Limbs

Jean-FrançoisUhl andClaudeGillot

Abbreviations

AAGSV Anterior accessory of the GSV CVD Chronic venous disease GSV Great saphenous vein LNVN Lymph node venous networks of the

groin

SSV Small saphenous vein

1.1 Introduction

The embryogenesis of the venous network of the lower limbs explains the main variations of the venous network supercial veins, perforating veins, and deep venous system. It is likely that the number of the so-called primitive chronic venous disease could be explained by unknown underlying anatomical abnormalities [1].

The muscular veins play an important role, due to the effect of the muscular pumps by their activation of the deep venous return and the aspiration of the supercial system via the perforator veins. They always act at the same level. This explains the anatomical xity of most of the perforators and the interest of their knowledge [2].

The color duplex is essential in any patient with chronic venous disease (CVD) to provide anatomical and hemodynamical data. Direct CT venography is a useful complement to get more detailed morphological information and a 3D map of the whole venous network [3].

These new imaging techniques are a useful complement to the classical descriptive anatomy. They improve our anatomical knowledge of the veins, which is useful for radiologists, angiologists, as well as vascular surgeons and students. The nal aim is to better perform venous mapping which is the keystone for any treatment.

1.2 The New Terminology

oftheVeins

A new terminology of the venous system was dened by a consensus conference of experts during the UIP Congress of Rome [4] in order to provide a common language between anatomists, radiologists, angiologists, and surgeons. The international nomenclature is summarized on the Fig.1.1 (veins) and Fig.1.2 (perforator veins).

J.-F. Uhl (*) · C. Gillot URDIA Anatomy Research Unit EA 4465, ParisDescartes University, Paris, France

https://t.me/med1917

J.-F. Uhl and C. Gillot

NOMENCLATURE OF THE VEINS OF THE LOWER LIMBS

International Interdisciplinary Consensus Committee (IUP. IFAA, FICAT)

SUPERFICAL VEINS

LONGITUDINAL OBLIQUE

INTERFASICAL (course within

the saphenous compartment)

1. Great Saphenous (GSV)

2. Small Saphenous (SSV)

3. Thigh extension of SSV

4. Anterior Accessory of GSV (upper portion)

EPIFASCIAL (course in the

superfical hypodermis)

4. Anterior Accessory of GSV

5. Superfical Accessory of GSV

6. Posterior Accessory of GSV

7. Superfical Accessory of GSV

8. Lateral plexus

SAPHENOUS COMPARTMENT

9. Anterior Thigh Circumflex V.

10. Posterior Thigh Circumflex V.

(Giacomin’s Anastomosis)

11. Leg intersaphenous W.

VALVES OF THE SAPHENO-FEMORAL

JUNCTION

SAPHENOUS FASCIA

Fig. 1.1 International nomenclature of the veins of the lower limb (from A.Caggiati)

15.

17.

1 Anatomy oftheVenous System oftheLower Limbs

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NOMENCLATURE of PERFORATING VEINS (PV) (main eponyms in brackets)

1. DORSAL FOOT PV

2. MEDIAL FOOT PV

3. LATERAL FOOT PV

4. PLANTAR FOOT PV

5. MEDIAL ANKLE PV

6. ANTERIOR ANKLE PV

7. LATERAL ANKLE PV

8. PARATIBLAL PV (SHERMAN, BOYD)

9. POSTERIOR TIBIAL PV (COCKETT)

10. ANTERIOR LEG PV

11. LATERAL LEG PV

12. MEDIAL GASTROCNEMIUS PV (GILLOT)

13. LATERAL GASTROCNEMIUS PV

14. INTERGEMELLAR PV (MAY) PARA-ACHILLEAN PV (BASSI)

16. MEDIAL KNEE PV SUPRAPATELLAR PV

18. LATERAL KNEE PV

19. INFRAPATELLAR PV

20. POPLITEAL FOSSA PV (DOOD, THIERI)

21. PV OF THE FEMORAL CANAL(DOOD)

22. INGUINAL PV

23. ANTERIOR THIGH PV

24. LATERAL THIGH PV

25. POSTERO-MEDIAL THIGH PV

26. SCIATIC PV

27. POSTERO-LATERAL PV (HACH)

28. PUDENDAL PV

29. SUPERIOR GLUTEAL PV

30. MID GLUTEAL PV

31. LOWER GLUTEAL PV

Main references:

Caggiati A, Bergan JJ, Gloviczki P, Jantet G, Wendell-Smith CP, Partsch. Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. J Vasc Surg. 2002;36(2):416–22.

Caggiati A, Bergan JJ, Gloviczki P, Eklof B, Allegra C, Partsch H. Nomenclature of the veins of the lower limb: extensions, refinements, and clinical application. J Vasc Surg. 2005;41(4):719–24.

Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, Smith PC. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs–UIPconsensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg. 2006;31(3):288–99.

Fig. 1.2 Nomenclature of the perforator veins (from A.Caggiati)

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J.-F. Uhl and C. Gillot

1.3 The Supercial Venous System

1.3.1 The Three Venous Compartments (Fig.

The subcutaneous tissues of the lower limbs are organized with two connective fasciae along the thigh and leg: supercially below the skin, formerly called “fascia supercialis,” and deeper, the deep fascia layer or muscular fascia, also called aponeurosis above the muscles.

These two fascia layers are continuous all along the limb. They are closely related to the saphenous veins: the supercial layer covers the saphenous trunks, while the tributaries, also called epifascial veins, are located subcutaneously. By denition between the two fascia layers, we have the saphenous compartment [5] easily recognized by echography in transversal slices, giving the sign of the “Egyptian eye” as shown in Fig.1.4 [6, 7]. This was validated by a consensus meeting organized before the UIP congress of San Diego [8].

1.3)

1.3.2 The Short Saphenous Vein (SSV)

Origin: The SSV is formed by two roots: the lateral perforators and the lateral malleolar plexus; the origin of the vein is often a plexus; there is commonly no lateral marginal vein (Fig. 1.5). The sural nerve is stuck to the SSV from the ankle to mid-calf.

The termination types of the SSV: The SSV termination or arch ends into the popliteal vein. The saphenous popliteal junction is frequently located close to the lateral aspect of the tibial nerve.

There are ve possible termination types for the SSV [9] according to the presence (A and B)

or the absence (C, D, and E) of SPJ (Fig.1.6).

Important point: The SSV is located close to the nerves at different levels which are high-

risk zones for the treatment of SSV, particularly by thermal ablation. In clinical practice, the clinician needs to be aware of danger zones in treatment of venous disease with SSV surgical approach and endovenous procedures. This is

Fig. 1.3 The three compartments of the venous system of the lower limb, separated by three layers: (1) the skin, (2) the saphenous fascia, and (3) the muscular fascia. In the deep plan, under the muscular fascia, is located the deep venous system: deep trunks (c) and muscular veins (d)

inside the muscles (4). In the saphenous compartment (saphenous eye), between the two fascia layers are located the saphenous trunks (b). Under the skin is located the tributaries (a) of the saphenous trunks

1 Anatomy oftheVenous System oftheLower Limbs

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GSV

Fig. 1.4 The “Egyptian eye,” echographic view of the saphenous compartment. MF muscular fascia, SF saphenous fascia, GVS great saphenous vein, Tr tributary of GVS

Fig. 1.5 The lateral perforators of the foot and origin of the small saphenous vein (SS).

Dorsal supercial arch (DA), malleolar plexus (MP), fth metatarsal bone (M5), common trunk of the lateral foot perforator

veins (C), retrotendinous perforator vein (Ror cunean Cu), intertendinous perforator vein (I), inframalleolar perforator vein (S), bular perforator (P)

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J.-F. Uhl and C. Gillot

Fig. 1.6 The ve different types of termination of the short saphenous vein (SSV). With a saphenous popliteal junction (SPJ): A (modal arch) and B (high SPJ more than

particularly true: [10] At the lower third of the calf, the sural nerve is stuck to the SSV trunk.

– At the apex of the calf (formation of the sural

nerve by its two tibial and bular branches)

– In the popliteal fossa crossing the tibial nerve

and commonly the nerve of the medial gastrocnemius muscle (Fig.1.5)

The surgeons should be aware of these risky zones to avoid nerve trauma during the treatment of SSV.

The anatomical knowledge of the sural nerve pedicle (Fig.1.7) is also useful to avoid the risk of injection of the SSV artery. These anatomical features explain the usefulness of ultrasonographic mapping prior to any treatment and as a control during any invasive procedure of SSV.

5cm above the crease). Without SPJ: C (Giacomini continuation), D (short type), E (plexiform termination)

The thigh or deep extension of the SSV: Also named postaxial or thigh or dorsal or cranial extension of the SSV (companion vein of the postaxial nerve of the embryo), it is located below the muscular fascia, close to the femoral posterior cutaneous nerve (Fig.1.8).

It is connected to the deep muscular veins of the thigh (semimembranosus and biceps).

It commonly extends with the Giacomini vein (inter saphenous anastomosis) to join the GSV below the groin.

1.3.3 The Great Saphenous Vein

(GSV) [11]

Identication: The identication of the GSV is made by color duplex: it is easily located inside

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