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1 Anatomy oftheVenous System oftheLower Limbs
https://t.me/med1917
Fig. 1.7 The sural
nerve pedicle. Left:
drawing of the sural
nerve pedicle. The
“common” sural nerve
(1) is formed at the apex
of the calf (wire arrow)
by the medial branch (2)
coming from the tibial
nerve (T) and the lateral
one (3) coming from the
common bular nerve.
The inter-gastrocnemial
vein or vein of the sural
nerve (4) is located just
below the deep fascia of
the SSV (7) next to the
small saphenous artery
(5). Please notice the
vicinity of the tibial (T)
and medial
gastrocnemial nerve (9)
close to the arch of the
SSV (7). 8 = popliteal
vein 6 = medial
gastrocnemial pedicle.
Right: Anatomical
dissection of the calf
showing the same
7
the saphenous compartment or echographic
“eye,” as in Fig.1.2.
Origin: Begins by three roots below the anterior part of the tibial malleolar area with (Figs.1.9
and 1.14):
– The medial marginal vein of the foot
– The inframalleolar perforator
– The dorsal communicating vein of the foot
joining the anterior tibial veins
The termination of the GSV (arch or French
“crosse”) is always located in the inguinal crease.
Complex connections exist at the root of the
thigh; each of them could be the leak point of a
truncal reux of the GSV at the thigh level
(Fig.1.10): medially, with the pudendal and perineal network [1–3], upward with the tributaries
of the abdominal wall (b) or iliac area (a), and
downward with the Giacomini vein (f) and the
posterior accessory saphenous vein (g).
A number of variations of these tributaries
have been described, but the important point is
the presence of a constant segment delimited
by the two last valves of the GSV termination:
the terminal valve (close to the saphenous
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Fig. 1.8 The deep or
thigh extension of the
SSV (DE) also has
accompanying nerve:
the femoral posterior
cutaneous nerve. It
should be distinguished
from the deep venous
arcades (A and aa)
located along the great
sciatic nerve, connected
to the deep femoral vein
(DFV) upward
J.-F. Uhl and C. Gillot
femoral junction or ostium) and the preterminal valve, located 15–25mm below. All tributaries of the GSV end into this intervalvular
segment.
Anatomy and hemodynamics of this intervalvular segment are mostly important to be
checked. This could be assessed by duplex
between the terminal reux (Fig. 1.11) and the
preterminal one (Fig.1.12) [12, 13].
1.3.4 The Anterior Accessory Great
Saphenous Vein (AAGSV)
Its origin is usually made by lateral branches of
the knee or of the lateral leg. The AAGSV then
crosses the anterior aspect of the thigh to join
the inguinal area. Located subcutaneously, it
goes through the fascia 10–12 cm below the
inguinal fold, located here inside its own
1 Anatomy oftheVenous System oftheLower Limbs
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9
Fig. 1.9 Origin of the GSV at the ankle and medial perforators of the foot. Great saphenous vein (GSV), posterior tibial veins (PTV), lateral plantar veins (LPV), medial
plantar veins (MPV), perforator of the rst metatarsal
(P1), malleolar perforator (Mp), navicular perforator
Fig. 1.10 Crossroad
connections of the GSV
termination at the root of
the thigh: Perineal (2, 3)
and pudendal (1)
anastomoses. Supercial
circumex iliac vein
(Ci), abdominal
subcutaneous (Epi),
external pudendal (Pu),
anterior accessory
saphenous vein (AAS),
great saphenous vein
(GSV), Giacomini vein
(G), posterior accessory
saphenous vein (PAS),
terminal valve (TV), and
AASV
preterminal valve (PTV)
(Np), medial marginal vein of the foot (MMV), anterior
perforator of the foot (P). Please notice that the direction
of the blood in the medial perforators is paradoxal: from
the deep system toward the supercial system (medial
marginal vein)
Epi
GSV
Ci
PASV
TV
PTV
2
3
G
Pu
1
10
AASV
AASV
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J.-F. Uhl and C. Gillot
Ci
Epi
Pu
PTV
GSV
Fig. 1.11 Intervalvular segment of the GSV termination
with tributaries: case of a terminal reux down to the GSV
trunk. Supercial circumex iliac vein (Ci), abdominal subcutaneous (Epi), external pudendal (Pu), anterior accessory
saphenous vein (AAS), great saphenous vein (GSV), terminal valve (TV), preterminal valve (PTV), femoral vein (FV)
Ci
Epi
Pu
PTV
GSV
Fig. 1.12 Intervalvular segment of the GSV termination
with tributaries: case of a preterminal reux of the GSV trunk
FV
TV
FV
TV
saphenous compartment. It is differentiated
from the GSV by the alignment sign: the vein
is located in the same sagittal axis of the femoral vein.
1.4 The Perforators Veins
The perforator veins join the supercial to the
deep system. The theory of the hemodynamical
levels [14] explains their location always at the
same level, according to the anatomy of the muscular veins.
In fact, the muscular veins are mostly important for hemodynamics: they constitute the active
part of the deep system because of their aspiration power on the supercial system via the
perforators.
For efcacy reasons, the perforators have a
relatively xed location just in front of the muscular veins in order to optimize the venous drainage. This explains the constancy of their
anatomical pattern. These anatomical considerations are useful for the investigators in daily
practice. The Atlas book of Gillot [2] shows their
average location according to the tibia’s length
(Fig.1.13).
In practice, the PVs are not single and straight
connections from the deep to the supercial system: they are frequently plexus shaped dividing
into several tortuous branches and connected
with the muscular veins (Fig.1.13). These connections also make truly subfascial interperforator anastomoses which are probably
responsible for the high recurrence rate after surgical treatment, as reported in a 3 years follow-up
study [15].
1 Anatomy oftheVenous System oftheLower Limbs
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Fig. 1.13 The levels of the leg and calf perforators (from
the Atlas book of Gillot). Ankle (A) less than 5cm, inferior posterior tibial (IPT) 5–9cm, inferior posterior tibial
It is important to highlight the role of the
lymph node perforators of the groin.
The lymph node venous networks of the groin
(LNVN) are characterized by three features:
– Their trans-nodal route
– Their network shape connections with the
GSV and mostly the AAGSV
– The existence of direct perforators that join
the common femoral vein by [16]
They should be checked during any assessment of CVD patients. They can be found, thin
and competent, in any healthy individual. They
could be seen in primary CVD, but are more
commonly found in REVAS following groin
surgery, and are associated with multiple sinuous
neovascular channels. Their presence is an absolute contraindication for any surgical approach of
the groin:
(IPT) 10–15cm, inferior paratibial (IPT), superior paratibial (SPT). The groups of the calf PV: polar (Po) posterior
(Pt), central (Ce), and anterior (Ga)
Echo-guided sclerotherapy is recommended.
1.5 The Deep Venous System
Is located by denition below the muscular fascia, including two parts:
1.5.1 The Deep Venous Trunks
Begin at the foot with the foot pump located in
the plantar veins [17].
The lateral plantar veins are bigger and join
the plexus-shaped medial plantar at the calcaneus
plexus. This originates the two posterior tibial
veins (Fig.1.9). These veins are commonly mak-
ing a network at the lower part of the leg
(Figs. 1.14 and 1.15), which is a mechanism
against reux.
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J.-F. Uhl and C. Gillot
Fig. 1.14 Anatomical dissection (medial view of a right
leg). The medial perforators of the leg are colored in red
(see blue circles). They are connected to the branches of
Fig. 1.15 Anatomical dissection with latex injection and
colored segmentation: The plexus of the posterior tibial
veins. The medial plantar veins (1) join the lateral ones (2)
at the level of the calcaneus plexus (c). They drain the
the great saphenous vein (light blue) and connected
between them by an inter-perforator anastomosis (in
yellow)
blood into the medial marginal vein (3) by the medial perforators. They are not arranged in a plexus in the lower
part, showing two veins (arrows)
ab cd
1 Anatomy oftheVenous System oftheLower Limbs
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Dorsally, the anterior tibial veins come from
an anastomosis with the submalleolar perforator.
Laterally, the two bular veins are small veins
running upward inside the brous bula’s canal
at the lower part of the leg. They become bigger
veins above the arcade of the hallux exor longus
after receiving the huge lateral veins of the soleus
muscle (Fig.1.16).
The popliteal vein is formed by two roots [14,
18]: lateral one coming from the bular and
medial from the posterior tibial. They could join
at different levels and so receive the anterior tibial veins in different ways as shown on the
Fig.1.17. Up to the adductor arcade, the popliteal
vein becomes the femoral vein, usually coming
with a small collateral canal.
Fig. 1.16 The two bular veins go up into the bular
canal (dotted line): the upper limit of this brous and bony
canal is marked by the arcade of the hallux exor longus
PV
cc
PV
SAT
IAT
cc
SAT
IAT
(green arrow). The bular veins (in red) receive at this
level the huge lateral veins of the soleus muscle
MR LR
SAT
IAT
MR LR
FV
PTV
Tri truncular
15 %
Fig. 1.17 The four different arrangements of the roots of
the popliteal vein (Gillot). (a) Tritruncular dispositive, (b)
idem with small lateral root, (c) bitruncular with main
medial, (d) bitruncular with main lateral root. PV popli-
PTV
Tri truncular
small lat. root
50 %
FV
PTV PTV
Bi truncular
Main root = medial
20 %
teal vein, MR medial root, LR lateral root, SIAT superior
anterior tibial vein, IAT inferior anterior tibial vein, PTV
posterior tibial vein, FV bular vein, cc collateral canal
FV
Bi truncular
Main root = lateral
15 %
SAT
IAT
FV
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J.-F. Uhl and C. Gillot
The three main variations of the femoral vein
22]:
are [
– Modal type of a big femoral vein along the
artery and nerve inside the femoral canal.
– Unitruncular dispositive made of a big axial
vein draining into the deep femoral vein and
a hypoplastic femoral vein. (This axio-femo-
ral trunk is characterized by its particular
location, running vertically along the sciatic
nerve.)
– Bitruncular dispositive with both veins of sim-
ilar diameter.
The adductor canal (or Hunter’s canal) is a
narrowed area with rigid walls located at the
femoropopliteal junction. Its role in the venous
outlet syndrome is probably underestimated
[
23]. In clinical vascular practice, investiga-
tors should keep in mind that a duplex ultrasound at the precise level of the outlet
(11–13cm from the condyle) should be routine, checking for:
Fig. 1.18 The three venous axis in the embryo. In red the
axial vein. Commonly, it will become hypoplastic, sciatic
arcade (SA) which is a small arcade in the adult. Please notice
the high connection with the hypogastric vein. In green the
deep femoral (DF), with its three perforators (P1, P2, P3). In
blue the modal femoral vein (FV) is dominant in the modal
anatomy. The persistence of a big axial vein is fed by the
ischiatic vein (IV) coming from the internal iliac vein (II)
According to embryology [19, 20, 21], with the
three venous axes (Fig.1.18), the femoral axis could
be distinguished into three dispositives (Fig.1.19).
1. A possible extrinsic compression of the
venous axis inside the canal
2. A dilatation of the derivative routes, particularly the venous arcades of the semimembranosus muscle (Fig.1.24).
1.5.2 The Muscular Veins
The muscular veins and the veno-muscular
pumps of the lower limb [20].
At theLeg Level
At the leg level: mainly the soleus and gastrocnemial veins
1 Anatomy oftheVenous System oftheLower Limbs
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IG
DF
SNA
MODAL (88%) Unitruncular (3%) Bitruncular (9%)
Fig. 1.19 Anatomical variations of the femoral vein.
Modal anatomy is the most common (88%); the axial vein
is reduced to a small sciatic nerve arcade (SNA) along the
ischiatic nerve, connected to the pelvis by the inferior gluteal vein IG.In the case of the nonregression of the axial
vein, it could give either an axio-femoral trunk in 3%
FV
P2
AFT
CF
CC
P3
Adductor’s
canal
(with a hypotrophic femoral vein reduced to a small collateral canal, cc) or a bitruncular dispositive (9%) with
both axes of similar diameter. DF deep femoral vein, CF
common femoral vein, IG inferior gluteal vein, P2, P3
deep femoral vein perforators
AF
CF
The veins of the soleus are divided into two
parts. The lateral is the bigger; its huge veins
are draining vertically into the bular veins
above the arcade of the hallux exor longus.
The medial part is smaller, draining horizontally into the tibial posterior veins (Figs.1.20,
1.21, and 1.22).
The gastrocnemial veins include the medial
veins (bigger, in light blue) and the lateral ones.
For both muscles, the vascular pedicle is
emerging from the hilum and ends in the lateral
aspects of the popliteal vein (Fig.1.23). A com-
mon trunk of the medial veins with the SSV is
found in 30% of the cases.
Important point, the origin of the gastrocnemial veins takes place at the lower part of the
muscles from perforator veins by a terminoterminal connection.
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J.-F. Uhl and C. Gillot
Fig. 1.20 Systematization of the veins of the soleus muscle. Laterally (bigger) draining vertically in the bular
veins above the arcade of the hallux exor longus (HFL).
Fig. 1.21 Anatomical dissection after latex injection and
colored segmentation (lateral view of a right leg): the
veins of the soleus muscle. The lateral veins (in blue) are
bigger, ending in the bular veins (in pink). The medial
Medially draining horizontally in the posterior tibial veins
(PT). Please notice the medial leg perforators. Of the great
saphenous vein (GS) territory
veins of the soleus (in green) end in the posterior tibial (in
light blue). Please notice the hemodynamical levels shown
on the yellow labels on the top
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