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10
N. Morrison
should attempt to achieve the most ergonomically
optimal position (Fig. 2.1 ) in order to maximize
the successful access to the target veins. It is
unlikely the sclerotherapist will “hit” every vein,
no matter how skilled, but a position that allows
for relaxed large muscle groups (abdominal,
back, and leg) will greatly enhance the function
of fi ne muscle groups (forearm, wrist, hand, and
fi ngers), which in turn will lead to greater suc-
cess. On the contrary, poor, uncomfortable ergo-
nomic positions for the patient and sclerotherapist
(Fig. 2.2 ) will limit one’s ability to inject veins
successfully and lead to sub-optimal results.
Why Do Sclerotherapy
Why establish sclerotherapy in a phlebology
practice? Sclerotherapy will be the foundation
of the phlebology practice, upon which other
treatment modalities will be based. From the
young female patient who comes to the practice
with a few telangiectasias to the older male or
female patient with severe chronic venous
insuf fi ciency, leg ulcers, and severely limited
physical activities because of symptoms, sclero-
therapy will be a fundamental part of the treat-
ment plan for nearly all patients. Whether using
dilute liquid sclerotherapy for tiny telangiecta-
sias, or ultrasound guided foam sclerotherapy
for the large incompetent truncal veins, tributar-
ies, and perforators, sclerotherapy will play an
important role in returning the patient’s legs to a
healthy state. Interestingly, in a typical phlebol-
ogy practice, over 50% of patients present with
only cosmetic complaints. However, when these
patients are thoroughly screened and undergo
duplex examination, only about 20% will be
found to have purely “cosmetic” vein disease.
All others will have underlying venous
insuf fi ciency contributing to the appearance of
the telangiectasias, to a greater or lesser extent,
and will require correction of the underlying
venous insuf fi ciency prior to sclerotherapy for
the telangiectasias.
Ultrasound guided liquid sclerotherapy is con-
sidered by many to be less effective than foam
sclerotherapy for permanent vein sclerosis in
large veins [ 3– 6 ] . Utilization of foam for large
truncal veins has fundamentally changed the con-
ventional wisdom regarding successful chemical
ablation of saphenous and large tributary veins.
Very good midterm results have been reported
1–3 years following duplex guided chemical
ablation using foamed detergent sclerosants
[
22– 24, 26, 27 ] .
Fig. 2.1 Good ergonomic
position for sclerotherapist
with hands in “neutral”
position to avoid muscle
fatigue
https://t.me/med1917
112 Setting Up Sclerotherapy in a Phlebology Practice
How to Start
Probably the fi rst important decision is whether,
and to what degree one wants to become involved
in phlebology as a specialty. If an af fi rmative
decision is made, one can then begin to acquire
the knowledge and training in speci fi c skills
needed to function well in phlebology.
For the practitioner new to the fi eld of phlebol-
ogy, numerous venues for training are available,
with many countries supporting active phlebologic
societies dedicated to advancement of the treatment
of patients with venous disorders by providing
courses designed to help practitioners acquire the
knowledge and skills necessary to successfully treat
the full spectrum of patients with venous disease.
Most national phlebologic societies offer courses
and practical symposia to teach the principles of
diagnosis and treatment of venous disease, while
valuable training may also be found at subspecialty
meetings that include phlebologic training. Many
private practitioners provide individualized training
in a phlebology practice setting whereby one can
obtain as much practical training as one feels is nec-
essary to become pro fi cient. And phlebology fel-
lowship and preceptorship training through
universities or national phlebologic societies are
available. There are also private commercial com-
panies that offer a complete turn-key package,
including training, that will allow a specialist in
another fi eld to convert to the fi eld of phlebology,
while other companies arrange for a practitioner to
join a group practice, with some training available.
An internet search targeting phlebology and other
specialty society websites will provide a place to
start the search for more information.
Fig. 2.2 Position of
sclerotherapist will lead to
fatigue, while patient position
without cushioning between
legs will be uncomortable
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12
N. Morrison
Conclusion
Over the past decade minimally invasive pro-
cedures for treatment of even the most
advanced venous insuf fi ciency have become
available, and this trend towards less invasive
therapeutic modalities is expected to continue.
Sclerotherapy (more recently referred to as
“endovenous chemical ablation”) is playing
an ever more important role. It will remain
essential for the phlebologist to be fully cogni-
zant of and pro fi cient in sclerotherapy.
References
1. Sadick N. Choosing the appropriate sclerosing
concentration for vessel diameter. Dermatol Surg.
2010;36:976–81.
2. Rabe E, Pannier F. Sclerotherapy of varicose veins with
polidocanol based on the guidelines of the German
Society of Phlebology. Dermatol Surg. 2010;36:968–75.
3. Hamel-Desnos C, Allaert F-A. Liquid versus foam
sclerotherapy. Phlebology. 2009;24:240–6.
4. Coleridge SP. Foam and liquid sclerotherapy for vari-
cose veins. Phlebology. 2009;24 Suppl 1:62–72.
5. Yamaki T, Nozaki M, Iwasaka S. Comparative study of
duplex-guided foam sclerotherapy and duplex-guided
liquid sclerotherapy for the treatment of super fi cial
venous insuf fi ciency. Dermatol Surg. 2004;30:718–22.
6. Ouvry P, Allaert F-A, Desnos P, Hamel-Desnos C.
Ef fi cacy of polidocanol foam versus liquid in sclero-
therapy of the great saphenous vein: a multicentre ran-
domised controlled trial with a two-year follow up.
Eur J Vasc Endovasc Surg. 2008;36(3):366–70.
7. Gillet J-L, et al. Side-effects and complications of
foam sclerotherapy of the great and small sapheous
veins: a controlled multicentre prospective study
including 1025 patients. Phlebology. 2009;24:131–8.
8. Ceulen R, et al. Microembolism during foam sclerotherapy
of varicose veins. N Engl J Med. 2008;358 (14):1525–6.
9. Forlee M, Grouden M, Moore D, Shanik G. Stroke
after varicose vein foam injection sclerotherapy. J
Vasc Surg. 2006;43:162–4.
10. Bush RG, Derrick M, Manjoney D. Major neurologi-
cal events following foam sclerotherapy. Phlebology.
2008;23(4):189–92.
11. Guex JJ, et al. The French polidocanol study on long-
term side effects: a survey covering 3,357 patient
years. Dermatol Surg. 2010;36:993–1003.
12. Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser
C. Systematic review of foam sclerotherapy for vari-
cose veins. Br J Surg. 2007;94:925–36.
13. Breu FX, Guggenbichler S, Wollman JC. 2nd
European Consensus Meeting of Foam Sclerotherapy
2006. Vasa. 2008;37(S71):3–29.
14. Morrison N, Neuhardt DL, Rogers CR, McEown J,
Morrison T, Johnson E, Salles-Cunha SX.
Comparisons of side effects using air and carbon
dioxide foam for endovenous chemical ablation.
J Vasc Surg. 2008;47:830–6.
15. Wright DD, et al. High prevalence of right-to-left shunt in
patients with symptomatic great saphenous incompetence
and varicose veins. J Vasc Surg. 2010;51(1):104–7.
16. Morrison N, Neuhardt D. Foam sclerotherapy: cardiac
and cerebral monitoring. Phlebology. 2009;00:1–8.
17. Regan JD, et al. Clinical signi fi cance of cerebrovascu-
lar gas emboli during polidocanol endovenous ultra-
low nitrogen microfoam ablation and correlation with
magnetic resonance imaging in patients with right-to-
left shunt. J Vasc Surg. 2011;53(1):131–7.
18. Cabrera J, Redondo P, Becerra A, Garrido C, Cabrera Jr J,
Garcia-Olmedo MA, et al. Ultrasound-guided injection
of polidocanol microfoam in the management of venous
leg ulcers. Arch Dermatol. 2004;140:667–73.
19. Cavezzi A, Frullini A. The role of sclerosing foam
in ultrasound guided sclerotherapy of the saphenous
veins and of recurrent varicose veins: our personal
experience. Aust NZ J Phlebol. 1999;3:49–50.
20. Kakkos SK, Bountouroglou DG, Azzam M,
Kalodiki E, Daskalopoulos M, Geroulakos G.
Effectiveness and safety of ultrasound-guided foam
sclerotherapy for recurrent varicose veins: Immediate
results. J Endovasc Ther. 2006;13:357–64.
21. Kern P, Ramelet AA, Wutschert R, Bounameaux H,
Hayoz D. Single-blind, randomized study comparing
chromated glycerin, polidocanol solution, and polido-
canol foam for treatment of telangiectatic leg veins.
Dermatol Surg. 2004;30:367–72.
22. Myers KA, Jolley D, Clough A, Kirwan J. Outcome
of ultrasound-guided sclerotherapy for varicose
veins: medium-term results assessed by ultrasound
surveillance. Eur J Vasc Endovasc Surg. 2007;33:
116–21.
23. Coleridge SP. Chronic venous disease treated by ultra-
sound guided foam sclerotherapy. Eur J Vasc Endovasc
Surg. 2006;32:577–83.
24. Wright D, Gobin JP, Bradbury AW, Coleridge Smith P,
Spoelstra H, Berridge D, et al. Varisolve polidocanol
microfoam compared with surgery or sclerotherapy in
the management of varicose veins in the presence of
trunk vein incompetence: European randomized con-
trolled trial. Phlebology. 2006;21:180–90.
25. Ma RW, Parsi K, et al. Three cases of stroke following
peripheral venous interventions. Phlebology 2011:1–5.
26. Rasmussen LH, Eklof B, et al. Randomized clinical
trial comparing endovenous laser ablation, radiofre-
quency ablation, foam sclerotherapy and surgical
stripping for great saphenous varicose veins. Br J
Surg. 2011;98(8):1079–87.
27. Darvall KA, Bradbury AW, et al. Duplex ultrasound
outcomes following ultrasound-guided foam sclero-
therapy of symptomatic recurrent great saphenous
varicose veins. Eur J Vasc Endovasc Surg. 42(1),
107–14
https://t.me/med1917
13
N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,
DOI 10.1007/978-1-4471-2891-5_3, © Springer-Verlag London 2013
3
A thorough understanding of the anatomy of the
super fi cial venous system and consistent use of the
accepted nomenclature will make treating patients
and communicating fi ndings more successful.
The deep venous system (Fig. 3.1 ) begins in
the foot as the plantar veins which drain into the
posterior tibial veins. In the calf there are three
sets of paired tibial veins that share the names
and follow the anterior and posterior tibial and
peroneal arteries. These veins connect in the
upper calf to form the popliteal vein. The anat-
omy of this con fl uence of veins is quite variable.
Generally, the posterior tibial and the larger per-
oneal veins join fi rst and at a higher level the
anterior tibial veins cross the interosseous mem-
brane before joining.
Veins from the soleus muscles drain into the
peroneal veins. Veins inside the bellies of the
medial and lateral gastrocnemius also join the pre-
viously mentioned con fl uence to help create the
popliteal veins. The intramuscular gastrocnemius
and soleal veins are large volume and valveless
and are know collectively as sinusoidal veins.
Since these veins are in the muscles, they are
exposed to high external pressures, and function as
the pumping chambers of the musculovenous
Venous Anatomy of the Lower
Extremity
Neil M. Khilnani
N. M. Khilnani , M.D.
Weill Cornell Vascular and
the Division of Interventional Radiology,
New York Presbyterian Hospital-Weill Cornell
Medical Center , 416 East 55th Street,
New York, NY 10022 , USA
e-mail: nmkhilna@med.cornell.edu
a
e
d
c
b
g
f
h
Fig. 3.1 Deep veins of the lower extremity, frontal
view. A – paired posterior tibial veins. B – paired
anterior tibial veins. C – paired peroneal veins. D –
popliteal vein. This vein is often duplicated partially
or completely. E – medial gastrocnemius veins. F –
femoral veins (This vein is often duplicated; it is dupli-
cated in this diagram). G – deep femoral vein (This
vein can occasionally be large and continuous with the
popliteal vein as in this illustration). H – common
femoral vein
https://t.me/med1917
14
N.M. Khilnani
pump of the calf. The gastrocnemius veins are
larger and generally easier to fi nd on ultrasound.
There are usually two larger ones in the medial
belly and two smaller ones in the lateral belly of
the muscle. Typically they are seen joining the
popliteal vein just below the saphenopopliteal
junction. The gastrocnemius veins occasionally
drain directly into the small saphenous vein 1–2 cm
before the saphenopopliteal junction.
The popliteal vein may form as a single or
paired vein with some of the constituents drain-
ing into one or the other popliteal vein in the case
of a duplication [
1 ] . Duplications can also occur
at a higher level even if the vein begins as a single
trunk. At the adductor canal the name of the vein
changes to the femoral vein. By international
consensus, the pre fi x “super fi cial” has been
dropped when describing this vein in the thigh
[ 2 , 3 ] . The use of this pre fi x is strongly discour-
aged as it has been responsible for confusion for
the lay public as well as with non-vascular health
care providers who have misinterpreted the vein
as not part of the deep venous system.
The popliteal veins occasionally have a con-
spicuous connection to the deep femoral venous
system. It is important to realize that occasion-
ally the diameter of this connection between the
popliteal vein with the deep femoral vein can be
large and the femoral vein itself smaller in cali-
ber as a normal variant, in the absence of prior
venous occlusion. It is important to distinguish
this anatomy from femoral vein narrowing and
prominent deep femoral vein collateral fl ow in
patients following an old femoral vein thrombosis.
In patients with prior thrombosis other evidence
of deep vein thrombosis is typical seen such as
thickened vein walls, non-compressible vein
narrowing, calci fi cations, webs and tortuous
collaterals.
The femoral vein also has frequent segmental
duplications (Fig.
3.1 ). The femoral vein and the
deep femoral vein join to form the common fem-
oral vein at a level just below the saphenofemoral
junction.
Although the super fi cial venous anatomy seems
“variable” to the uninitiated, it is quite predicable
with certain components more or less developed in
a given patient. The super fi cial venous system of
the lower extremity is composed of innumerable
subcutaneous collecting veins, the saphenous
trunks and their tributaries.
The most recognized components of the
super fi cial venous system are the Great and Small
Saphenous Veins. The use of the terms “long”,
“greater”, “short” and “lesser” have also been
discouraged by international consensus to avoid
confusion often caused by the use of abbrevia-
tions. In addition the consensus statement has
standardized the names of the major tributaries of
the saphenous veins.
The deep veins are found deep to the fascial
investiture of the muscular compartment. The
super fi cial veins are super fi cial to the muscular
fascia. The saphenous veins are in a space where
the muscular fascia splits in two with the saphen-
ous veins deep to the “super fi cial fascia” but
super fi cial to the “muscular fascia” in a compart-
ment known as the saphenous space (Fig. 3.2a , b ).
As a result, the saphenous veins and some of their
major tributaries are often described as “intra-
fascial veins.”
The great saphenous vein (GSV) begins on the
dorsum of the foot and ascends the medial calf
and thigh to join the common femoral vein at the
Fig. 3.2 Illustration of an axial section through the thigh
( a ) and calf ( b ) to illustrate the locations of the GSV ( a )
and SSV ( b ) within the saphenous space
Subcutaneous fat Small saphenous v.
Saphenous sheath
Gastrocnemius mm.
Great saphenous v.
b
a
Skin
Muscle
Saphenous
sheath
https://t.me/med1917
153 Venous Anatomy of the Lower Extremity
fossa ovale (Fig. 3.3 ). It is usually visible just in
front of the medial malleolus but may also be vis-
ible in the calf for signi fi cant lengths in very thin
individuals. It is usually found just posterior to
the medial knee. It has two important thigh and
calf tributaries known as anterior and posterior
circum fl ex veins of the calf and thigh respec-
tively. The circum fl ex veins travel obliquely to
the course of the GSV and are variably developed
in each individual. Of note, the posterior
circum fl ex vein of the calf has previously been
known as the posterior arch vein as well as
Leonardo’s Vein. In addition there are three
smaller tributaries that drain into the GSV just
below the saphenous-femoral junction (SFJ).
These are important in that they are usually
ligated during conventional surgical treatment
along with the GSV (high ligation). It is felt that
the ligations may be responsible for frustrated
venous drainage of their tributaries which has
been postulated as a mechanism for the frequent
new varicose veins which develop in the region
of the ligation (development of the so called
neovessels.)
Veins parallel to the GSV are named based on
their locations with respect to the fascia. A vein
that runs parallel to the course of the GSV but is
outside the fascia (usually directly super fi cial to
the path of the GSV) is known as the Super fi cial
Accessory SV (Fig. 3.4a , b ). These common veins
are often segmental in the calf and or thigh and
may serve to be the primary fl ow channel with the
Femoral V
Anterior circumflex
vein of the thigh
Anterior circumflex
vein of the calf
Posterior circumflex
vein of the calf
Great saphenous vein
Posterior circumflex
vein of the thigh
Fig. 3.3 The GSV and its primary tributaries. The vein
segments shaded in grey in the saphenous compartment.
Those shaded in blue are super fi cial to the super fi cial
fascia
Fig. 3.4 ( a ) Frontal view ( on lef t) and selective axial
views ( on the right ) of the course of an extra-fascial tribu-
tary vein as it joins the intra-fascial GSV. The overlying
elliptical cylinder tracing depicts the super fi cial and deep
fascia, that creates the saphenous space. The Super fi cial
Accessory Saphenous Vein ( SASV ) is a common tributary
of the GSV that runs parallel to the course of the GSV but
outside of the saphenous space. Frequently, the GSV is
segmentally hypoplastic. In these cases the patent GSV
segments can be connected to a SASV which bridges the
hypoplastic segment and provides a straight line conduit
to connect these disconnected segments. ( b ) Lateral view
of the course of an extra-fascial vein as it joins the intra-
fascial GSV
Skin
a
b
Superficial fascia
Deep fascia
Fat
https://t.me/med1917
16
N.M. Khilnani
true GSV either being congenitally very small or
absent in the segments in which it is present.
A vein that runs parallel to the GSV but within
the saphenous space of the thigh would be referred
to as an Anterior or Posterior Accessory GSV,
depending on its position relative to the GSV. The
Anterior Accessory GSV (AAGSV) is a common
parallel channel to the GSV and is frequently
responsible for anterior thigh varicose veins. The
AAGSV can be developmentally larger than the
GSV, may serve as the major super fi cial vein in
the thigh connection between the calf GSV and
the femoral veins. Developmental variants are
common and in some cases, the AAGSV may the
dominant vein and as such can “replace” the GSV
(Fig. 3.5 ). Usually in such cases, the termination
of the “GSV” persists at the SFJ but it is small in
caliber and only drains small tributaries.
One hundred to one hundred and fi fty perfo-
rating veins connect the super fi cial veins to the
deep system at many levels. Many of these perfo-
rating veins connect un-named super fi cial veins
directly to the deep system are un-named. A new
nomenclature has been developed for naming the
important perforating veins. This nomenclature
discourages the use of previously popular
eponyms and replaces them with topographically
based descriptors.
Clinically important connections include the
medial thigh perforating veins between the GSV
and the femoral vein in the medial mid and low
thigh, (previously known as the Dodd’s and
Hunter’s perforators), the paratibial perforating
veins between the GSV and the upper posterior
tibial veins (previously known as the Boyd’s per-
forating veins) and the posterior tibial perforating
Anterior Accessory Great
saphenous vein
ab
Great
saphenous vein
Anterior Accessory
Great saphenous vein
B
C
Fig. 3.5 Anterior Accessory GSV ( AAGSV ) variant
connections. ( a ) The AAGSV in this extremity is the domi-
nant pathway connecting the GSV of the calf with the
femoral vein. The GSV is present but small. ( b ) The AAGSV
in this extremity is the only pathway connecting the GSV of
the calf with the femoral vein. The GSV is aplastic
https://t.me/med1917
173 Venous Anatomy of the Lower Extremity
Fig. 3.6 ( a ) Posterior
view of the lower
extremity demonstrating
the SSV and its primary
connections. ( b ) Lateral
view of the lower
extremity, with the head of
the patient to the left of
the page, demonstrating
the SSV and its central
connections
Gluteal V
Giacomini V
to deep system
via perforator
Popliteal V
Small
saphenous V
Cephaled extension
Gastrocnemious V
a
b
Small saphenous V
Popliteal V
Popliteal A
veins between the posterior circum fl ex vein of
the calf (previously known as Leonardo’s Vein as
noted above) and the posterior tibial veins (previ-
ously known as the Cockett’s perforators). Many
other perforating veins exist and are named based
on their location.
The Small Saphenous Vein (SSV) begins on
the lateral aspect of the foot, passes posterior to
the lateral malleolus and then ascends up the
midline of the calf (Fig.
3.6a , b ).
The cephalad termination of the SSV is vari-
able. The classic anatomy is for the SSV to enter
the popliteal fossa and then to drain into the
popliteal vein just above the level at which the
two heads of the gastrocnemius muscle diverge. It
does so by joining the popliteal directly or less
commonly after joining a gastrocnemius vein
fi rst. However, a dominant popliteal termination
is present in at most 60% of cases. In about 15%
of cases the dominant portion of the SSV will ter-
minate into a deep vein of the posterior thigh just
above the popliteal space via a perforating vein. In
about 25% of cases, the SSV will extend even
more cephalad. The cephalad (or “thigh”) exten-
sion travels in a space similar to the saphenous
vein, deep to the super fi cial fascia but super fi cial
to the muscular fascia. These cephalad termina-
tions of this vein are variable and include termina-
tion, in descending order of frequency, into a vein
which communicates with the GSV (the cephalad
extension in this case has been commonly known
as the Giacomini Vein or now, the Intersaphenous
https://t.me/med1917
18
N.M. Khilnani
Vein in the new nomenclature), into a higher pos-
terior thigh perforating vein and into a gluteal
vein (which passes under the gluteal fold to later
drain into the internal iliac vein tributaries). Very
rarely, the SSV may terminate below the level of
the popliteal fossa either into a perforating vein or
into a gastrocnemius vein. Practically, combina-
tions of the described SSV termination patterns
are common in many patients with one pattern
being the dominant form of drainage and or
pathology in each case. We feel it appropriate to
characterize SSV as having a SPJ, a cephalad
extension to a certain level or both in our report-
ing of the Duplex evaluation of this vein.
It is important to distinguish the SSV from the
sciatic vein, which could be confused as the SSV
by those who are not aware of its existence. The
sciatic vein is usually dif fi cult to see in normal situ-
ations. However, when enlarged by re fl ux, the sci-
atic vein can be found on the lateral calf, in the
same intrafascial location as the SSV. However, the
sciatic vein enters the popliteal fossa more lateral
than the SSV and then goes deep to the deep fascia
to run cephalad with the sciatic nerve. In normal
patients this vein does not exist. However, in mul-
tiparous women either the vein or much more com-
monly a network of veins can be seen to re fl ux in or
adjacent to the sciatic nerve, often coalescing into a
common intrafascial vein trunk following the
course of the common peroneal nerve into the calf
and feeding into calf varicose veins.
As a fi nal point, it is valuable to know that the
GSV is adjacent to the saphenous nerve (sensory)
from about 6 cm below the knee to the ankle.
Similarly, one should be aware that the SSV runs
adjacent to the sural nerve (sensory) from the mid
calf to the foot.
References
1. Dona E, Fletcher JP, Hughes TM, Saker K, Batiste P,
Ramanathan I. Duplicated popliteal and super fi cial
femoral veins: incidence and potential signi fi cance.
Aust N Z J Surg. 2000;70(6):438–40.
2. Caggiati A, Bergan JJ, Gloviczki P, Jantet G,
Wendell-Smith CP, Partsch H, for the International
Interdisciplinary Consensus Committee on Venous
Anatomical Terminology. Nomenclature of the veins of
the lower limbs: an international interdisciplinary con-
sensus statement. J Vasc Surg. 2002;36:416–22
http://
www.jvascsurg.org/article/S0741-5214(02)00070-8/
abstract
.
3. Caggiati A, Bergan JJ, Gloviczki P, Eklof B, Allegra C,
Partsch H, for the International Interdisciplinary
Consensus Committee on Venous Anatomical
Terminology. Nomenclature of the veins of the lower
limb: extensions, re fi nements, and clinical application.
J Vasc Surg. 2005;41(4):719–24
http://www.ncbi.nlm.
nih.gov/pubmed/10843400
.
https://t.me/med1917
19
N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,
DOI 10.1007/978-1-4471-2891-5_4, © Springer-Verlag London 2013
4
Introduction
As the Twentieth Century faded away and the
new century began most of the dogma surround-
ing venous disorders faded away with the memo-
ries of the century past. The basis for this shift in
attitude and approach had been laid years earlier
by the development fi rst of the continuous wave
Doppler and then the Duplex Doppler. As applied
to venous disease, this led fi rst to the develop-
ment of accurate diagnosis and then to uncover-
ing the faults of existing therapy. Diagnosis of
venous re fl ux and identi fi cation the faulty seg-
ments of venous dysfunction developed in the
vascular laboratories of Strandness [ 1 ] and then
Nicolaides [ 2 ] . Very quickly, the mysteries of
venous physiology and Pathophysiology were
revealed (Table 4.1 ).
In Table 4.1 , the results of a very carefully
performed epidemiologic study are summarized.
The results are based on Duplex Doppler studies
of participants and reveal the precise incidence of
pathophysiologic changes in an ethnically diverse
population.
Physiology of the Lower Extremity
Veins
The venous system serves as a reservoir and trans-
port system for circulating blood. It is estimated
that 60–75% of the blood in the body is found in
the veins. It is the smallest veins that function as
the reservoir for much of the body’s blood vol-
ume. About 80% of the total is contained in veins
that are less than 200 m m in diameter.
The splanchnic venous circulation and the cuta-
neous veins are richly supplied with sympathetic
nervous system fi bers, as are veins in skeletal
muscle. These are responsive to catecholamines.
Arterial pressures are generated by muscular
contraction of the heart but pressures in the
venous system are largely determined by gravity.
With the body in the horizontal position pressures
in the veins of the lower extremity are similar to
the venous pressure in the abdomen, chest, and
extended arm.
However, in an upright position dramatic changes
in venous pressure occur. The only point at which
the pressure remains constant is a stable point just
below the diaphragm. All pressures distal to this
point are increased due to the weight of the blood
column from the right atrium. In the upright posi-
tion, approximately 500 ml of blood accumulates in
the lower extremities largely because of re fl ux
through the valve less vena cava and iliac veins.
Some of this becomes tissue fl uid that diffuses into
the tissues, is collected by the lymphatic system,
and eventually returns to the venous system.
Pathophysiology of Venous Disease
John Bergan
J. Bergan , M.D.
9850 Genesee, Suite 410 ,
La Jolla , CA 92037 , USA
https://t.me/med1917
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