Transcript 1150_Neuhardt_OC13B7x

Anatomy and Function of the LE
Muscle Pumps –
What’s the Primary Culprit?
Valvular Incompetence
vs
Muscle Pump Dysfunction
Diana L. Neuhardt, RVT, RPhS, FSVU
CompuDiagnostics, Inc.
Phoenix, Arizona
Conflict of Interest
• none
Introduction
Muscular pumps ARE the
peripheral heart of the
venous system
Efficiency based on two
mechanisms
One we study all the time….
Second we ????
Keep these images in mind
Deep Compartment - Anatomy
• LE deep vein structures location
• Intermuscular
• Between one muscle group or another
• Between a muscle group and a fascial structure
• Intramuscular
• Within muscular fascia
Francesechi C, Zamboni P. Principles of Venous Hemodynamics
Nova Science Publishers 2009
Deep Compartment
Intra
Intra
Inter
Inter
Physiologic Basis Superficial and Deep Venous
Flow – Within The Venous Heart
• During muscular contraction (intra/extra muscular location of
deep veins)
• Termed venous “SYSTOLE” – blood movement (flow)
• During muscular relaxation
• Termed venous “DIASTOLE” –
• Gravitational force!
Physiologic Basis – Barrier to Gravity
• Balance of flow “suspended” and regulated by a
series of one-way bicuspid valves
• Pressure gradient
• Energy
• Defy gravity
• FIRST mechanism

Valves point to the direction of drainage
Venous Duplex Flow Dynamics
• During muscular contraction – systole
• During muscular relaxation – diastole
Reflux Determination
• Venous valves normally close when there is a reversal of the
normal antegrade pressure gradient
• Reflux = abnormal pressure gradient that occurs across vein valve
sites when valves are damaged (or absent) – retrograde flow
Duplex Ultrasound - Overview
• Duplex ultrasound diagnostic investigation is most often used to
determine the presence, site and extent of thrombus in deep or
superficial veins.
• Duplex ultrasound is considered the gold standard for examination of
venous valvular insufficiency – we study this one mechanism of a two
part system
• ?Other factors might influence our findings and discovery of venous
valvular flow….i.e. the 2nd mechanism of the venous heart
Everything (?) You NEED to
Know But Forgot to Ask About
the Other Mechanism
Veno-Muscular
Pumps
The Resources for all this Information –
Thank you
• J-F Uhl*† and C Gillot† URDIA Anatomy Research Unit EA4465,
University Paris Descartes, Paris, France; †Varicose Veins Surgical
Centre – 113 Avenue Victor Hugo, 75116 Paris, France
• Anatomy of the foot venous pump: physiology and influence on
chronic venous disease Phlebology 2012:1–12
• Anatomy of the veno-muscular pumps of the lower limb. Phlebology
2015. 30(3) 180-193
Veno-Muscular Pumps – 4 of them!
• Foot
• Leg (soleal)
• Gastrocnemius
• Thigh
Veno-Muscular Pumps – Foot & Calf pumps
Figure 1 Venomuscular foot and calf pumps during walking (from Gardner and Fox, 1993). (a) Activation
of the distal calf pump. (b) Activation of the foot pump. (c) Activation of the proximal calf pump
Veno-Muscular Pumps - FOOT
• The Lejars’ concept of the venous sole of the foot is incorrect: the true blood
venous reservoir of the foot is located deeply in the plantar veins, between the
plantar muscles. The medial and mostly lateral plantar veins converge into the
plexus shaped calcaneal crossroad, where the blood is ejected upwards into the
two posterior tibial veins.
Anatomy of the foot venous pump: physiology and influence on chronic venous disease Phlebology 2012:1–12
Veno-Muscular Pumps - FOOT
• The two main medial perforator veins of the foot are clearly visible, ending in the
GSV: navicular (N) connected to the medial plantar veins and sub malleolar (M) to
the calcaneal plexus (C). They are provided with valves (painted in yellow)
allowing blood to go from the deep to the superficial system, a particularity of the
foot
Anatomy of the foot venous pump: physiology and influence on chronic venous disease Phlebology 2012:1–12
Veno-Muscular Pumps - FOOT
• Here there is something unique to the foot: the directional flow of the blood from
deep to superficial.
Anatomy of the foot venous pump: physiology and influence on chronic venous disease Phlebology 2012:1–12
Observational Examination –
Plantar Venous Pump - Intermuscular
“The plantar veins play an important role in the physiology of the venous
return since a venous reservoir of 25 mL of blood is mobilized upwards
with each step during walking.
Therefore, the impairment of the foot pump by a static foot disorder
should be considered as an important risk factor for chronic venous
disease, and should be evaluated and corrected in any patient with
venous insufficiency.”
Phlebology 2012:1–12
Observational Examination –
Plantar Venous Pump - Intermuscular
“It is crucial to look for foot static disorders in patients with chronic
venous disease.
Such disorders are any foot dysmorphism (flat or hollow foot) that may
reduce the efficacy of the foot pump, but which have also been proved to
be responsible for an impairment of the calf pump.
In such cases, treatment with an insole will reduce both abnormalities
and thereby improve the venous insufficiency and the symptoms of the
patient, which are not always of venous origin.”
Phlebology 2012:1–12
Veno-Muscular Pumps – Soleus Muscle
Anatomy of the veno-muscular pumps of the lower limb Phlebology 2015 30 (3) 180-193
Veno-Muscular Pumps – Soleus Muscle
At the leg level, the lateral veins of
the soleus are the bigger ones. They
drain vertically into the fibular veins.
The medial veins of the soleus,
smaller, join the posterior tibial veins
horizontally.
Anatomy of the veno-muscular pumps of the lower limb Phlebology 2015 30 (3) 180-193
Veno-Muscular Pumps – Gastrocnemial
Anatomy of the veno-muscular pumps of the lower limb Phlebology 2015 30 (3) 180-193
Veno-Muscular Pumps - Gastrocnemial
At the popliteal level, medial gastrocnemial veins are the
largest veins, which end uniquely as a large collector into the
popliteal vein above the knee joint.
This explains the power of the gastrocnemial pump: during
walking, the high speed of the blood ejection during each
muscular systole acts like a nozzle creating a powerful jet
into the popliteal vein. This also explains the aspiration
(Venturi) effect on the deep veins below.
Anatomy of the veno-muscular pumps of the lower limb Phlebology 2015 30 (3) 180-193
Veno-Muscular Pumps - Gastrocnemial
Possible anatomical configurations of
the gastrocnemial pump.
(a) Plexus shaped of bifid
gastrocnemial trunk;
(b) Muscular degenerescence or
special disposition of the
popliteal vein.
(c) Poor muscular collectors.
(d) Ideal pump
Anatomy of the veno-muscular pumps of the lower limb Phlebology 2015 30 (3) 180-193
Veno-Muscular Pumps – Thigh Pumps
Anatomical slice of the mid thigh showing the
muscles, in particular the semimembranosus
muscle and its venous arcades. 1: Vastus
medialis; 2: Vastus lateralis; 3: Biceps femoris; 4:
Sartorius; 5: Semitendinosus; 6:
Semimembranosus; 7: Popliteal artery; 8:
Popliteal vein; 9: Venous arcades of the
semimembrabosus; 10: Great saphenous vein;
F: Femur. On the right side: posterior view of
the limb: The posterior muscles of the thigh:
Biceps femoris (3) and semimembranosus (6)
muscles
Anatomy of the veno-muscular pumps of the lower limb Phlebology 2015 30 (3) 180-193
Veno-Muscular Pumps – Thigh Pumps
The role of safety valve of the semimembranosus muscle.
During the powerful ejection of the calf pump into the
popliteal vein, the whole volume cannot be absorbed by
the femoral vein due to the rigidity of the Hunter’s canal. A
part of the blood is shunted by the venous arcades of the
semimembranosus muscle. 1: Lower part, expandable, of
the popliteal vein below the Hunter hiatus; 2: Deep femoral
vein; 3: Afferent branches; 4: Efferent branches; 5: Arcades;
6: Gastrocnemial collector; 7: Gastrocnemius; 8: Small
saphenous vein; H: Hunter’s canal hiatus.
Anatomy of the veno-muscular pumps of the lower limb Phlebology 2015 30 (3) 180-193
Veno-Muscular Pumps – Thigh Pumps
The thigh pump of the semimembranosus
muscles pushes the blood of the deep femoral
vein together with the quadriceps veins into the
common femoral vein.
Anatomy of the veno-muscular pumps of the lower limb Phlebology 2015 30 (3) 180-193
Veno-Muscular Pumps – Summary
Two Mechanisms of the Peripheral Heart
The synchronization of the different veno-muscular pumps during
walk is crucial: foot, then leg, popliteal and finally thigh pumps.
The venous valves play a key role allowing, during muscle
contraction, the unidirectional venous flow to the heart, and
avoiding reflux of blood due to the gravitational forces that occur
during muscular diastole
Anatomy of the veno-muscular pumps of the lower limb Phlebology 2015 30 (3) 180-193
Clinical Examination
Careful clinical history & inspection
should reveal the patient’s symptoms,
their severity, and whether they are due
to venous disease rather than to
coexisting non-venous musculoskeletal,
arterial, or neurological pathology
Most importantly: calf pump function
–C-Clinical
• C0: no visible or palpable signs of venous disease
• C1: telangiectasias or reticular veins
• C2: varicose veins
• C3: edema
• C4: skin changes without ulceration
• 4a: pigmentation or eczema
• 4b: lipodermatosclerosis or atrophie blanche
• C5: healed venous ulcer
• C6: active venous ulcer
Eklof B, Rutherford RB, Bergan JJ, et al. American Venous Forum International Ad Hoc Committee for the Revision of the CEAP
Classification. Revision of the CEAP classification for chronic venous disorders; consensus statement. J Vasc Surg 2004;40:1248-52.
Observational Examination
Careful observational
examination should
reveal whether the
patient has a functional
calf pump
Observational Examination
Insert video patient
walking
Careful observational
examination should
reveal whether the
patient has a functional
calf pump
Observational Examination
Careful observational
examination should reveal
whether the patient has a
functional calf pump
How Will Talk Help You?
• Insert video patient walking
Conclusion
Muscular pumps ARE the peripheral heart of the venous system of the
lower limbs and play a crucial role in the venous return
Efficiency based on two mechanisms
Efficacy of the impulse-aspiration pumps – veno-muscular pump
Venous valvular dynamics
References
• J-F Uhl*† and C Gillot† URDIA Anatomy Research Unit EA4465, University Paris
Descartes, Paris, France; †Varicose Veins Surgical Centre – 113 Avenue Victor
Hugo, 75116 Paris, France
• Anatomy of the foot venous pump: physiology and influence on chronic venous
disease Phlebology 2012:1–12
• Anatomy of the veno-muscular pumps of the lower limb. Phlebology 2015. 30(3)
180-193