Transcript 0820_Cushing_EB3A3x

Deep and Superficial
Venous Anatomy
Robert Cushing, MD, FACPh
Carmel, CA
Disclosure
I have nothing to disclose
relevant to this presentation
There is new venous nomenclature
Learn this new terminology
and use it
The attached references detail
these changes and are excellent
Learn to correlate venous anatomy
with venous ultrasonography
The following two articles are
outstanding references regarding
how to accomplish this
Abdominal Pelvic Venous Anatomy
Venous Compartments
Subfascial
(deep venous system)
Intrafascial
(saphenous compartment – between
saphenous fascia and muscular fascia)
Epifascial
(tributary & reticular veins/telangectases)
Deep venous system
(Iliofemoral)
Superficial venous
system
Great Saphenous Vein
Terminal Valve
Subterminal Valve
Image Courtesy of Diana Neuhardt, RVT
Proximal GSV tributaries drain
lower abdominal and inguinal
regions and flow into the most
proximal GSV segment, between
the two valves
Superficial circumflex iliac vein
(lateral)
Superficial external pudendal vein
(infero-medial)
Superficial epigastric vein
(supero-medial)
Saphenofermoral junction
Superficial Epigastric
GSV
CFV
Image Courtesy of Diana Neuhardt, RVT
Great Saphenous Vein lies within the saphenous
compartment
Saphenous “Eye” is ultrasound marker of GSV anatomy and
demonstrates the saphenous compartment
Image Courtesy of Diana Neuhardt, RVT
Image Courtesy of Diana Neuhardt, RVT
Anterior Accessory
Great Saphenous Vein
Junctional origin
- lies lateral to the GSV – courses over the
femoral vessels and demonstrates
“alignment sign” on US
- has its own intra-fascial compartment which
joins the GSV’s fascial compartment just
before entering the SFJ
- essentially opens directly in to the deep
system
- is not a tributary of the GSV
the
FA
CFV
common saphenous trunk
FA FA
CFV
CFV
GSV
AAGSV
common saphenous trunk
FA FA
CFV
CFV
CFV
FA
origin
GSV
AAGSV shared fascial
common saphenous trunk
“eye”
GSV
AAGSV
FA FA
CFV
CFV
CFV
FA
AAGSV
GSV
AAGSV
GSV
common
saphenous
trunk
AAGSV within its own fascia
“eye”
FA FA
CFV
CFV
CFV
FA
AA(G)SV is not the Anterior Thigh Circumflex Vein
(previously known as the Anterolateral Tributary Vein)
which is a true tributary of the GSV and exits from
the GSV more distally
GSV tributaries
Anterior Thigh Circumflex Vein
(formerly Anterolateral Tributary Vein)
Posterior Thigh Circumflex Vein
(formerly Posteromedial Tributary Vein)
These veins exit the GSV in the
proximal thigh
Vein of Giacomini
(the only vein
likely to retain
its eponym)
Enters GSV via
Posterior Thigh
Circumflex Vein
Small Saphenous Vein
Saphenopopliteal Junction
SSV termination is variable but
most often enters the Popliteal
fossa 2-4 cm above the Popliteal
skin crease
SSV lies in its own fascial compartment
Image Courtesy of Diana Neuhardt, RVT
Thigh (cranial) extension of the Small Saphenous
Vein ascends in the groove between the Biceps
Femoris and Semimembranosus musculature
and terminates in thigh or gluteal perforators
Note proximity to Popliteal Artery
Image Courtesy of Diana Neuhardt, RVT
If the SSV thigh extension
communicates with the GSV it
forms the Vein of Giacomini
Perforating Veins
Perforator veins “perforate”
the deep muscular fascia,
crossing fascial planes,
draining superficial to deep
with a one way valve
protecting unidirectional
inward flow
New nomenclature
eliminates use of
eponyms
Inguinal perforator
Saphenofermoral junction
GSV to Common Femoral
Vein
Popliteal fossa perforator
Saphenopopliteal junction
SSV to Popliteal Vein
Femoral canal perforators
formerly Dodd & Hunter
perforators
GSV to Femoral Vein
Paratibial perforators
formerly Sherman & Boyd
perforators
GSV to Posterior Tibial Veins
Posterior tibial perforators
formerly Cockett perforators
Posterior accessory GSV of the leg
(formerly Leonardo’s Vein or the
Posterior Arch Vein)
to Posterior Tibial Veins
Lateral Venous System
Embryologic remnant of the
Vena Marginalis Lateralis
Formerly Lateral subdermic
plexus of Albenese
Drains lateral thigh and leg
Surface veins drain into deep system
via multiple perforators
References – Venous Anatomy and
Pathophysiology
Mauriello, John, MD “The New Anatomy of the
Lower Limbs” Phlebological Surgery Section
News, Volume 1, No.2 Fall, 2003
Feied, Craig F., MD “Venous Anatomy and
Pathophysiology” Venous Disease for Clinicians,
1st Edition, 2004
The Vein Book J. Bergan et al, 1st edition,
2007, Elsevier Academic Press
Handbook of Venous Disorders Gloviczki
et al, 3rd edition, 2009, Hodder Arnold
Nomenclature of the veins of the lower
limbs: An international interdisciplinary
consensus statement – Caggiati et al –
J Vasc Surg 2002; 36: 416-22
Nomenclature of the veins of the lower limbs:
An international interdisciplinary consensus
statement – Caggiati et al,
J Vasc Surg, 2005; 41: 719-24
Duplex ultrasound investigation of the veins in
chronic venous diseases of the lower limbs – UIP
Consensus Document Part I: Basic Principles
Coleridge-Smith, et al,
Phlebology, 2006; 21: 158-167
Duplex ultrasound investigation of the veins in
chronic venous disease of the lower limbs – UIP
Consensus Document Part II: Anatomy
Cavezzi, et al, Phlebology 21: 168-179
Can Saphenous and Sural Nerve Paresthesia be
Prevented During ELT? T. King, presentation
at European Venous Forum, 06/25/10
Thank you for your attention