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Extremity Venous Anatomy and Sonographic Evaluation


VENOUS ANATOMY:
***Remember proximal used to be defined as closest to the point of origin*** BUT current vascular nomenclature refers to proximal as being closest to the heart  EX: The "proximal" SFV is in the upper thigh and closer to the heart than the "distal" SFV in the lower thigh
Vein walls are composed of the same three layers as an artery but the media layer is much thinner. The venous valves are extensions of the intimal layer.
Central Veins:
  •  Inferior Vena Cava IVC - confluence of iliac veins
  •  Hepatic veins
  •  Superior Vena Cava SVC - confluence of innominate veins
  •  Portal vein-confluence of SMV and splenic vein

Lower Extremity Deep Veins:
Deep digital veins > metatarsal veins > PTVs and peroneal veins > tibioperoneal trunk > ATVs > popliteal vein > superficial femoral vein > common femoral vein > external iliac vein
  • Veins in the lower extremity originate at the confluence of the venules of the deep digital veins
  • Metatarsal veins drain the blood from the foot
  • Deep venous arches empty their blood into tibial veins
  • Calf and forearm veins are referred to as venae comitantes because 2 veins of the same name follow the same course as a single artery of the same name
Anterior Tibial Veins:
  • 2 veins originates at the plantar arches
  • Course cephalad anterolateral to the tibial bone and the interosseous membrane to reach the tibioperoneal trunk
  • Travels between the tibial head and fibula head to join the popliteal vein
  • Best scan approach is anterior calf with slightly lateral probe position
Posterior Tibial Veins:
  • 2 veins originate at the confluence of the plantar arches
  • At the ankle the PTVs course posterior to the medial malleolus and anterior to the Achille's tendon then course cephalad through the calf posterior to the tibial bone
  • Best scan approach is to place probe on the medial calf, angling through to the lateral side; PTVs most anterior on image and peroneals visible beneath them
Peroneal Veins:
  • In the lower calf/ankle 2 veins course lateral to the PTVs and medial to the fibula,
  • Continue in a cephalad course up the midline of the posterior calf, posterior to the fibula
  • 2 peroneal veins and 2 posterior tibial veins merge to form a single tibio-peroneal trunk in the upper calf
  • Best scan approach is to place probe on the medial calf, angling through to the lateral side; PTVs most anterior on image and peroneals visible beneath them
Popliteal Vein:
  • Tibioperoneal trunk merges with the two anterior tibial veins to form the popliteal vein in the popliteal fossa
  • Courses posterior to the popliteal artery
  • Becomes the femoral vein at adductor hiatus in the distal thigh
  • Best scan approach is to place probe on the posterior popliteal fossa; popliteal vein demonstrated ANTERIOR to the popliteal artery on the image due to the scan approach
Femoral Vein:
  • AKA superficial femoral vein (SFV); nomenclature recommendations remove the term superficial to alleviate confusion regarding this deep vein
  • Extends from adductor hiatus to join the profunda femoral vein at the groin
  • Courses posterior to the femoral artery
Profunda Femoral Vein:
  • AKA deep femoral vein (DFV); nomenclature recommendations remove the terms superficial and deep to alleviate confusion regarding both of these veins being part of the deep venous system
  • Joins the femoral vein to form the common femoral vein just below inguinal ligament
  • Drains the muscles in the thigh (quadriceps)
Common Femoral Vein:
  • Becomes external iliac vein just above inguinal ligament at the groin crease
  • Courses medial and posterior to common femoral artery
Internal Iliac Vein:
  • Courses medial to the external iliac vein
  • Drains the pelvic organs (NOT the gonads)
External Iliac Vein:
  • Courses lateral to the internal iliac vein and anterior to the external iliac artery
  • Joins the internal iliac vein to form the common iliac vein
Common Iliac Vein:
  • Courses anterior to the common iliac artery
  • Right and left common iliac veins merge at the level of L5 to form the IVC
  • IVC empties into the right atrium

Klippel - Trenaunay - Weber Syndrome:
  • Congenital absence of the deep veins
  • Causes numerous superficial varicosities and clusters of varicosities
Lower Extremity Superficial Veins:
  • Located within 2cm of the skin surface
  • Course within the subcutaneous fat layer of the leg
  • Veins of the superficial system always course between the superfical and deep fascial layers; use this characteristic location to differentiate from dilated tributaries of the superficial system
Great Saphenous Vein (GSV):
  • Longest vein in the body
  • Originates on the dorsum of the foot at the medial end of the distal venous arch
  • Travels anterior to the medial malleolus
  • Ascends medial thigh with the great saphenous nerve
  • Penetrates the deep fascia through the foramen ovale in the groin and terminates the saphenofemoral junction
  • Also connects to deep system through multiple perforating veins
  • Superficial epigastric vein is the most proximal tributary of the GSV and usually descends into groin to join the GSV near the saphenofemoral junction
  • Commonly used as a bypass graft for cardiac and arterial bypass surgery
Anterior Accessory Saphenous Vein (AASV):
  • Most easily identified at the groin
  • Ascends along the thigh to join the GSV near the groin
  • Differentiated from the GSV by its course anterior to the femoral artery instead of medial to it (GSV)
  • Not visible in all patients; can be a sign of dilated superficial system and reflux
Small Saphenous Vein (SSV):
  • AKA short saphenous vein
  • Dorsal vein of the little toe joins the lateral end of the dorsal venous arch to form the SSV
  • Originates posterior to lateral malleolus and Achilles tendon
  • Ascends along the midline aspect of posterior calf to enter the popliteal space between the two heads of the gastrocnemius muscles
  • Usually joins the popliteal vein in knee/distal thigh area but many variations in termination possible
  • Course of the vessel on the posterior calf described as a "stocking seam"
  • Numerous small vessels connect the SSV to the GSV in the calf
Perforators:
  • Connect superficial and deep systems to equalize pressure between the two systems
  • Begin in the saphenous compartment and penetrate the deep fascia to join the deep veins
  • Normal flow is described as centripetal or from superficial system toward the center of the leg to the deep system
  • PTV connected to distal GSV near ankle
  • 3 ankle perforators called Crockett's Perforators (posterior tibial perforators)
  • Boyd's Perforators (paratibial perforators) located in the knee area; connect GSV to PTVs
  • Dodd's Perforators located in distal thigh; connect GSV to FV
  • Hunterian Perforators located in proximal thigh; connect GSV to FV
  • Lateral perforator connects to SSV near the mid calf
  • Each leg normally has about 100 perforators
  • Normally <2mm diameter, >4mm usually has reflux
  • Flow is normally from superficial system to deep system****
  • Ankle perforator damage/dilatation involved in stasis ulcers
  • Dilated perforators can occur in response to DVT formation

Communicating Veins:

  • Connect the great and short saphenous veins
  • Never penetrate the deep fascia
  • Posterior arch vein extends cephalad from the ankle to join the GSV in the mid calf; communicates with the posterior tibial perforators (Crockett's perforators) and plays a major role in venous stasis ulcers
  • Vein of Giacomini originates at the saphenopopliteal junction (SSV/POP) behind the knee and extends up the posterior thigh to become the posterior circumflex vein that joins the GSV
Sural Veins (sinusoid or saccular veins):
  • Dilated vessels between soleal and gastrocnemius muscles of the calf
  • Serve as blood reservoirs for the legs
  • Important for calf muscle pump and lower extremity venous flow
  • Gastrocnemius veins; have an accompanying artery with each set; usually seen as two pairs, lateral and medial sets; may see three pairs; most commonly drain into the popliteal vein
  • The gastrocnemius veins cannot be followed to the ankle and this characteristic can be used to differentiate them from the tibial veins
  • Soleal veins are thick walled reservoirs within the soleal muscle; no artery with them; do NOT contain valves; drain into either the posterior tibial or peroneal veins
Valves:
  • Extensions of the intimal layer
  • Valves contain two leaflets (bicuspid)
  • Primary purpose is to allow unilateral flow direction in veins
  • Helps keep flow moving from superficial to deep system and from peripheral to deep veins
Venous valves normally allow flow to move in one direction in the vessel, toward the heart.
Note the thin echogenic flaps of the venous valve as it opens and closes.
Upper Extremity Venous Anatomy:
Deep venous flow: Venules > deep digital veins > metacarpal veins > deep venous arches > radial/ulnar veins > brachial vein(s) > axillary vein > subclavian vein > innominate vein > SVC > right atrium
  • Veins of the upper extremity originate at the confluence of the venules of deep digital veins of the fingers
  • Metacarpal veins to deep venous arches which converge into the radial and ulnar veins at the wrist
  • Calf and forearm veins are referred to as venae comitantes because 2 veins of the same name follow the same course as a single artery of the same name
Radial Veins:
  • Deep veins of the forearm
  • Pair of veins that course adjacent to the radial artery along the lateral aspect of the forearm (anatomic position)
  • Join with the paired ulnar veins to form the brachial vein(s) at the antecubetal fossa; can be one or two brachial veins
Ulnar Veins:
  • Deep veins of the forearm
  • Pair of veins that course adjacent to the ulnar artery along the medial aspect of the forearm (anatomic position)
  • Join with the paired radial veins to form the brachial vein(s) at the antecubetal fossa; can be one or two brachial veins
Brachial Vein(s):
  • Deep vein(s) of the proximal arm
  • Brachial vein(s) courses through anterior upper arm to meet the medial basilic vein at the axilla to become the axillary vein
Axillary Vein:
  • Deep vein
  • Segment formed from the brachial/basilic junction
  • Joins the cephalic vein to form the subclavian vein adjacent to lateral clavicle
Subclavian Vein:
  • Deep vein
  • Formed by axillary and cephalic junction
  • Located deep to the clavicle, usually courses somewhat parallel to clavicle
  • Ends when  internal jugular vein merges with it to form the innominate vein
Brachiocephalic Vein:
  • AKA innominate vein
  • Internal jugular vein drains blood from the head/neck and joins the subclavian vein to form the innominate vein (brachiocephalic vein)
  • Right and left brachiocephalic veins join to form the SVC
  • Right brachiocephalic vein courses lateral and anterior to the right brachiocephalic artery
  • Left brachiocephalic vein courses anterior to the left common carotid artery and right brachiocephalic artery to join the right brachiocephalic vein (NO left brachiocephalic artery)
  • ***2 Innominate veins(Right and Left), 1 innominate artery (first branch of aortic arch)
  • Right and left innominate veins merge to form the superior vena cava (SVC) which empties into the right atrium of the heart
Basilic Vein: 
  • Superficial vein until it reaches the proximal arm and penetrates the deep fascia
  • Considered superficial vein in the forearm and deep vein in the proximal arm due to its location in reference to the fascia
  • Originates medially in wrist, adjacent to ulnar bone, courses superiorly along the medial arm to join brachial vein in  axilla
  • Axillary vein formed by the junction of the basilic and brachial veins just distal to the axilla
Cephalic Vein: 
  • Superficial vein
  • Originates laterally in wrist, adjacent to radial bone
  • Courses superiorly along the lateral aspect of the arm to join axillary vein at shoulder
  • Most common upper extremity vein used for arterial bypass
Antecubital Vein:
  • AKA median cubital vein
  • Superficial vein
  • Connects cephalic and basilic veins in antecubital fossa
  • Commonly used to draw blood

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