Extremity Venous Anatomy and Sonographic Evaluation

•  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

• 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

• 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

• 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

• 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

• 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

• 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

• 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)

• Becomes external iliac vein just above inguinal ligament at the groin crease
• Courses medial and posterior to common femoral artery

• Courses medial to the external iliac vein
• Drains the pelvic organs (NOT the gonads)

• 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

• 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

• Congenital absence of the deep veins
• Causes numerous superficial varicosities and clusters of varicosities

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• Deep vein
• Segment formed from the brachial/basilic junction
• Joins the cephalic vein to form the subclavian vein adjacent to lateral clavicle

• 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

• 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

• 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

• 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

• AKA median cubital vein
• Superficial vein
• Connects cephalic and basilic veins in antecubital fossa
• Commonly used to draw blood