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Lower Extremity
Venous Anatomy
SON 1311
Cross-Sectional Anatomy
Eastern Florida State College
Harry H. Holdorf
PhD, MPA, RDMS (Ob/Gyn, Ab, BR), RVT, LRT(AS), CCP
Cross-Sectional Anatomy
• Venous Legs
– LE Venous system
Q: Why are we covering the LE venous
system so early in our education?
A: The LE venous system is more often than
not, a straight line. If the beginning
sonographer can master the LE venous
system, all the other studies may be easier
to grasp.
Venous Gross Anatomy
• Lower Extremity Veins
– Note: The anatomical relationship of the
veins to the heart is the same as for the
arteries. Veins located at the ankle are
considered distal: while veins located
closer to the heart (e.g., Femoral) are
considered more proximal
– Note: Be sure to know the orientation of
vessels from medial to lateral and from
lateral to medial
The paired, deep veins of the calf (Anterior
Tibials, Peroneals, and posterior tibilas,
follow the corresponding arteries: are called
comitantes (corresponding veins).
• Paired peroneal veins (PerV)
– Formed by confluence of venules
– Empties the lateral leg
– Paired veins may form common trunk and
carry blood cephalad into tibial-peroneal trunk
• Paired posterior tibial veins (PTV)
– Formed by confluence of venules
– Empties back of leg
– Paired veins may form common trunk and
carry blood cephalad into tibial-peroneal trunk
• Paired anterior tibial veins (ATV)
– Formed by confluence of venules
– Empties front of leg
• Popliteal vein (PopV)
– Formed by union of ATV and Tib-Peroneal
Trunk
– Usually just below the knee
– Becomes femoral vein (previously called
superficial femoral vein) when passes
through adductor hiatus in lower thigh
Adductor hiatus
The adductor hiatus is a hiatus (gap)
between the adductor magnus muscle
and the femur that allows the passage of
the femoral vessels from the anterior thigh
to the posterior thigh and then the
popliteal fossa.
• Femoral Vein (FV)
– Popliteal vein becomes FV when vein
passed through adductor hiatus
• Common Femoral Vein (CFV)
– Formed by joining of FV & Deep femoral
vein
Common Femoral Vein 5
Formed by 6 and 8
• External iliac Vein (EIV)
– Common femoral vein becomes EIV when
passes through inguinal ligament
• Common Iliac Vein (CIV)
– Formed by confluence of external and
internal iliac veins
The inguinal ligament
• Because the left common iliac vein
passes under the right common iliac
artery, extrinsic compression may be
evident.
• This pressure point may account for left
sided DVT; also known as May-Thurner
Syndrome
May-Thurner Syndrome
• Inferior Vena Cava (IVC)
– Formed by confluence of common iliac
veins
– Commonly at level of 5th lumbar vertebra
– Carries blood into right atrium of heart
Superficial Veins
• Small saphenous (formally
lesser) vein (SSV)
– Ascends back of calf joining
popliteal vein
Superficial Veins
• Great (formerly Greater) Saphenous
Vein (GSV)
– Longest vein in the body, originating on
dorsum of foot, traveling medially to
saphenofemoral junction in the groin
(about level of CFA bifurcation)
Great Saphenous Vein
Perforators
• Carry blood from superficial veins into
deep veins
• Posterior arch vein
– Has three ankle perforators
– Plays major role in development of venous
stasis ulcers
Blood Flows from superficial veins (S) to
the deep venous system (D)
Important perforators of the
Posterior Arch Vein
Posterior arch vein
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October, 2015
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October, 2015
Factors Affecting Venous Flow
• Venous-Skeletal muscle pump ‘Venous
heart’
• The GREAT MUSCLE PUMP = Calf
muscle
• Muscle contraction squeezes vein
propelling blood upward-forward
Hholdorf.com
October, 2015
A word about Hydrostatic Pressure
February, 2007
Effective Calf Muscle Pump
• Blood moves from superficial system (s)
to deep system (D)
• Competent valves prevent reflux
• Venous volume and pressure decreases
• Venous return to heart increases
Hholdorf.com
October, 2015
Ineffective Calf Muscle Pump
• Incompetent valves cause reflux
• Venous volume and pressure increases
• Results in venous pooling and
ambulatory venous hypertension.
Hholdorf.com
October, 2015
Respiration
Inspiration (Phasic)
• Decrease in intra-thoracic pressure
• Increases blood flow from upper
extremities
• Increase in intra-abdominal pressure
• Decreases blood flow from lower
extremities
Hholdorf.com
October, 2015
Respiration
Exhalation
• Increase in intra-thoracic pressure
• Decreases blood flow from upper
extremities
• Decrease in intra-abdominal pressure
• Increases blood from lower extremities
Hholdorf.com
October, 2015
Valsalva Maneuver
Patient takes in deep breath & holds it,
then bears down (as if having a bowel
movement)
Intra-thoracic and intra-abdominal
pressure increases significantly
All venous return halted
Veins will enlarge
Hholdorf.com
October, 2015
Vein Valves
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October, 2015
Importance of the Greater Saphenous
Vein
•
The great saphenous vein (GSV), previously also called the long saphenous vein, is a large,
subcutaneous, superficial vein of the leg. It is the longest vein in the body running along the medial length
of the leg.
Clinical significance
•
Pathology of the great saphenous vein is relatively common, but in isolation typically not life-threatening.
•
Varicose veins: The great saphenous vein, like other superficial veins, can become varicose; swollen,
twisted and lengthened, and generally considered to be unsightly.
•
Thrombophlebitis The GSV can thrombose. This type of phlebitis of the GSV is usually not life-threatening
in isolation; however, if the blood clot is located near the sapheno-femoral junction or near a perforator vein,
a clot fragment can migrate to the deep venous system and to the pulmonary circulation. Also it can be
associated with, or progress to a deep vein thrombosis which must be treated.
The vein is often removed by cardiac surgeons and used for auto transplantation in coronary artery bypass
operations, when arterial grafts are not available or many grafts are required, such as in a triple bypass or
quadruple bypass.
February, 2007
Vein Mapping for Coronary Artery bypass
graft surgery
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A tourniquet is placed around the upper thigh or the patient is placed in reverse
Trendelenberg to aid in venous filling.
The LSV is carefully traced onto the exterior of the leg using a surgical marker.
Beginning distally at the medial malleolus, a generous amount of ultrasound gel
is applied to the donor leg.
The focus is set to a depth of 2.8 cm to the scan area below the knee and may
be adjusted to greater depths as the thigh is reached.
The vein is identified and confirmed on the ultrasound screen as a tubular,
compressible structure.
The LSV is accurately followed up the medial aspect of the leg and marked for
the entire length of its course.
The caliber of the vein is assessed and measured at multiple sites and
adjustment is made for distension.
February, 2007
Superficial Veins - GSV
Images courtesy of Phillips - ATL
Hholdorf.com
October, 2015
Superficial Veins - GSV Sheath
Greater saphenous sheath
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October, 2015
Superficial Veins – Groin Tributaries
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October, 2015
Deep Veins – Full Length
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October, 2015
Deep Veins – Gastrocnemius Veins
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October, 2015
Deep Veins – Popliteal Vein
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October, 2015
Deep Veins – Iliac Veins
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October, 2015
Inferior Vena Cava
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October, 2015
Perforator Veins – Flow Direction
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October, 2015
Duplex-Color Flow Imaging
• Identify venous thrombosis – help
differentiate acute from chronic
• Evaluate non-occluding/partial thrombus
• Detect calf lesions
• Distinguish between extrinsic compression
and intrinsic obstruction
• Evaluate soft tissue masses
• Detect venous incompetence
• Document re-canalized channels or
collateralization
Hholdorf.com
October, 2015
Limitations of Duplex Imaging
• Sources of false-Positive studies
include:
– Extrinsic compression: e.g., tumors such
as SVC syndrome, ascites, pregnancy
– Peripheral arterial disease (PAD):
decreased venous filling
– Chronic obstructive pulmonary disease
COPD: Elevated central venous Pressure
– Improper Doppler angle or probe pressure
Hholdorf.com
October, 2015
Patient Positioning
• Peripheral veins: Lower Extremities
– Facilitate venous filling: i.e., reverse
Trendelenburg
– Diminish extrinsic compression: e.g.,
extreme Left lateral decubitus position
February, 2007
Technique
• Coaptation: From the Latin word
meaning “To fit together” is another
word for compressibility
February, 2007
Venous Flow Patterns
• Evaluate venous Doppler signals in
sagittal view:
Spontaneous
Phasic (with respiration)
Augment with distal compression
Augment with proximal release
February, 2007
Cross-Section of the Femoral vein
High thigh: left leg
February, 2007
Longt Normal Superficial Vein and
Superficial Femoral Artery
February, 2007
Longt: Superficial Femoral Vein with clot
Note: Femoral Artery anterior
February, 2007
Cross-Section
Popliteal Vein
February, 2007
Popliteal vein and Artery:
“Double scoop ice cream cone” sign
February, 2007
Distal Augmentation
• With distal augmentation of the calf
area, flow in the femoral vein initially
goes cephalad.
• With the release of the calf area, flow
should not reflux back down the leg.
• This maneuver demonstrates
competent venous valves.
February, 2007
Compression Technique
February, 2007
Deep Vein Thrombosis of the superficial
femoral vein
February, 2007
February, 2007
February, 2007
Homework
Show images of the following
• Augmentation with Distal Compression
• Augmentation with Proximal Release
• The mickey mouse sign (of the lower
venous legs)
• Coaptation of the popliteal vein
– To include compression and non
compression images
• Coaptation of the femoral vein
– Same images required as above
February, 2007
Holdorf