Anatomy of the Superficial Venous System of the Leg

352 Review

Anatomy of the superficial venous system of the leg

E. Brenner Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Austria

Keywords musculature are found inside, followed by nensystem ein, die V. saphena magna kon- Great saphenous vein, small saphenous vein, dense bundles of circularly arranged smooth stant im Hiatus saphenus, die V. saphena par- accessory saphenous veins, superficial cir- musculature. In the tunica externa longitudi- va in etwas mehr als zwei Dritteln der Fälle in cumflex iliac vein, superficial epigastric vein, nal muscle fiber bundles can also be found. der Fossa poplitea. Zudem bestehen zahlrei- external pudendal vein, perforating veins Both the great and the small saphenous vein che Verbindungen zwischen oberflächlichem lie in their own fascial sheath, the floor of und tiefem Venensystem über die Vv. perfo- Summary which is formed by the crural fascia or the rantes. Die oberflächlichen Venen stehen un- The superficial venous system of the leg starts fascia lata and their superficial leaf by the re- tereinander über Vv. communicantes in Ver- with the epifascial veins, i.e. the various sub- spective saphenous fascia. Within these „sa- bindung. In den oberflächlichen Venen finden cutaneous venous networks, the accessory phenous compartments“ the respective veins sich zahlreiche parietale Klappen, zumeist mit saphenous veins, superficial epigastric vein, are laterally anchored by saphenous liga- zwei, in kleineren und kleinsten Venen auch the superficial iliac circumflex vein, and the ments. About 60 large-volume, clinically sig- mit nur einem Klappensegel. An der Mündung external pudendal veins. These flow into the nificant perforating veins connect the superfi- der V. saphena magna kann sich zudem eine two intrafascial veins, the great and the small cial with the deep venous system. At least ostiale Klappe, Astklappe, befinden. Die Wand saphenous veins. These, in turn, enter the one flap in each perforating vein prevents der oberflächlichen Venen besitzt den typi- deep venous system, the great saphenous backflow from the deep venous system. schen dreischichtigen Aufbau mit einer Tunica vein constantly in the saphenous hiatus, the intima, einer Tunica media und einer Tunica small saphenous vein in just over two thirds externa. Die Tunica intima besitzt, zumindest of cases in the popliteal fossa. In addition, nu- in der V. saphena magna nachgewiesen, eine merous connections exist between the super- Schlüsselwörter Membrana elastica interna. In der Tunica me- ficial and the deep venous system by the per- V. saphena magna, V. saphena parva, Vv. sa- dia finden sich innen longitudinal angeordne- forating veins. The superficial veins communi- phenae accessoriae, V. circumflexa ilium su- te Bündel glatter Muskulatur, nach außen ge- cate with each other by communicating veins. perficialis, V. epigastrica superficialis, V. pu- folgt von dichten Bündeln zirkulär angeord- Within the superficial veins numerous parie- denda externa, Vv. perforantes neter glatter Muskulatur. In der Tunica exter- tal valves exist, mostly with two, in smaller na können ebenfalls noch längsgerichtete and smallest veins also with only one valve Zusammenfassung Muskelfaserbündel zu finden sein. Sowohl die leaflet. At the entrance of the great saphen- Das oberflächliche Venensystem des Beines V. saphena magna als auch die V. spahena

ous vein into the femoral vein, there may also beginnt mit den epifaszialen Venen, das sind parva liegen in einer eigenen Faszienhülle, Heruntergeladen von: Thieme Gruppe. Urheberrechtlich geschützt. be an ostial valve. The wall of the superficial die diversen Venennetze der Subkutis, die deren Boden von der Fascia cruris bzw. der veins has the typical three-layered structure Vv. saphenae accessoriae, die V. epigastica su- Fascia lata und deren oberflächliches Blatt with a tunica intima, a tunica media and a perficialis, die V. circumflexa ilium superficia- von der jeweiligen Fascia saphena gebildet tunica externa. The tunica intima comprises, lis und die Vv. pudendae externae. Diese mün- wird. Innerhalb dieser „Saphenous Compart- at least in the great saphenous vein, an inter- den in die beiden intrafaszialen Venen, die ments“ werden die jeweiligen Venen durch nal elastic membrane. In the tunica media, V. saphena magna und die V. saphena parva Ligamenta saphena seitlich verankert. Etwa longitudinally arranged bundles of smooth ein. Diese wiederum münden in das tiefe Ve- 60 großvolumige, klinisch bedeutende Vv. perforantes verbinden das oberflächliche Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages. mit dem tiefen Venensystem. Zumindest eine Klappe in einer V. perforans verhindert dabei Correspondence to: Anatomie des oberflächlichen Venensystems des einen Rückstrom aus dem tiefen Venensys- Ao.Univ.Prof. Dr.med.univ. Erich Brenner, MME(Bern) Beines Sektion für klinisch-funktionelle Anatomie, Medizin- Phlebologie 2018; 47: 352–362 tem. ische Universität Innsbruck https://doi.org/10.1055/s-0038-1675460 Müllerstrasse 59, 6020 Innsbruck, Österreich Received: 03. September 2018 Tel: +43–512–9003–71121, Accepted: 26. September 2018 E-Mail: [email protected]

Phlebologie 6/2018 © Georg Thieme Verlag KG 2018 E. Brenner: Anatomy of the superficial venous system of the leg 353

Introduction Ostial valves lie at the confluence of two veins, anchored in the wall of the larger The superficial venous system is basically vein immediately below the orifice of the different from the deep venous system. lesser vein where it enters the trunk (22, Superficial veins run independently of the 41). They consist of one or two valve cusps arteries. They can be divided into two or leaflets (41); in the case of only a single groups: the epifascial veins and the intra- valve leaflet, the free border is typically di- fascial veins. rected towards the heart, while the distal • The epifascial veins lie within the sub- edge attached to the vein wall surrounds cutaneous tissue and flow into the in- the opening of the smaller vein. Ostial trafascial veins, i.e. they are usually valves are found mainly in the deep venous tributaries to the intrafascial veins. system (coronary sinus (35), great cardiac • The intrafascial veins lie on the superfi- vein (35), mesenteric veins (13), renal veins cial fascia and are partially separated (15), gonadal veins (50), vertebral veins from the rest of the subcutaneous con- (40), inferior thyroid vein (40), superior nective tissue by their own distinct fas- phrenic vein (40), posterior intercostal cia. veins (31), hepatic veins (31), azygos vein (44), and the deep veins of the leg (34)); The superficial venous system includes all however, ostial valves are also an – albeit the veins that lie above the fascia that inconsistent – finding at the saphenofemo- covers the entire body – the ‘superficial fas- ral junction (49). Ostial valves do not have cia’ running beneath the skin. These veins an agger (thickened area at the base of the differ from the deep veins in several ways: valve) (22). • Superficial veins basically run indepen- The parietal valves within the lumen of dently of the arteries; they therefore lack the vein have to be distinguished from the any arterio-venous coupling that acts as ostial valves. Franklin KJ (22) cited Sappey a mechanism to propel blood flow along PC (42), saying “A valve which is not in- Fig. 1 Ostial and parietal valves: a, valve placed the veins. serted into the circumference of the actual at the orifice of the renal vein in the sheep; seen • Superficial veins lie more or less directly entry is not an ostial, but a parietal valve, in face [luminal view]; a‘, the same in ideal sec- on the superficial fascia, i.e. in the deep no matter how near it is to the entry”. Pa- tion; b, the ordinary semilunar [parietal] valve or deepest layers of the subcutaneous rietal valves are classic pocket valves and from the tube of a vein; b‘, the same in section; c, tissue. Some of these veins, in particular usually have two valve cusps, single-leaflet imperfect [ostial] valve at orifice of intercostal the great and small saphenous veins, parietal valves are rare and are found only vein; c‘, section of imperfect [ostial] valve at ori- have their own distinct fascia separating in small veins and venules (3; 17). It is of fice of hepatic vein; d, the same in face (the dotted lines in a, c and d correspond to the ori- them from the rest of the subcutaneous particular note that the number of valves in fices of the respective veins); e, very imperfect tissue, and are known as intrafascial these very small vessels is highest in re- [parietal] valve; e‘, the same in section; f, plan of

veins. gions overlying bones and tendons, that is double valve at orifice of vein; f‘, the same in sec- Heruntergeladen von: Thieme Gruppe. Urheberrechtlich geschützt. • Superficial veins connect to the deep to say, in areas where venous ulcers are tion; g, ideal section of small valve and sinus; h, veins at their inherent junctions but also most likely to occur (3) (▶ Fig. 1). section of a sinus without a valve. Source: Salter to varying extents through the anasto- As a rule, the cusps of these parietal SJH (41). moses formed by perforating veins. The valves are about twice as long as the diam- superficial veins also form interconnect- eter of the vein in which they are situated In cross-section, the agger is a triangular ing networks through communicating (22). On their luminal aspect, they contain fibromuscular structure, whose base is lo- veins. an internal elastic membrane (51). They cated within the circular muscle of the vein consist of thin, half-moon-shaped folds of wall and whose tip forms the base of the Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages. intima, extending from the vein wall into valve cusp (19). It contains smooth muscle Venous valves the lumen. Neither nerves nor blood in a specific arrangement, following the vessels are present in the cusps (9; 14). The agger’s line of anchorage to the vein wall. The direction of blood flow in the superfi- thickened tissue where the valve cusps at- Taken in the normal direction of flow, cial veins is determined by the venous tach to the vein wall is known as the agger the parietal valve that lies between the ori- valves. These valves are specialised struc- or limbus; the area where the two leaflets fice of the most proximal tributary vein tures formed from the intima (28). Two abut at their insertion into the vein wall is and the opening of the vein itself into the types of valve can be distinguished: ostial the commissure. The agger is roughly next venous trunk is called the terminal valves, also called branch valves, and parie- horseshoe-shaped with the convex side valve (15; 24; 34). In addition, there is tal valves (22). lying distally. usually a preterminal valve. This valve lies

distally, i.e. before the opening of the im- na leaves the vein wall and switches to the portant tributaries into the respective sa- luminal side of the valve cusp at the agger; phenous vein, looking in the direction of although the vein wall itself contains elastic flow. fibres around the valve sinus, they are not contiguous with the internal elastic lamina (51) (▶ Fig. 3). Wall structure A smooth transition to the tunica media occurs through the increase of smooth Although all the veins in the human body muscle cells. Their arrangement here is al- have basically the same function, namely to together denser, so that little room remains store and return blood to the heart, the for collagen fibrils and elastic fibres. In ad- structure of the vein wall varies consider- dition, there are blood vessels and nerve ably between various sections of the body. plexuses (vasa and nervi vasorum) (53). In general, the vein wall possesses a tunica The muscle fibres have a circular arrange- intima (interna), a tunica media, and a ment in the tunica media (media circula- tunica adventitia (externa). The tunica inti- ris). Smaller veins have a loose circular ma consists of at least a continuous en- muscle layer with fine elastic fibres lying in Fig. 2 Histological cross-section of the great sa- dothelium and subendothelial connective between the muscle cells; the thickness of phenous vein at the level of a parietal valve: the tissue. The intima is also responsible for the the circular muscle layer increases with the tunica media consists of circular smooth muscle formation of venous valves (see above). diameter of the vessel and appears domi- (media circularis) and partially developed longi- There is no blanket description of the nant in the large epifascial venous trunks tudinal muscle (media longitudinalis). The tunica further structures, divided into the layers (28). After the age of 20, longitudinal adventitia also contains numerous longitudinal previously mentioned, which fits all the ve- muscle fibre bundles develop inside the cir- muscle fibre bundles. nous vessels. While arteries by definition cular media. These may disappear again α-SMA/ haematoxylin/lithium carbonate. Own have smooth muscle in the tunica media, with advancing age (4). Elastic fibre net- image. Source: Division of Clinical and Functional veins may have smooth muscle in all three works lie on the surface of the muscle layer, Anatomy, Medical University of Innsbruck layers (e.g. the iliac and femoral veins), with the fibres predominantly running may contain very few muscle fibres, or longitudinally (28). Adjacent to the tunica even none at all (e.g. veins in the brain and intima in the great saphenous vein (GSV), meninges) (4) (▶ Fig. 2). there is a section of variable width with Two factors are decisive in the morphol- longitudinal smooth muscle cells (51). In ogy of the vein wall: first, the level of the between the individual muscle cells or hydrostatic pressure of the column of blood bundles are tightly packed undirected col- pressing on the vein wall and secondly, the lagen fibres and moderately thick elastic mechanical demands made on the vein fibres arranged longitudinally (51). A layer wall by the surrounding tissue (32). of circular muscle consisting of 5–8 overly-

The structure of the wall of the superfi- ing layers of smooth muscle cells is found Heruntergeladen von: Thieme Gruppe. Urheberrechtlich geschützt. Fig. 3 Histological longitudinal section of the cial veins in the leg has to cope with the to the outside (51). great saphenous vein at the level of a parietal high hydrostatic pressure in the vessel and Descriptions of the structure of the tuni- valve cusp: the internal elastic lamina extends the low external pressure from the sur- ca adventitia are contradictory: the transi- from the valve cusp; there is no clearly structured rounding loose connective tissue. All the tion to the tunica adventitia has been de- continuous internal elastic lamina around the superficial veins therefore have a high pro- scribed as the region where there are no sinus. L: lumen; S: sinus; a: agger. Weigert’s elastic portion of circular smooth muscle fibres longer any muscle cells (53) but other stain. Own image. Source: Division of Clinical and (21). sources declare that spiral or longitudinal Functional Anatomy, Medical University of Inns- Beneath the layer of endothelium, the bundles of muscle fibres are still to be bruck Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages. tunica intima consists of a loose extracellu- found in the adventitia (4; 51). Rieger and lar matrix with collagen and elastic fibres, co-workers also report that these longitudi- The subcutaneous tissue is divided into but also smooth muscle cells (53). Most of nal muscle fibre bundles develop over the a true subcutaneous layer and an epifascial the muscle fibres run longitudinally and course of a lifetime into the most important layer by a stratified wide-meshed lamellar strengthen the vein wall (4). Middle-sized component of the vessel wall (38). The ad- system (29). The larger subcutaneous veins and large veins also have a more-or-less ventitia consists of loose connective tissue are suspended in the epifascial layer by a complete internal elastic membrane (the and contains vasa vasorum, which are three-dimensional network of tensioning internal elastic lamina). It is found mainly found in larger numbers in the epifascial lamellae (28) that safeguards against strain in the segments between the valves. At the veins than in the deep veins, plus bundles and overstretching given the great flexibil- level of the valves, the internal elastic lami- of nerve fibres and lymphatic vessels (28). ity (23).

Phlebologie 6/2018 © Georg Thieme Verlag KG 2018 E. Brenner: Anatomy of the superficial venous system of the leg 355

Superficial veins of the leg V. circumflexa V. epigastrica superficialis ilium superficialis Clinical focus on the superficial veins of the leg lies firstly on the epifascial manifes- V. femoralis V. pudenda externa tations of chronic venous insufficiency, Vv. circumflexae laterales femorales varicose veins, and – as a complication – Vv. circumflexae mediales femorales venous leg ulcers, and secondly on the V. saphena accessoria possibility of harvesting these veins, es- V. poplitea V. profunda pecially the great saphenous vein, for the femoris V. saphena parva purpose of bypass grafting ( Fig. 4). V. femoralis ▶ Vv. tibiales The two large intrafascial veins of the Vv. tibiales anteriores leg are the great saphenous vein (GSV) and posteriores Vv. fibulares the small saphenous vein (SSV). These Fig. 4 terms are thought to come from the Greek Venous flow in the V. saphena magna meaning ‘clearly evident, albeit badly de- right leg. a) Anterior V. poplitea veloped“, because these vessels are easily thigh; b) Posterior calf seen due to their superficial position. The (Source: Teubner P. Der venöse Blutabfluss. In: Greek term is σφυριτις φλεψ (37). The two V. saphena Bommas-Ebert U, parva systems are connected by communicating Teubner P, Voss R, Edi- b veins that differ greatly from person to per- tors. Kurzlehrbuch V. saphena parva son. In addition to the junctions of the Anatomie und Em- superficial veins with the deep venous sys- bryologie. 3rd edition. Vv. tibiales anteriores tem, they are also connected by perforating Thieme; 2011. doi:10.1055/b-002–2 Vv. fibulares Vv. tibiales posteriores veins. The direction of the valves in these a veins allows the additional flow of blood 1536) from the superficial to the deep system. The groups of perforators are designated calf. It usually opens into the great saphen- investigations, we found that this valve was according to their topographical position ous vein just below the knee. The distal (or present in about 70% of cases; the average and further divided into subgroups (16). crural) anterior accessory of the GSV (vena distance from the opening was 39 mm. In saphena accessoria anterior distalis (sive rare cases, further parietal valves can be The great saphenous vein (vena cruris), formerly the anterior arch vein found proximally in the common femoral saphena magna) (vena arcuata cruris anterior) runs almost vein (33). An infrasaphenic valve, i.e. the parallel to the infrapatellar branch of the first parietal valve distal to the orifice of the The great saphenous vein (GSV) has its saphenous nerve. GSV, was relatively common, being present origin in the medial marginal vein at the The GSV has numerous tributaries in in 87% of cases; the average distance from medial border of the foot. It becomes the the thigh, which mostly open in the region the orifice was about 50 mm. In about half

GSV proper when it enters its own fascial of the saphenofemoral junction (SFJ); this of the cases we found a second distal parie- Heruntergeladen von: Thieme Gruppe. Urheberrechtlich geschützt. compartment in front of the medial mal- anatomical region was referred to as the tal valve and, rarely, even a third (33). leolus. It runs up the medial aspect of the ‘crosse’ in earlier times. Even though the Well-known large named veins open at calf, crosses the knee joint just behind the term saphenofemoral junction has been the SFJ but there are also small unnamed medial femoral condyle in most cases, and commonly used in the English literature, tributaries. These small tributaries mostly enters the femoral triangle at the medial discrepancies remain as to whether the originate around the superficial inguinal border of the sartorius muscle. The GSV term covers only the actual opening of the lymph nodes; there may also be veins ac- passes through the saphenous opening in GSV into the common femoral vein or, as companying the vessels and nerves (venae the fascia lata to open into the common fe- recommended by the International Union comitantes, venae vasorum, venae nerv- Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages. moral vein. of Phlebology (UIP), the entire area from orum) and small cutaneous veins. The In the lower leg the GSV has two main the preterminal valve to the orifice (15; 16). major superficial inguinal tributary veins tributaries. The leg portion of the posterior The saphenofemoral junction also includes or [major] saphenous junctional tributaries accessory of the GSV (vena saphena acces- the relevant portions of the common femo- form the confluence of the superficial in- soria posterior distalis (sive cruris)) was ral vein between the supra- and infrasa- guinal veins, sometimes also known as the formerly known as the posterior arch vein phenic valves. Venenstern (venous star) from the Ger- (vena arcuata cruris posterior); it originates The suprasaphenic valve is the first pa- man. This term, however, does not indicate behind the medial malleolus and runs up- rietal valve in the common femoral vein lo- any uniform vascular pattern: any of these wards in a posteromedial position about 3 cated immediately above (proximal to) the veins may open independently into the cm from the great saphenous vein in the orifice of the great saphenous. In our own great saphenous vein or form trunks with

one or more of the other large tributaries, vein (12%). They drain the external channels that drain into the superficial in- or even, if only rarely, open into the com- genitalia (scrotum or labium majus) and guinal lymph nodes (nodi lymphatici in- mon femoral vein. Usually three or four may anastomose with the dorsal vein of guinales superficiales, tractus horizontalis large tributaries open into the saphenofe- the penis or clitoris, respectively. et verticalis). moral junction. Given the large number of • Anterior accessory of the GSV (vena sa- The fascia lata is the fascial sheath sur- theoretically possible patterns, many of phena accessoria anterior (proximalis rounding the entire thigh. It has various which have already been demonstrated, it sive femoris)): The proximal (femoral) openings for nerves and vessels to pass does not really seem worthwhile to classify anterior accessory of the GSV has its through. The largest opening allows the the SFJ variants, as many authors have own fascial sheath, similar to that of the great saphenous vein to enter the subfascial tried to do. great saphenous vein with its saphenous compartment and is called the saphenous • Superficial circumflex iliac vein (vena fascia. However, in only 50% of cases opening. The proximal, lateral and distal circumflexa ilium superficialis): In 83% does it open into the saphenofemoral margins form the falciform margin, while of cases, it enters the GSV, on average junction, at an average distance of 20 the medial margin does not have a sharp about 11 mm (maximum 2 cm) before mm from the saphenofemoral orifice. It border. Here the fascia curves more deeply the GSV opens into the common femo- forms trunk veins with the superficial and, as a relatively thin sheet of connective ral vein. It is therefore usually the most circumflex iliac vein and/or the superfi- tissue, separates the distal extension of the proximal of the tributaries emptying cial epigastric vein. It drains the anterior vascular lacuna (containing the femoral ar- into the SFJ. This tributary forms a com- and lateral thigh. Its main branch runs tery and common femoral vein) from the mon trunk with the superficial epigas- superficially following the course of the distal extension of the femoral canal (with tric vein in 30% of cases, and occasion- deep vessel/nerve pathway with the fe- the lymph vessels and nodes of the deep in- ally also includes the external pudendal moral artery and vein (alignment sign) guinal group). The main branches of the vein (vena pudenda externa). The and can be clearly distinguished from nerves (femoral branch of the genitofemo- superficial circumflex iliac vein drains the great saphenous vein, which lies cor- ral nerve, anterior cutaneous branches of the lateral lower abdomen as well as the respondingly medially. the femoral nerve) do not usually pass hip region and the lateral aspect of the through the saphenous opening, but mostly upper thigh. From our own investigations, the (proxi- through the fascia lata laterally to it. • Superficial epigastric vein (vena epigas- mal) posterior accessory of the GSV (vena The subcutaneous tissue is divided by trica superficialis): In just about 80% of saphena accessoria posterior [proximalis septa running in both the vertical plane cases, this large tributary opens into the sive femoris]) does not count as a large from superficial to deep, and in the hori- SFJ about 12 mm from the saphenofe- tributary of the saphenofemoral junction, zontal plane parallel to the fascia lata. Just moral orifice. It may form a trunk with even though it is sometimes still included below the surface, the septal separation is the superficial circumflex iliac vein in the confluence of superficial inguinal mostly incomplete. Somewhat deeper these alone (32%) or also include the (proxi- veins in the anatomical literature, a cir- connective tissue membranes form the cri- mal) anterior accessory of the GSV cumstance that can be attributed to it occa- briform fascia (fascia subcutanea cribrosa), (18%). The superficial epigastric vein sionally opening into one of the other large in particular over the saphenous opening drains the lower and medial part of the tributaries (34). Even though it frequently similarly to the abdomen, which was form-

anterior abdominal wall from about the (85%) opens into the great saphenous vein, erly referred to as the superficial femoral Heruntergeladen von: Thieme Gruppe. Urheberrechtlich geschützt. level of the umbilicus. Superiorly it an- it does so at an average distance of more fascia or the fascia of Scarpa. astomoses with the thoracoepigastric than seven centimetres (74 mm) from the The saphenous fascia (10; 11). The GSV vein, which in turn opens into the axil- saphenofemoral orifice. It therefore lies dis- is fixed in its intrafascial position by its lary vein in the axilla. Around the um- tal to the preterminal valve. In addition, it own fascia. The saphenous fascia is formed bilicus, this venous system connects ultimately represents the actual outlet of from a semi-transparent fibroelastic mem- with the paraumbilical veins, constitut- the long dorsal vein(s), the small saphen- brane in the lower thigh, reinforced by ing an important portacaval anastomo- ous vein and its proximal extension, the fe- transverse strands of connective tissue. It is sis. The paraumbilical veins may dis- moropopliteal vein. considerably thinner in the subinguinal re- Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages. tend to become a caput medusae when gion, over the saphenous opening, where the flow in the portal vein is obstructed. Fascial relations of the great sa- the connective tissue strands are arranged • External pudendal vein(s) (vena(e) pu- phenous vein (8) radially or irregularly. Proximally, the sa- denda(e) externa(e)): There are usually phenous fascia attaches to the inguinal liga- two external pudendal veins that unite The superficial compartment of the thigh, ment. into one large tributary before opening the subcutaneous tissue, is bordered by This fascia creates an isolated great sa- into the GSV about 17 mm (maximum skin on the outside and the fascia lata on phenous compartment. In the upper thigh 5 cm) from the saphenofemoral orifice the inside. Within this subcutaneous com- it contains the GSV and its vasa vasorum, in 90% of cases. They form trunks, es- partment lie all the superficial veins, but the superficial inguinal lymph nodes, and pecially with the superficial epigastric also (cutaneous) nerves and lymphatic the openings of the tributaries that have

Phlebologie 6/2018 © Georg Thieme Verlag KG 2018 E. Brenner: Anatomy of the superficial venous system of the leg 357 previously pierced the saphenous fascia. of the GSV. In our investigations, we found The saphenous nerve still lies beneath the a proximal extension of the SSV in 84% of fascia lata is the upper thigh, not piercing cases; this frequency correlates well with the vastoadductor membrane (subsartorial the number of posterior accessory veins fascia) and subsequently the fascia lata opening into the GSV (85%) (▶ Fig. 5). until the lower thigh; it comes to lie adjac- However, there is a wide range of vari- ent to the GSV, which it accompanies ants depending on how well the individual through the rest of the lower leg. The GSV components are developed, especially the is anchored to the fascial walls of the sa- saphenopopliteal junction and the proxi- phenous compartment by lateral connect- mal extension of the SSV. In the course of ive tissue laminae (the ‘saphenous liga- our investigations, we identified a ‘normal’ ment’). This configuration gives rise to the saphenopopliteal junction in 56% of cases, ultrasound image of the ‘saphenous eye’. sometimes with a very fine vessel or a Double great saphenous veins can be double SSV, while a regular network of fine diagnosed only when two veins lie within veins was present in 15% of cases. the great saphenous compartment; if the The saphenopopliteal junction was second vein lies superficially to the saphen- completely absent in the remaining cases ous fascia and runs parallel to the GSV, this (29%), with only a fine proximal extension is designated as a superficial accessory to to be found (43). The saphenopopliteal the GSV. junction usually opens into the popliteal vein from the (postero)lateral direction. Its Small saphenous vein (vena saphe- position in relation to the two large nerve na parva) (8) trunks in the popliteal fossa, the tibial nerve and the common fibular nerve, is The small saphenous vein (SSV) originates important. We found that the tibial nerve behind the lateral malleolus as the continu- lies laterally to the saphenopopliteal junc- ation of the lateral marginal vein, where it tion in about two-thirds of cases and medi- also receives its main afferent veins. The ally in the other third. Particular attention SSV is the long posterolateral vein of the needs to be paid to the common fibular lower leg, where it receives the lateral acces- nerve as it sometimes, although rarely sory saphenous vein of the leg, and continu- (2.5% of cases), lies medial to the sapheno- es as the proximal extension of the small sa- popliteal junction and then crosses the po- phenous vein, also known as the femoropo- pliteal fossa relatively obliquely. pliteal vein, on the posterior aspect of the calf. This proximal extension moves around Fascial relations of the small sa- the upper thigh medially and ultimately phenous vein (8)

opens into the GSV as the posterior acces- Heruntergeladen von: Thieme Gruppe. Urheberrechtlich geschützt. sory vein. In the vicinity of the popliteal Like the great saphenous vein, the SSV and Fig. 5 Proximal extension of the small saphen- fossa, this long posterior intrafascial vein its proximal extension also have their own ous vein (vein of Giacomini): The small saphenous relatively often anastomoses with the popli- (small) saphenous fascia (11; 12). Our in- vein continues into the thigh as its proximal extension as a vessel of almost the same diameter; teal vein to a varying extent. This anastomo- vestigations showed that this fascia begins it winds around the upper thigh and opens into sis is actually a saphenopopliteal perforating near the lateral malleolus and extends up- the great saphenous vein. There is a robust perfor- vein but is referred to in general clinical wards along the whole lower leg (43). Only ator to the popliteal vein in the vicinity of the po- terms as the saphenopopliteal junction (the the saphenopopliteal junction ultimately pliteal fossa (the saphenopopliteal junction). Left ‘crosse’ in European countries). The outflow pierces the popliteal fascia to reach the po- leg. Own image, prepratation for dissection Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages. of the saphenopopliteal junction forms the pliteal vein. course. Source: Division of Clinical and Functional boundary between the SSV itself and its The situation may also arise here that an Anatomy, Medical University of Innsbruck proximal extension. Anglo-American litera- accessory vein lies superficially outside this ture does not recognise the term ‘crosse’ and fascia, which is then called the superficial uses the term saphenopopliteal junction. accessory vein. perforating veins in each leg. About 60 of The proximal extension of the small sa- these are key perforating veins, accompa- phenous vein continues proximally into the Perforating veins nied by cutaneous arteries in the thigh and thigh: it usually lies in its own fascial com- lower leg, as direct outflows of the saphen- partment and finally opens into the great The superficial venous system and the deep ous system. Another approximately 90 saphenous vein as the posterior accessory venous system are connected by up to 150 clinically less relevant perforating veins

pierce the fascia via intermuscular septa, In clinical practice, the perforating veins The perforating veins of the lateral leg sometimes paired with the cutaneous ar- were often given eponymous names that connect veins of the lateral superficial ve- teries. They drain mainly the subcutaneous still appear, even though they were often nous plexus with the fibular veins (venae tissue and are accompanied by subcu- inaccurate from a historical point of view fibulares). taneous nerves, lymph vessels, and the vasa and sometimes confusing. In the more re- The perforating veins of the posterior vasorum of the saphenous system. Anasto- cent literature therefore, thoroughly de- leg are divided into medial gastrocnemius moses in the subcutaneous tissue, at the scriptive topographical terms are preferred. perforators (in the medial calf), lateral ga- fascial openings, and in the subfascial tis- Perforators are grouped on the basis of strocnemius perforators (in the lateral sue connect the two venous outflow sys- their topography (▶ Table 1). calf), intergemellar perforators that con- tems. The blood flow is directed from The perforating veins of the foot (venae nect the SSV to the deep calf veins (also superficial to deep by means of one to three perforantes pedis) are divided into dorsal called the mid-calf perforator of May), and parietal valves; if there is only one valve, it (intercapitular), medial, lateral, and plantar para-Achillean perforators that connect the is always located shortly before the vein foot perforators. A consistent large perfor- SSV with the fibular veins (also called the opens into the deep system. These valves ating vein connects the dorsal venous arch perforator of Bassi) some 5 cm proximal to protect the superficial venous system of the foot with the deep veins of the foot in the calcaneus. against reflux from the deep venous sys- the first intermetatarsal space. The perforating veins of the knee (venae tem, for example by appropriate muscle The perforating veins of the ankle perforantes genus) are designated as medi- contractions. The wall structure of the per- (venae perforantes tarsalis) are divided into al knee perforators, suprapatellar or infra- forating veins is approximately the same as medial, anterior, and lateral groups and patellar perforators, lateral knee perfor- that of the superficial veins. Neither sys- usually lack valves. ators, and popliteal fossa perforators, ac- tematic and topographic anatomical par- The perforators of the leg (venae perfor- cording to their location. These perforating ameters, nor the nature, number or struc- antes cruris) are divided into four main veins, too, usually lack valves. ture of their valves or even special features groups. The perforators of the medial leg The perforating veins of the thigh of their wall structure explain why some are designated as paratibial and posterior (venae perforantes femoris) are also perforating veins tend to become incompe- tibial perforating veins. Paratibial perfor- grouped on the basis of their topography. tent while others do not. ators connect the main trunk or tributaries On the medial thigh are the perforators of Perforating veins are very numerous of the GSV with the posterior tibial veins the femoral canal (Dodd) and the inguinal and very variable with respect to arrange- and run close to the medial surface of the perforators, which connect the GSV or its ment, connection, size, and distribution. tibia. They correspond to the so-called tributaries with the femoral vein at the Most anatomical investigations have not Sherman PV (at the lower and mid leg) and groin. The anterior thigh perforating veins found any consistency in the number and Boyd PV (at the upper leg). Posterior tibial pierce the quadriceps femoris. The lateral position of these connecting pathways. On perforating veins (Cockett perforators) thigh perforating veins pierce the lateral the other hand, clinical authors emphasise connect the posterior accessory great sa- muscles of the thigh. On the posterior that the regularity that can be seen in this phenous vein with the posterior tibial veins thigh, the perforating veins are designated respect is relatively high. Apparently even (venae tibiales posteriores). There are as posteromedial thigh perforators piercing the smallest perforating veins can be dem- usually three perforating veins (lower, the adductor muscles, sciatic perforators

onstrated radiologically or surgically ex- middle, and upper) which lie at a distance lying along the midline of the posterior Heruntergeladen von: Thieme Gruppe. Urheberrechtlich geschützt. posed in living patients, especially when of 6 cm, 13.5 cm, and 18.5 cm proximal to thigh, posterolateral thigh perforators the venous flow is obstructed for some rea- the sole of the foot along ‘Linton’s line’; this piercing the biceps femoris and semitendi- son, although they cannot always be seen is an imaginary vertical line along the calf nosus muscles (also called the ‘perforator in anatomical preparations. starting about a fingerbreadth behind the of Hach’), and pudendal perforators. The course of the perforating veins medial malleolus. The point where the The perforating veins of the gluteal re- passes two topographic regions: the super- upper posterior tibial perforator pierces the gion (venae perforantes glutealis) are di- ficial or subcutaneous part and the deep or fascia is known in clinical terms as the so- vided into superior, mid, and lower perfor- subfascial part. The subcutaneous part is leus point. In addition, there may be a ators. Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages. short and frequently uniform. The subfas- further perforating vein higher up on Lin- cial part is much longer and often shows ton’s line, at a distance of approximately 24 Fascial openings morphological variation. The perforating cm from the sole of the foot, known as the veins change their morphological appear- 24-cm PV. The perforating veins pierce the fascia ance most often in the subfascial section: The perforating veins of the anterior leg through oval apertures whose long axis lies there may be double veins, branched, ar- connect the anterior tributaries of the GSV in the same direction as the fascial fibres boreal, or complex vessels. The subcu- to the anterior tibial veins (venae tibiales and whose edges are reminiscent of the fal- taneous part often crosses the superficial anteriores). They consistently lie some 2 ciform margin of the saphenous opening. nerves, while the subfascial part lies close cm to 5 cm lateral to the anterior border of These margins are formed by thickened to a small, thin artery. the tibia. bundles of fibres that intersect at the

Tab. 1 Overview of the perforating veins. Sources: Caggiati A, Bergan JJ, Gloviczki P, Jantet G, Wendell-Smith CP, Partsch H and the International Interdisci- plinary Consensus Committee on Venous Anatomical Terminology (16), Ströbel P (48) Location Subgroup (eponym) Average number Connecting between ... Gluteal Superior gluteal PV 4 – 6 subcutaneous veins and superior gluteal veins Inferior gluteal PV 4 – 7 subcutaneous veins and inferior gluteal veins Thigh Medial thigh PV: PV of the femoral canal (Dodd) 3 – 5 great saphenous vein (small saphenous vein) and femoral vein Inguinal PV 1 superficial and deep circumflex iliac veins Anterior thigh PV 6 – 12 branches of the great saphenous vein and muscle veins Lateral thigh PV 3 – 9 Posterior thigh PV: Posteromedial PV 1 – 5 great saphenous vein and femoral vein Sciatic PV 2 – 3 cranial extension of small saphenous vein and femoral vein Posterolateral PV (Hach) 3 – 9 subcutaneous venous plexus and muscle veins Pudendal PV 2 subcutaneous venous plexus and pudendal vein Knee Medial knee PV 3 – 5 small saphenous vein and popliteal vein Anterior knee PV: Suprapatellar PV 1 – 2 Infrapatellar PV Lateral PV 4 lateral venous plexus and popliteal vein Posterior or popliteal fossa PV 4 small saphenous vein and popliteal vein Lower leg Medial leg PV: Paratibial PV (Sherman’s or Boyd’s) 4 great saphenous vein and posterior tibial vein Posterior tibial PV (Cockett) 3 (- 5) posterior accessory great saphenous vein and anterior tibial vein Anterior leg PV 3 anterior tributaries of the great saphenous vein and anterior tibial vein Lateral leg PV 3 – 5 lateral branches of the small saphenous vein and fibular vein Posterior leg PV: Medial gastrocnemius PV posterior branch of the great saphenous vein and gastrocnemius veins Lateral gastrocnemius PV small saphenous vein and gastrocnemius veins Intergemellar PV (May) 1 Heruntergeladen von: Thieme Gruppe. Urheberrechtlich geschützt. Para-Achillean PV (Bassi) small saphenous vein and fibular vein Ankle Medial ankle PV (May/Kuster) 3 dorsalis pedis vein and great saphenous vein Anterior ankle PV 2 origin of fibular vein and small saphenous vein Lateral ankle PV 2 – 3 Foot Dorsal foot PV 10 – 14 plantar vein and great or small saphenous vein Medial foot PV 6 dorsalis pedis vein and great or small saphenous vein

Lateral foot PV 6 fibular vein and small saphenous vein Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages. Plantar foot PV 13 – 16 deep plantar veins and the venous network of the sole of the foot (rete venosum plantare) angles. Tent-like sheaths are formed from with a similar, although not so strongly de- penetrate the fascia in a downwards direc- the loose fine-fibred superficial layer of the veloped, supporting matrix on the inside of tion, rarely also running upwards. They fascia together with the fibrous system of the fascia. The openings are usually located firstly run for some distance between two the vascular sheaths of the perforating in the intermuscular septa, especially in the fascial sheets, sometimes with an intrafas- veins. The perforators are also equipped lower leg. The perforating veins usually cial sheath, e.g. along the medial tibial mar-

gin. It is often the case that several perfor- tween the free margin of the fascial open- tergo’; for instance, a pressure increase in ating veins open into the deep veins ing and the widened vein wall, trophic dis- the vena cava also occurs with a sudden through a common trunk segment. orders in the vascular territory may ensue. cardiac arrest (39). The ‘vis a fronte’ of the Based on macroscopic preparations, right atrial diastolic suction also has an af- Sander (1959) distinguished three types of fect on the filling of the heart; however its fascial opening for perforating veins – ap- Functional aspects (1, 2) effects on the peripheral venous system parently irrespective of the local fascial tex- have not yet been investigated. However, ture: The venous system as a whole makes only a the heart rate does not correlate with the • The most commonly occurring type of small contribution to the overall peripheral frequency of the valve closure cycles in the fascial opening is the ‘hole’. Tensioning resistance (venules and veins together ac- GSV (46; 47). The mechanics of respiration fibres in the intersecting fibre bundles count for about 7% [27]), yet it contains act in the same direction, i.e. ‘vis a fronte’ form a rounded opening through which three-quarters of the blood volume. The (25), but once again there is no correlation the perforators usually pass steeply. most important parameters of the venous between the respiratory rate and the valve These fascial holes are so firm due to system are therefore volume and com- closure cycles (46; 47). The muscle and their intersecting and interwoven fibres pliance of the vein wall. These parameters joint pumps have been described as an im- that no alteration in shape is possible on can be measured easily and reliably in rou- portant drive mechanism (18; 25), al- tension, i.e. the aperture does not widen tine clinical practice by means of venous though there are dissenting voices on this or narrow (an example of this type is occlusion (photo) plethysmography. Apart issue (26), especially as their function dep- seen in the caval opening in the central from factors of age and body position, the ends on active movement. When the tendon of the diaphragm). venous tone itself depends greatly upon muscles are active, these pumps certainly • The ‘funnel’ is to be found as the con- temperature, so that corresponding investi- contribute to the venous return; when the struction where the superficial fascia is gations should be carried out only at con- body is completely at rest, asleep for in- associated with a muscle septum. The stant (and recorded) ambient temperatures stance, this mechanism stops working. opening in the fascia is funnel-shaped, after adequate acclimatisation. It is understandable that disorders of the running along the septum into the Pharmacological venous vasoconstric- connections between the superficial and deeper layers; the funnel thus formed tion can be achieved by the local adminis- deep venous systems lead to serious prob- does not merge with the vascular sheath tration of α-adrenergic agonists, 5-HT re- lems. This involves not only the saphenofe- of the penetrating vessels (perforating ceptor agonists, ergot alkaloids, angiotensi- moral and saphenopopliteal junctions but vein with accompanying artery and nogen, and angiotensin I and II, as well as also the perforating veins. lymph vessels) but also ends with a various prostaglandins. Applying cold is A vicious circle ensues: instead of blood sharp margin. Sander asserted that it also well-known to cause vasoconstriction flowing into the deep system, there is back- stands to reason that tension on the fas- (45). Vasodilatation of previously con- flow (reflux) from the deep veins. This in cia would not cause this type of opening stricted veins can be seen with the use of turn increases the superficial blood vol- to change shape, either. β-adrenergic agonists, muscarinic choli- ume. The superficial veins dilate as a result, • The rarest type of fascial opening is the nergic receptor agonists, nitrates, calcium causing more venous valves to stretch and ‘slit’, which is found only where the fas- antagonists, bradykinin, substance P, and become incompetent. Conversely, (patho-

cial fibres are running in the same direc- some prostaglandins. It seems that veins logical) changes in the vein wall, such as Heruntergeladen von: Thieme Gruppe. Urheberrechtlich geschützt. tion and the veins pass through entirely. are also basically able to accomplish spon- thickening of the intima and media or an This is particularly the case over the ro- taneous peristaltic contraction (5; 6). increase in collagen and a decrease in the bust bellies of the calf muscles. The The full mechanism that drives the elastic fibres, can disrupt the normal func- veins pass straight through a slit-like blood in the veins towards the heart re- tioning of the veins and give rise to venous opening in the parallel fibre bundles, mains conspicuously unexplained. Rather, insufficiency (20). whose edges diverge perpendicularly to a whole bunch of factors combine to enable The endothelial cells of the veins con- the fascial plane. If the fascia is slack, the the venous blood flow. These include the tain numerous Weibel-Palade bodies filled vein widens the slit, but when the oft-mentioned ‘vis a tergo’ (force acting (WPBs). The WPBs store von Willebrand Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages. fascia is tensed, the slit narrows, thus from behind), the ‘vis a fronte’ (force acting Factor (vWF), an adhesive glycoprotein es- compromising the perforator. from in front), the muscle pump, and the sential to haemostasis. If the endothelium mechanics of respiration (52). The pressure is damaged, vWF binds platelets that coat The perforating veins are nearly always ac- gradient from the postcapillary area to the the defect immediately and allow it to be companied by small arteries and lymph heart is a sufficient ‘vis a tergo’ to maintain covered with new epithelial cells later. vessels; deep anastomoses where the vein a slow blood flow, at least with the body passes through the fascia alone could be lying horizontally (25). This volume trans- Conflict of interest demonstrated only in the foot. If incompe- port, which is ‘pushed’ by the systolic ejec- tent varicose perforating veins trap the ac- tion from the left ventricle, cannot, how- The author declares that he has no conflicts companying arteries and lymphatics be- ever, represent the sole origin of the ‘vis a of interest.

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