High Level Overview: Venous Anatomy of Lower Extremities

High Level Overview:

Venous Anatomy of Lower Extremities

Barbara Deusterman, RN What does this anatomy lecture have to do with visually-guided sclerotherapy (VGS)?

May 11, 2015 2 Anatomy of a Vein

Almeida, Jose. Atlas Of Endovascular Venous Surgery. Philadelphia, PA: Elsevier, 2011. 12. Print.

May 11, 2015 3 Competent or “normal” valve

Venous valves are bicuspid (two) flap like structures made of elastic tissue. The valves function to keep blood moving in one direction.

May 11, 2015 4 Normal Flow

Deep Veins Perforating veins Large Superficial veins Tributary veins Reticular veins Venules

Capillaries http://www.biosbcc.net/doohan/sample/htm/vessels.htm

May 11, 2015 6 What makes up the venous system?

• Deep venous system: the channel through which 90% of venous blood is pumped out of the legs

• Superficial venous system: the collecting system of veins

• Perforating veins: the conduits for blood to travel from the superficial to the deep veins

• Musculovenous pump: Contraction of foot and leg muscles pumps the blood through one-way valves up and out of the legs

May 11, 2015 7 Deep and Superficial System Location and Communication

http://www.phlebology.org/pdfs/Ch1_pp1-4.pdf May 11, 2015 Almeida, Jose. Atlas Of Endovascular Venous Surgery. Philadelphia, PA: Elsevier, 2011. 8 Deep System Basics

May 11, 2015 9 Deep System Common Femoral Vein

Deep Femoral Vein Femoral Vein

Popliteal Vein Posterior Tibial Vein Peroneal Vein Anterior Tibial Vein

May 11, 2015 10 Superficial System Basics

May 11, 2015 11 Great Saphenous Vein

Saphenofemoral Junction (SFJ)

Great saphenous vein

Medial malleolus

Dorsal venous arch http://www.phlebology.org/pdfs/Ch1_pp1-4.pdf Almeida, Jose. Atlas Of Endovascular Venous Surgery. Philadelphia, PA: Elsevier, 2011.

May 11, 2015 12 Small Saphenous Vein

Saphenopopliteal junction

Small saphenous vein

Lateral malleolus

Bergan, JJ. The Vein Book, 2007 Elsevier Academic Press, page 22

May 11, 2015 13 What connects the Superficial and Deep Systems?

May 11, 2015 14 Perforators

May 11, 2015 15 Copyright 2012 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610. Published by American Medical Association.

Management of Varicose Veins and Venous Insufficiency. May 11, 2015 Hamdan, Allen JAMA. 308(24):2612-2621, December 26, 2012. 16 DOI: 10.1001/jama.2012.111352 Nerves of Phlebologic Interest

May 11, 2015 17 Nerves

The Saphenous nerve is the largest and longest branch of the femoral nerve and supplies the skin over the medial side of the leg

The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon

Almeida, Jose. Atlas Of Endovascular Venous Surgery. Philadelphia, PA: Elsevier, 2011. Bergan, JJ (2007), The Vein Book, Chapter 35, pp 315-321

May 11, 2015 18 May 11, 2015 Clemente Carmine, Anatomy, 3rd Edition, 1987, Urban and Schwarzenberg, Figs. 460, 461 19 How does the blood get back to the heart?

May 11, 2015 20 Muscular Pumps

• Normal venous return requires a “pump”

• Muscle action send blood up the veins of the leg and competent valves prevent reflux/retrograde blood flow

• There are three muscular pumps in the legs • Foot • Calf • Thigh

May 11, 2015 21 Calf Muscle Pump

May 11, 2015 22 Calf muscle pump

May 11, 2015 23 What happens when the venous system is broken?

May 11, 2015 24 Management of Varicose Veins and Venous Insufficiency. Hamdan, Allen , JAMA. 308(24):2612-2621, December 26, 2012.DOI: 10.1001/jama.2012.111352 3 Reflux

Venous reflux is considered to be significant if retrograde flow lasts more than 0.5 seconds in superficial veins

May 11, 2015 26 Reflux: How does it contribute to Varicose Veins?

May 11, 2015 28 Vein branching leading to the saphenous truncal veins include:

 Telangiectasias (also known as telangiectatic or spider veins) o Are flat red vessels on the skin’s surface o 0.1 mm – 1 mm in diameter  Venulectasias (venules) o Are bluish vessels which may be distended above the skin o 1 – 2 mm in diameter  Reticular veins (also known as feeder veins) o Have a cyanotic hue o 2 – 4 mm in diameter o Associated with telangiectasias  Varicose veins o Have incompetent valves with increased venous pressure leading to progressive dilation and tortuosity of the vein walls 1. Primary varicose veins – likely due to multiple factors such as hereditary, female sex hormones, obesity, pregnancy, or long episodes of standing (hydrostatic force) 2. Secondary varicose veins (less common) – involves trauma, congenital absence of valves in vein walls, or obstruction May 11, 2015 29 Lateral Subdermal Plexus

May 11, 2015 30 Telangiectasias

May 11, 2015 31 Reticular Veins

May 11, 2015 32 Varicose Veins

May 11, 2015 33 Thank you!

May 11, 2015 34