10.2478/chilat-2013-0010 ACTA CHIRURGICA LATVIENSIS • 2013 (13) ORIGINAL ARTICLE Variations in Lower Limb Deep Venous Anatomy in Latvia Dainis Krievins *, ***, Regina Zarina R, ***, Janis Savlovskis **, ***,*, Polina Dombure *, **** * Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia ** Department of Radiology, Pauls Stradins Clinical University Hospital, Riga, Latvia *** University of Latvia, Riga, Latvia **** Riga Stradins University, Riga, Latvia Summary Introduction. During the last several decades there have been many new methods introduced for the treatment of lower limb chronic venous insufficiency (laser, foam, subendothelial and thermal coagulation methods). Venous system of lower limbs often presents anatomic variations including venous duplications. Knowledge of venous system variations in the lower limb area is of particular importance due to correct interpretation of imaging in relation to deep vein thrombosis (DVT). There was only a small number of studies published on anatomic variations of venous system in the lower limbs. To the best of our knowledge there have been no previous studies on anatomic variations of lower limb deep venous system performed in Latvia. Aim of the study. To retrospectively review of 216 patients (432 lower limbs) phlebograms in order to establish deep venous system anatomic variations in Latvian population and compare our results to other publications. Materials and methods. Retrospective analysis of 432 lower limb phlebograms performed at Pauls Stradins Clinical University Hospital (Riga, Latvia) of 216 patients treated in different ortopedic centers of Latvia during 2009 and 2012. Assessment made using DICOM Synedra view personal software. Study protocol was developed for definition of veins and assessment of phlebogram images in accordance with anatomic definitions used in previous studies. Two independent radiologists assessed data. Visualised duplications in the deep venous system of both lower limbs in patients were registered (common iliac vein, external iliac vein, common femoral vein, femoral vein, deep femoral vein, popliteal vein). Blood vessels have been listed as single, double or triple / complex. The presence of DVT was recorded upon assessment of phlebograms. Statistical analysis performed using SPSS 20.0 software (IBM). Parametric data comparison performed using Student t-test and ANOVA. Non-parametric data comparison performed using chi-square and Mann Whitney tests. Data comparison type was assessed using Kolmogorova-Smirnovs test. The results are presented as the average ± standard deviation. Results. Retrospective analysis of 432 lower limb phlebograms was performed in 216 patients. Average age of the patients was 34.4 years (range 19-90). 101 patients were female (47%) and 115 (53%) were male with no statistical venous variation differences found between two genders, which is explained by both age and gender (p > 0.05). Analysis of calf vein, popliteal vein and femoral venous variations provided a strong correlation between larger number of duplications in one limb and possibility of such variations in the other limb of the same patient (all p < 0.001). Conclusion. We conclude that there are frequent anatomic variations in SFV and popliteal veins seen in Latvian population. All patients included in this study had high DVT risk, much higher than in the average Latvian population. In almost every sixth Latvian person there is some form of deep veins hypoplasia found. Keywords: venous anatomy; deep veins; femoral vein; popliteal vein; calf veins; venography. INTRODUCTION with the development of minimally invasive surgical Up to 73% of women and 53% of men worldwide are interventions methods for the treatment of lower limb diagnosed with chronic venous insufficiency (CVI). In chronic venous insufficiency (laser, foam, subendothelial Europe over one third of population is diagnosed with and thermal coagulation methods). The understanding CVI, 40-60% of females and 15-30% of males (5). of lower limb normal anatomy changes is important in Furthermore, deep venous thrombosis (DVT) occurs order to prevent unforeseen complications in this region for the first time in about 100 persons per 100 000 during intervention. each year (6). Precise diagnosis and proper treatment Veins serve as the best material for arterial grafting and reduce morbidity and mortality from DVT. Therefore it therefore the understanding of deep and superficial is essential to understand the normal anatomy of lower veins condition is especially important. Apart from that limb venous system in order to establish correct diagnosis sometimes the duplication of femoral vein is used in and provide treatment. There are frequent variations arterial reconstructions if large saphenous vein is not found in deep veins of lower limbs. Duplications of available. femoral veins may be one of the potential reasons for There is a small number of studies published on wrong DVT diagnosis. anatomic variations in venous system. Quinlan et al The significance of lower limb normal venous report that the incidence of femoral veins’ duplications anatomy and its variations was determined in line is approximately 20-25%, however this incidence could 51 ACTA CHIRURGICA LATVIENSIS • 2013 (13) be higher if also partial duplications were taken into that was defined as the vessel that most closely followed account (5). the course of the superficial femoral artery. Position of Until now there have been no studies on lower limb FV duplication was registered as medial or lateral against deep venous system anatomic variations performed in the true FV, or both, if such duplications were from Latvia. The aim of this study was retrospective analysis both sides of the true FV. Lengths of FV duplications of lower limb deep venous system variations in Latvia were divided into the following length groups: 1-5 cm, and comparison of results to published data on other 6-10 cm, 11-20 cm, 21-30 cm and 31 cm or larger. In populations. addition to that the level of lowest duplication point was recorded: above or in adductor channel region, above MATERIALS AND METHODS or under patella. Each direct FV and deep femoral vein Retrospective analysis of lower limb phlebograms in junctions with distal anastomoses have been recorded. 216 patients (432 limbs) was performed. Phlebographies The presence of DVT was recorded upon assessment of were performed in the period between 2009 and 2012 phlebograms. in Pauls Stradins Clinical University Hospital (Riga, Statistical analysis performed using SPSS 20.0 software Latvia). All patients have undergone hip or knee (IBM). Parametric data comparison performed using endoprosthetic replacement and received prophylactic Student t-test and ANOVA. Non-parametric data anticoagulant therapy in different ortopedic clinics in comparison performed using chi-square and Mann Latvia. The subiect group represents unselected patients Whitney tests. Data comparison type was assessed using proportionally coming from all regions in Latvia. Kolmogorova-Smirnovs test. The results are presented Phlebography was performed in order to exclude DVT, as the average ± standard deviation. which is an often complication after joint replacement surgery. Phlebograms of 15 patients have been excluded RESULTS from the study due to poor imaging quality preventing Retrospective analysis of 432 lower limb phlebograms from assessing venous anatomy. was performed in 216 patients. Average age of the Phlebograms were assessed using DICOM Synedra view patients was 34.4 years (range 19-90). Out of all patients personal software. Prior to commencing the study there 101 patients were female (47%) and 115 (53%) were was a study protocol developed for definition of veins male with no statistical venous variation differences and assessment of phlebogram images in accordance found between two genders, which is explained by both with anatomic definitions used in previous studies. age and gender (p > 0.05). Analysis of calf vein, popliteal Two independent radiologists assessed data. In case of vein and femoral venous variations provided a strong discordance of the results between them, patient was correlation between larger number of duplications in re-evaluated and final conclusion made. one limb and possibility of such variations in the other Visualised duplications in the deep venous system of limb of the same patient (all p < 0.001). both lower limbs in patients was registered (common The majority of anterior tibial veins and posterior tibial iliac vein, external iliac vein, common femoral vein, veins and peroneal veins were paired – respectively: femoral vein, deep femoral vein, popliteal vein). Blood 71% (307 and 432), 90% (388 and 432) and 89% (384 vessels have been listed as single, double or triple / and 432). Single veins were seen in 26% (111 our of complex. 432), 9% (39 out of 432) and 5% (23 out of 432) cases In-flow point (junction) of every limb’s vein into the respectively. Three or more peroneal veins were found calf or popliteal vein and the location of this junction in 6% (25 out of 432), part of anterior tibial veins in with respect to other vessels was marked. Using this 3% (14 out of 432), posterior tibial veins in 1% (5 out information the classification was made defined as calf’s of 432) patients. Drainage of the peroneal veins into veins join in trifurcation before creating a popliteal vein. the trifurcation occurred in 67% (288 out of 432) of Hypoplasticity of calf’s deep veins was also marked.