Linda Antonucci, RPhS, RVT, RDCS

Linda Antonucci, RPhS, RVT, RDCS

DISCLOSURE Linda Antonucci, RPhS, RVT, RDCS I have no financial relationships to disclose relevant to this talk.

SIMILARITIESBETWEEN ARTERIES AND VEINS Composed of three layers Tunica Intima or Interna Endothelial cells Tunica Media Smooth muscle cells Tunica Adventitia or Externa Collagen fibers Sympathetic nerve fibers Vaso vasorum

MAJOR DIFFERENCES Vein media is thinner and has significantly less elastin Veins are not as structurally robust as the arteries Venous media is weaker predisposing it to dilatation and damage

MAJOR DIFFERENCES con t Veins have Valves Prevent reflux Reduplication of intima Bicuspid Opposite each other Pouched appearance when closed

3 MAJOR COMPONENTS OF THE VENOUS SYSTEM Deep system Superficial system Communicating system

3 SEPARATE FASCIAL PLANES A thorough knowledge of each plane and fascial compartment is a prerequisite of understanding the relationship between the deep and superficial system. Epifascial Compartment Superficial Reticular Veins Interfascial Compartment Superficial Axial Veins Subfascial Compartment Deep Veins

DEEP & SUPERFICIAL FASCIAL PLANES ALL veins located ABOVE the muscular fascia are SUPERFICIAL VEINS Muscular fascia ALL veins located BENEATH the muscular fascia are DEEP VEINS

PERFORATOR VEINS PERFORATE the muscular fascia connecting the deep and superficial systems

INTERFASCIAL VEINS INTERFASCIAL VEINS are located WITHIN the SAPHENOUS COMPARTMENT Saphenous compartment

EPIFASCIAL VEINS EPIFASCIAL VEINS are located ABOVE the superficial fascia in the subcutaneous compartment Subcutaneous compartment and are called reticular and communicating veins.

TRIBUTARIES NOT BRANCHES Veins that cross the superficial fascia connecting a superficial vein to another superficial vein are called tributaries. All telangiectasia are considered dermal veins.

UPDATED NOMENCLATURE In 2001 the International Interdisciplinary Committee drafted a document that attempted to unify the official Terminologia Anatomica regarding the veins of the lower limbs In 2002 the committee s recommendations were published in the Journal of Vascular Surgery and they further refined this terminology in an addendum in 2005 Journal of Vasc Surg 2002; 36: 416-22 Journal of Vasc Surg 2005; 41: 719-24

NOMENCLATURE CHANGES TO THE DEEP SYSTEM Inguinal crease to knee External Iliac Vein - EIV Common Femoral Vein - CFV Femoral Vein FV (formerly SFV) Deep Femoral Vein (DFV) or Profunda Femoris Vein (PFV) Popliteal vein PV Perforators

DEEP SYSTEM CON T Knee to Ankle Popliteal Vein PV Anterior Tibial Veins (2) ATV Posterior Tibial Veins (2) PTV Peroneal Veins (2) Per V Sural Veins Soleal Veins Gastrocnemius Veins Medial Lateral Intergemellar Perforators ALL deep calf veins run in PAIRS

NOMENCLATURE CHANGES TO THE SUPERFICIAL VENOUS SYSTEM Great Saphenous Vein GSV (formerly Greater or Long SV) Anterior Accessory Great Saphenous Vein - AAGSV Posterior Accessory Great Saphenous Vein - PAGSV Superficial Accessory Saphenous Vein SASV Anterior Thigh Circumflex Vein ATCV Posterior Thigh Circumflex Vein - PTCV Small Saphenous Vein - SSV (formerly Lesser or Short SV) Thigh Extension or Cranial Extension of the SSV - TE or CE Vein of Giacomini - VOG Intersaphenous Vein - ISV Tributaries Lateral Venous System - LVS

Superficial Venous System The major players are the GSV and SSV

GSV TERMINATES at SAPHENOFEMORAL JUNCTION ORIGIN anterior to the medial malleolus

SSV ORIGIN posterior to the lateral malleolus SMALL TERMINATES at the SAPHENOPOPLITEAL JUNCTION approximately 60% ABOVE the knee crease approximately 40%

THIGH EXTENSION TERMINATION The thigh extension of the SSV may extend up and medially to join the posterior thigh circumflex or vein to form the Vein of Giacomini It may extend up to join the femoral vein via a posterior thigh perforator It may extend up to terminate in a gluteal vein or the LVS

VEIN OF GIACOMINI is an intersaphenous connection found in approximately 60% of limbs VOG connects GSV and SSV

CONFLUENCE OF THE INGUINAL VEINS Anterior Accessory Great Saphenous Vein ascends from the anterolateral thigh Posterior Accessory Great Saphenous Vein ascends from the posteromedial thigh Anterior Circumflex Vein courses obliquely from the lateral thigh and usually joins with the AAGSV or GSV Posterior Circumflex Vein courses obliquely from the posterior thigh and usually joins with the PAGSV

GSV AND AAGSV EYE SIGN Great Saphenous Vein ALIGNMENT SIGN Anterior Accessory Great Saphenous Vein Image courtesy of New Jersey Vein Center Image courtesy of Jeannie Melendez

Anterior Accessory Great Saphenous Vein Aligned with the Femoral Artery AAGSV FA Courses more anteriorly than the Great Saphenous Vein GSV Image courtesy of Jeannie Melendez

PERFORATOR VEINS The normal direction of drainage is from SUPERFICIAL to DEEP via the PERFORATORS

ELIMINATE EPONYMS CLASSIFY BY TOPOGRAPHY Proximal Thigh Perforator Distal Thigh Perforator Medial knee Perforators Medial Leg and Ankle Perforators

2 TYPES OF PERFORATORS Direct connect superficial to deep Indirect Intermediaries

MEDIAL THIGH PERFORATOR Thigh Medial thigh PV connects GSV and tributaries to FV

DEEP VEIN VARIANTS Duplication Femoral vein - approx 25% (40%) Popliteal vein - approx 25%

SUPERFICIAL VEIN VARIANTS Duplication Great saphenous vein 1% Small saphenous vein 4%

Normal GSV with GSV with Aplastic GSV GSV Leonardo s vein Large tributary Large tributary UIP consensus Document. Part II. Anatomy

HYPOPLASTICGSV W/LARGE TRIBUTARY GSV Image courtesy of Sanjeev Palta, MD Tributary HYPOPLASTIC GSV

SFJ VARIANTS Include but not limited to: Ectasia Independent Junction Common Trunk

SPJ VARIANTS 3 Most Common Ectasia High SPJ Absent SPJ

HIGH SPJ The SSV terminates above the crease joining with the FV approximately 25% 5% it joins with other posterior thigh veins The SSV may or may not have a Thigh Extension The thigh extension is present in approximately 75% of limbs

ABSENT SPJ At times the SSV does not have a direct relationship with the popliteal vein at all It continues cephalad as the thigh extension

COMPANION NERVES GSV - Saphenous nerve SSV - Sural nerve

References 1. Bergan, John J. The Vein Book. Boston: Elsevier, 2007. 2. Mitchel P. Goldman, Bergan, John J, and Jean-Jerome Guex. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. 4th ed. DVD-ROM. Boston: Elsevier, 2007. 3. A Practical Atlas of Functional Anatomy Web site, http://www.phebologia.com. (Accessed July 2007). 4. Kabnick, Lowell M.D., et al. Venous Ultrasound in the Office: A Hands-on Primer. Course Syllabus, July 28-29, 2006. 5. Cavezzi, A. et al. Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower Limbs UIP Consensus Document, Part II. Anatomy. European Journal of Vascular Surgery 2006;31 288-298. 6. Caggiati, Alberto M.D., PhD. et al. Nomenclature of the Veins of the Lower Limb: Extensions, Refinements, and Clinical Application. Journal of Vascular Surgery 2005;41: 719-724. 7. Neumyer, Marsha M. Vascular Technology and Review Pennsylvania State University College of Medicine. Hershey, PA. N.d. 2006. 8. Minn, Robert J., M.D., Neil M. Khilnanni, M.D., and Piyush Golia. Duplex Ultrasound Evaluation of Lower Extremity Venous Insufficiency. Journal of Vascular and Interventional Radiology, 2003, http://www.jvir.org/cgi/content/full/14/10/1233. 9. Daigle, Robert J. Techniques in Noninvasive Vascular Diagnosis: An Encyclopedia of Vascular Testing. 2nd ed. Littleton: Summer Publishing, 2002. 10. Weiss, Robert A., Craig F. Feied, and Margaret A, Weiss. Vein Diagnosis and Treatment: A Comprehensive Approach. New York: McGraw-Hill, 2001. 11. Ridgway, Donald P. Introduction to Vascular Scanning: A Guide for the Complete Beginner. 2nd ed. Pasadena: Davies Publishing, 2001. 12. Zwiebel, William J. Introduction to Vascular Ultrasound. 4th ed. Philadelphia: W.B. Saunders, 2000. 13. Case, Terrence D. Primer of Noninvasive Vascular Technology. New York: Little, Brown, 1995. 14. Strandness, D. Eugene, Jr., and Arina Van Breda. Vascular Diseases: Surgical & Intervention Therapy. New York: Churchill Livingsont, 1994. 15. Kempczinski, Richard F., and James S.T. Yao. Practical Noninvasive Vascular Diagnosis. 2nd ed. Chicago: Year Bood Medical Publishers, 1987.

Linda Antonucci, RPhS, RVT, RDCS Email - laveins@gmail.com