1. PhD, MPA, RDMS (Ob/Gyn, Ab, BR), RVT, LRT(AS), CCP
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

2. 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.

3. 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

4. The paired, deep veins of the calf (Anterior Tibials, Peroneals, and posterior tibilas, follow the corresponding arteries: are called comitantes (corresponding veins).

5. 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)
Empties back of leg

6. 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

7. 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.

9. Common Femoral Vein (CFV)
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

10. Common Femoral Vein 5 Formed by 6 and 8

11. 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

12. The inguinal ligament

13. 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

14. May-Thurner Syndrome

15. 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

16. Small saphenous (formally lesser) vein (SSV)
Superficial Veins
Small saphenous (formally lesser) vein (SSV)
Ascends back of calf joining popliteal vein

17. Great (formerly Greater) Saphenous Vein (GSV)
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)

18. Great Saphenous Vein

19. Carry blood from superficial veins into deep veins Posterior arch 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

20. Blood Flows from superficial veins (S) to the deep venous system (D)

21. Important perforators of the Posterior Arch Vein

22. Posterior arch vein

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27. Factors Affecting Venous Flow
Venous-Skeletal muscle pump ‘Venous heart’
The GREAT MUSCLE PUMP = Calf muscle
Muscle contraction squeezes vein propelling blood upward-forward
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28. A word about Hydrostatic Pressure
February, 2007

29. 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
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30. Ineffective Calf Muscle Pump
Incompetent valves cause reflux
Venous volume and pressure increases
Results in venous pooling and ambulatory venous hypertension.
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October, 2015

31. 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
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32. Respiration Exhalation
Increase in intra-thoracic pressure
Decreases blood flow from upper extremities
Decrease in intra-abdominal pressure
Increases blood from lower extremities
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33. 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
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34. Vein Valves
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35. 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

36. Vein Mapping for Coronary Artery bypass graft surgery
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

37. Superficial Veins - GSV
Images courtesy of Phillips - ATL
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38. Superficial Veins - GSV Sheath
Greater saphenous sheath
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39. Superficial Veins – Groin Tributaries
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40. Deep Veins – Full Length
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41. Deep Veins – Gastrocnemius Veins
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42. Deep Veins – Popliteal Vein
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43. Deep Veins – Iliac Veins
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44. Inferior Vena Cava
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45. Perforator Veins – Flow Direction
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46. 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
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47. 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
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48. Peripheral veins: Lower Extremities
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

49. Technique
Coaptation: From the Latin word meaning “To fit together” is another word for compressibility
February, 2007

50. Evaluate venous Doppler signals in sagittal view:
Venous Flow Patterns
Evaluate venous Doppler signals in sagittal view:
Spontaneous
Phasic (with respiration)
Augment with distal compression
Augment with proximal release
February, 2007

51. Cross-Section of the Femoral vein High thigh: left leg
February, 2007

52. Longt Normal Superficial Vein and Superficial Femoral Artery
February, 2007

53. Longt: Superficial Femoral Vein with clot Note: Femoral Artery anterior
February, 2007

54. Cross-Section Popliteal Vein
February, 2007

55. Popliteal vein and Artery: “Double scoop ice cream cone” sign
February, 2007

56. This maneuver demonstrates competent venous valves.
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

57. Compression Technique
February, 2007

58. Deep Vein Thrombosis of the superficial femoral vein
February, 2007

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60. February, 2007

61. 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