1. Deep and Superficial Venous Anatomy
Robert Cushing, MD, FACPh
Carmel, CA

2. Disclosure I have nothing to disclose relevant to this presentation

3. There is new venous nomenclature Learn this new terminology and use it The attached references detail these changes and are excellent

5. Learn to correlate venous anatomy with venous ultrasonography The following two articles are outstanding references regarding how to accomplish this

6. These references are listed at the end of the presentation

7. Abdominal Pelvic Venous Anatomy

10. Venous Compartments

11. Subfascial (deep venous system) Intrafascial (saphenous compartment – between saphenous fascia and muscular fascia) Epifascial (tributary & reticular veins/telangectases)

13. Deep venous system (Iliofemoral)

17. Superficial venous system

18. Great Saphenous Vein

20. Terminal Valve Subterminal Valve
Image Courtesy of Diana Neuhardt, RVT

21. Proximal GSV tributaries drain lower abdominal and inguinal regions and flow into the most proximal GSV segment, between the two valves

22. Superficial circumflex iliac vein (lateral) Superficial external pudendal vein (infero-medial) Superficial epigastric vein (supero-medial)

23. Saphenofermoral junction

24. Superficial Epigastric
GSV
CFV
Image Courtesy of Diana Neuhardt, RVT

25. Great Saphenous Vein lies within the saphenous compartment

26. Saphenous “Eye” is ultrasound marker of GSV anatomy and demonstrates the saphenous compartment
Image Courtesy of Diana Neuhardt, RVT

27. Image Courtesy of Diana Neuhardt, RVT

28. Anterior Accessory Great Saphenous Vein

29. Junctional origin. - lies lateral to the GSV – courses over the
Junctional origin lies lateral to the GSV – courses over the femoral vessels and demonstrates the “alignment sign” on US has its own intra-fascial compartment which joins the GSV’s fascial compartment just before entering the SFJ - essentially opens directly in to the deep system - is not a tributary of the GSV

30. FA
CFV

31. common saphenous trunkFA FA
CFV
CFV

32. AAGSV
GSV
common saphenous trunk FA FA
CFV
CFV
CFV FA

33. common saphenous trunk
AAGSV
shared fascial origin
GSV
common saphenous trunk
“eye”
GSV
AAGSV FA FA
CFV
CFV
CFV FA

34. common saphenous trunk AAGSV within its own fascia
“eye” FA FA
CFV
CFV
CFV FA

35. AA(G)SV is not the Anterior Thigh Circumflex Vein (previously known as the Anterolateral Tributary Vein) which is a true tributary of the GSV and exits from the GSV more distally

36. GSV tributaries Anterior Thigh Circumflex Vein (formerly Anterolateral Tributary Vein) Posterior Thigh Circumflex Vein (formerly Posteromedial Tributary Vein) These veins exit the GSV in the proximal thigh

37. Vein of Giacomini (the only vein likely to retain its eponym) Enters GSV via Posterior Thigh Circumflex Vein

38. Small Saphenous Vein

40. Saphenopopliteal Junction SSV termination is variable but most often enters the Popliteal fossa 2-4 cm above the Popliteal skin crease

41. SSV lies in its own fascial compartment
Image Courtesy of Diana Neuhardt, RVT

42. Thigh (cranial) extension of the Small Saphenous Vein ascends in the groove between the Biceps Femoris and Semimembranosus musculature and terminates in thigh or gluteal perforators

43. Note proximity to Popliteal Artery
Image Courtesy of Diana Neuhardt, RVT

44. If the SSV thigh extension communicates with the GSV it forms the Vein of Giacomini

45. Perforating Veins

46. Perforator veins “perforate” the deep muscular fascia, crossing fascial planes, draining superficial to deep with a one way valve protecting unidirectional inward flow

48. New nomenclature eliminates use of eponyms

49. Inguinal perforator Saphenofermoral junction GSV to Common Femoral Vein

50. Popliteal fossa perforator Saphenopopliteal junction SSV to Popliteal Vein

51. Femoral canal perforators formerly Dodd & Hunter perforators GSV to Femoral Vein

52. Paratibial perforators formerly Sherman & Boyd perforators GSV to Posterior Tibial Veins

53. Posterior tibial perforators formerly Cockett perforators Posterior accessory GSV of the leg (formerly Leonardo’s Vein or the Posterior Arch Vein) to Posterior Tibial Veins
These do not drain into the GSV of the leg

55. Lateral Venous System Embryologic remnant of the Vena Marginalis Lateralis Formerly Lateral subdermic plexus of Albenese Drains lateral thigh and leg Surface veins drain into deep system via multiple perforators

57. References – Venous Anatomy and Pathophysiology Mauriello, John, MD “The New Anatomy of the Lower Limbs” Phlebological Surgery Section News, Volume 1, No.2 Fall, Feied, Craig F., MD “Venous Anatomy and Pathophysiology” Venous Disease for Clinicians, 1st Edition, 2004

58. The Vein Book J. Bergan et al, 1st edition, 2007, Elsevier Academic Press Handbook of Venous Disorders Gloviczki et al, 3rd edition, 2009, Hodder Arnold Nomenclature of the veins of the lower limbs: An international interdisciplinary consensus statement – Caggiati et al – J Vasc Surg 2002; 36:

59. Nomenclature of the veins of the lower limbs: An international interdisciplinary consensus statement – Caggiati et al, J Vasc Surg, 2005; 41: Duplex ultrasound investigation of the veins in chronic venous diseases of the lower limbs – UIP Consensus Document Part I: Basic Principles Coleridge-Smith, et al, Phlebology, 2006; 21:

60. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs – UIP Consensus Document Part II: Anatomy Cavezzi, et al, Phlebology 21: Can Saphenous and Sural Nerve Paresthesia be Prevented During ELT? T. King, presentation at European Venous Forum, 06/25/10

61. Thank you for your attention