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Anatomy

CHAPTER 1 Anatomy

Stefano Ricci

Introduction
The anatomy Chapter in a modern text devoted to sclerotherapy is traditionally not the most fascinating aspect, as the anatomy rarely changes and is very
similar to that described in older texts. Anatomy chapters are rarely consulted because readers believe they know the basics of venous anatomy, but they
should be reviewed regularly and, as one uses duplex ultrasound, the importance of understanding anatomy increases greatly. While this Chapter reports on the
images and the concepts of the classic anatomy texts that we used during our university medical studies, it is clear from our experience with duplex ultrasound
observations that a ‘déjà vu’ sensation to anatomy is not entirely correct and anatomy is more than a fixed science – new understanding has been added.

Dissection anatomy, indeed, had its fullest expression from the late eighteenth to the early twentieth century (Mascagni, Gray, Sobotha, Testut, etc.) when all the
aspects of dissection anatomy where definitively studied (Fig. 1.1). In the past 50 years anatomical dissection has been little used to investigate venous
anatomy, probably because of the assumption that there is nothing new to discover (but also because it is more and more difficult to find cadavers for this
purpose). Meanwhile, most anatomical, clinical and surgical textbooks describe the superficial veins of the lower limb as a simple ‘tree’ formed by a few
constant and recognizable veins, though clinical experience often shows anomalies and variations with respect to the classical anatomical description or even
the complete absence of some of these veins. Furthermore, usually studies in the field of limb veins concern subjects with varicose pathology and rarely
subjects with a normal venous system.

Figure 1.1 Three plates from the ‘Piccola anatomia’, which was published in a reduced size because of the high printing costs of the time, are shown here.
These demonstrate that anatomical knowledge was already complete 200 years ago. (The ‘Grande Anatomia’ of Paolo Mascagni was published between 1823
and 1831 by Nicolò Capurro in Pisa).

Confirming this, the official Anatomical Terminology (Nomina Anatomica)1 includes only a limited number of veins and does not take into account their
numerous variations. Inadequacy of official anatomy has caused many authors to name single veins independently or even after the author’s name, which, in
the absence of an accepted interpretation frame has added some confusion. The nomenclature consensus statement of 2001 at the Rome UIP World Congress
was organized with the purpose of solving this problem (see Table 1.1).2

Table 1.1 Summary of important changes in nomenclature of lower extremity veins

Old Terminology New Terminology

Femoral vein Common femoral vein

Superficial femoral vein Femoral vein

Sural veins Sural veinsSoleal veinsGastrocnemius veins (medial and lateral)

Hunterian perforator Midthigh perforator

Cockett’s perforators Paratibial perforatorPosterior tibial perforators

May’s perforator Ankle lateral and medial perforators

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Gastrocnemius point Intergemellar perforator

Modified from Sherman RS: Ann Surg 130:218, 1949.

Contrast phlebography, until recently the ‘gold standard’ for venous investigation, has the major drawback of being practically never complete, but rather
showing only the veins filled by contrast media. Furthermore, it focuses mainly on deep veins and in pathologic conditions, and thus has not contributed much to
the understanding of normal vein anatomy.

Understanding of vein anatomy did not progress much until ultrasound imaging (USI), specifically duplex scanning (DS), became an established technique for
clinical investigation of patients with venous diseases. Technology simplifications and low costs have allowed its widespread use.

Ultrasound imaging makes it easy to observe the veins of the lower limb, unlike anatomical dissection and phlebography. Examination is non-invasive,
repeatable and relatively low in cost. Veins can be observed at full distension, with the patient in a standing position, so that, unlike with anatomical dissection,
their real volumetric relationship with the surrounding tissue is readily appreciated. Ultrasound images show not only the veins (as contrast phlebography does),
but their relation to surrounding anatomical structures, in particular muscle and fascial layers. This allows precise anatomical identification of the observed veins
(Fig. 1.2). Therefore, USI is a unique tool for the study of vein anatomy (US dissection) and makes it possible to verify data obtained from anatomical
dissections. In addition, DS allows the detection of blood flow in the observed veins with assessment of their function and involvement in venous pathology.
Interestingly, USI was first employed for the clinical identification of pathologically changed veins. Later it was used for collecting data on normal vein anatomy.3

Figure 1.2 Ultrasound imaging shows the veins and their relationship to the surrounding anatomical structures, in particular other vessels, lymph nodes, bones,
muscles and fascial layers. This allows precise anatomical identification of the observed veins.

In this Chapter vein anatomy is first described from the traditional point of view, and successively as observed by USI with special reference to the superficial
veins of the lower limb in relation to varicose vein disease and sclerotherapy. For this purpose an interpretation key is emphasized, which makes it possible to
categorize the extreme variability of the superficial veins of the lower limb into a limited number of specific anatomical and varicose patterns.

Nomenclature
Nomenclature used throughout the textbook conforms to that developed at the Venous Consensus Conference Classification in 1994.4 In addition, the newest
revisions of nomenclature and definitions are used, which were developed at the Nomenclature Congress in Rome in 2001 (Table 1.1).2,5 The long saphenous
vein is referred to by the English-Latin term great (GSV). The short saphenous vein is referred to using the English-Latin translation small (SSV), avoiding the
term ‘lesser’ as the L could be confused with the term ‘long’. Veins that ‘perforate’ the fascia are termed perforator veins. Veins that connect to other veins within
a fascial plane are referred to as communicating veins. The principal deep vein of the thigh is termed the superficial femoral vein, now properly called the
femoral vein. The superficial femoral vein actually has turned out to be a potentially lethal misnomer. It has been found that the use of this term is hazardous to
patients suspected of having deep venous thrombosis. Many primary care physicians have not been taught and are not aware of the fact that the superficial
femoral vein is actually a deep vein of the thigh and that acute thrombosis in this vessel is potentially life threatening.6

General Considerations
The veins of the lower limbs are traditionally described as consisting of two systems: one within the muscular compartment and its fascia, the deep system, and
one superficial to the deep fascia, the superficial compartment (Fig. 1.3).

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Figure 1.3 According to traditional description, superficial veins are separated from deep veins by muscular fascia.

(Adapted from Kubik S. Das Venensystem der unteren Extremitat – Der informierte Artz 4:31, 1985)

The lower limb deep venous system is found inside the muscles within the muscular fascia. This allows it to feel the effects of the tonus variations during
contraction–relaxation, being the only structure able to vary its volume.7 The superficial veins are in an extrafascial position with respect to the muscles,
although the most important (i.e. saphenous veins) are found with superficial fascia duplication.

The lower legs’ deep venous system cannot be seen as an independent entity, separated from the superficial veins. The venous function’s first purpose is to
organize the anti-gravity blood backflow to the right heart, taking advantage of it’s volume capacity (three times as much as in arteries), it’s low pressure and it’s
compliance, so that the reservoir (the interstitium, depending on lymphatics) may not be involved.7 Other primary important functions, although more localized,
are tissue drainage and thermoregulation. These three functions are assured in all different body positions and activity, otherwise ‘venous insufficiency’ occurs.8

Tissue drainage and the maintenance of volume flow are based on valvular and, more importantly, muscle function. Both systems strictly integrate with the
venous reservoir function, the respiratory function and the filling ‘vis-a-tergo’ due to the capillary network.7

Venous backflow represents about 10% of the total flow at rest, but increases heavily during dynamic conditions due to the physiologic alternate contraction–
relaxation of the flexor–extensor muscles. These act as a peristaltic pump and as a dynamic reservoir, conditioning either the squeezing (contraction) or the
distension (relaxation) of the deep veins (with action on the venous sole of the foot and, above all, ankle joint movement of particular amplitude conditioning the
most important calf pump (Fig. 1.4).

Figure 1.4 Physiologically, alternate contraction–relaxation of the flexor–extensor muscles acts as a peristaltic pump and as a dynamic reservoir, conditioning
either the squeezing (contraction) or the distension (relaxation) of the deep veins and the normal emptying of the superficial veins, provided there is normal
valvular function.

(Adapted from: Tibbs DJ, Sabiston DC, Davies MG et al, Varicose veins, venous disorders, and lymphatic problems in the lower limbs, Oxford University Press,
1997.)

Deep vein communications, mutual or with superficial veins, are extremely frequent so that the postural and the rest phases may address the venous backflow
through less resistant pathways, typically the deep veins in the physiologic situation.7

Deep Venous System

The structure of the deep venous system is shown in Figure 1.5.9 There are at least two deep veins for each of the three arteries (anterior and posterior tibial
arteries and peroneal artery), mutually communicating by transverse bridges (like a ladder). The extremely rich muscular plexus (also connected to the

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superficial veins) drains into these axial veins placed parallel to arteries. At the foot, axial veins are prevalent in the plantar region, where the first pump
mechanism is present (Léjars sole) (Fig. 1.6).10–12

Figure 1.5 In the leg two deep veins for each of the three arteries communicate by means of transverse bridges. At the knee and thigh, deep veins flow into the
collecting system ‘popliteal-femoral veins’. Several other secondary veins are present that can ensure a natural bypass when obstruction occurs to the femoral
vein. 1: obturator vein, 2: common femoral vein, 3: medial circumflex femoral vein, 4: profunda femoris vein, 5: perforating veins, 6: descending genicular vein,
7: popliteal vein, 8: posterior tibial vein, 9: proximal portion of the posterior tibial venous axis (common trunk), 10: posterior tibial veins, 11: peroneal
(interosseous veins), 12: short saphenous vein, 13: posterior subcutaneous femoral vein, 14: ischial vein, 15: inferior gluteal vein.

(Adapted from Kubik S. Das Vevensystem der unteren Extremitat – Der informierte Artz 4:31–38, 1985)

Figure 1.6 At the foot, axial veins are prevalent in the plantar region, where the first pump (although not the most important) mechanism is present (Léjars sole).

(Adapted from: Tibbs DJ, Sabiston DC, Davies MG et al: Varicose veins, venous disorders, and lymphatic problems in the lower limbs, Oxford University Press,
1997.)

At the soleus and gastrocnemius sites the veins are even larger in number and arranged in a spiral shape, due to the longitudinal excursion amplitude of the
muscles between contraction and relaxation. This creates a volume reservoir (pump chamber), and the relative muscles (soleus and gastrocnemius) are
responsible for both movement/standing position as well as pump function (the second and most important pump). This system is correctly termed the calf
muscle pump or peripheral heart (see Fig. 1.4).12

In contrast, posterior deep compartment veins (posterior tibial and peroneal) and anteroexternal compartment veins (anterior tibial) are rectilinear, as the
surrounding muscles lean against the bones and have a limited shortening during contraction.7

At the knee and thigh, deep leg veins flow into the collecting system (popliteal-femoral veins). They run in the popliteal crease and adductors canal, and are not
enwrapped by a muscular layer as the blood flow to the abdominal cavity has not been held back by compression.7 The other thigh veins (profunda femoris and
circumflex) are still deep intramuscular veins. The popliteal vein is also connected by anonymous muscular veins to the profunda femoris and the sciatic nerve
vein, creating a natural bypass when obstruction occurs to the femoral vein (thrombosis, extrinsic compression, bone fracture).13 Thanks to this autonomy, the
femoral vein is used as an alternative conduit when other more accessible superficial veins are unavailable (see Fig. 1.5).9

The common femoral vein collects the backflow of the lower limb and sends it to the pelvis (iliac veins and inferior vena cava), where aspiration
pleurodiaphragmatic forces prevail, together with vis-a-tergo of the renal veins. The common femoral vein in particular receives the GSV below the inguinal
ligament where it becomes the external iliac vein. A potential alternative way of discharge in this area is due to the obturator vein (normally draining part of the
muscles of the medial thigh) and the sciatic vein, often not macroscopically evident (first embryonic vein, secondarily replaced by the femoropopliteal axis,
which can be activated in certain conditions). Together with the superficial veins they can contribute to limb drainage in case of femoral thrombosis by their
connection to the hypogastric vein (see Fig. 1.5). However, the same system may be the cause of varices when endopelvic hypertension is transmitted to the
superficial limb veins. The sciatic vein may also be involved in congenital venous malformations, typically Klippel-Trenaunay syndrome.13

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Anatomy of the Superficial Veins

The most important superficial veins are the GSV and the SSV. It is generally thought that the term saphenous is derived from the Greek word saphenes,
meaning evident, but it could also come from the Arabic words el safin, which mean hidden or concealed.14 Of course, these terms were important in the
practice of blood letting.

Great saphenous vein

This vein begins on the dorsum of the foot as a dorsal venous arch and internal marginal vein. It passes anterior (10–15 mm) to the medial malleolus, crosses
the tibia at the distal third and runs along the tibial internal edge. At the knee the vein it bends posteriorly, running around the condilus femoralis, in contact with
the anterior edge of the sartorius muscle, then ascends in the anteromedial thigh, crosses the sartorius and adductor brevis and enters the Scarpa triangle to
empty into the common femoral vein (Fig. 1.7).9,15 This termination point is referred to as the saphenofemoral junction (SFJ) but is also known as the crosse,
which is the French description for its appearance as a shepherd’s crook. The average diameter of a normal GSV is 3.5–4.5 mm (range 1–7 mm).16

Figure 1.7 A, Traditional anatomical terms for the lower limb, medial aspect. 1: superficial epigastric vein, 2: pampiniform plexus, 3: external pudendal vein, 4:
superficial dorsal vein of the penis, 5: superficial medial circumflex femoral vein, 6: accessory posterior saphenous vein of the thigh, 7: femoropopliteal vein, 8:
great saphenous vein, 9: sartorius muscle, 10: anastomoses between the great and small saphenous veins, 11: posterior arcuate vein (posterior saphenous
vein of the leg or vein of Leonard), 12: medial marginal communicating veins, 13: plantar sole, 14: superficial dorsal metatarsal veins, 15: superficial dorsal
venous arch of the foot, 16: venous plexus of the dorsal surface of the foot, 17: anterior vein branch (anterior saphenous vein of the leg), 18: superficial femoral
vein, 19: perforating veins of Dodd, 20: accessory small saphenous vein (anterior accessory saphenous vein), 21: superficial inguinal lymph nodes, 22:
superficial lateral circumflex femoral vein, 23: common femoral vein, 24: superficial circumflex iliac veins.

B, The great saphenous vein (GSV) and its tributaries are occasionally well displayed on thin legs. ALTV, anterolateral thigh vein; AVL, anterior vein of the leg
(accessory saphenous vein); PAV, posterior arch vein.

(B, Adapted from Somjen GM: Dermatol Surg 21:35, 1995.)

The GSV receives multiple tributaries along its course. These usually lie in a less supported, more superficial plane above the membranous fascia. The
posterior arch vein, the anterior superficial tibial vein and the medial superficial pedal vein join the GSV in the lower leg. The posterior arch vein (known as the
vein of Leonardo, but now classified as the posterior accessory saphenous vein) is a major tributary to the GSV. It enters the GSV below the knee and
otherwise communicates with the deep venous system through multiple perforating veins. These are, in ascending order: the Cockett I, Cockett II and Cockett III
perforators and the 24-cm perforating vein, now called the upper, middle and lower posterior tibial perforators.

In the thigh, two main clusters of perforating veins connect the saphenous vein to the deep system. Just above the knee, there is the Dodd group, and in the
mid-thigh, the Hunterian perforators (now called mid-thigh perforators).

Two large tributaries in the upper third of the thigh – the posteromedial and anterolateral tributaries – join the GSV proximally. These veins usually enter the
GSV before it dives posteriorly to penetrate the deep fascia at the fossa ovalis. Both the medial and lateral superficial thigh veins may be so large that they are
mistaken for the GSV itself.17 A variable number of perforators connect the GSV to the femoral, posterior tibial, gastrocnemius and soleal veins.18

Small saphenous vein

The SSV is the most prominent and physiologically important superficial vein below the knee (Fig. 1.8).9 Like the GSV, the SSV has a thick wall and usually
measures 3 mm in diameter when normal.19 It begins at the lateral aspect of the foot and ascends posterior to the lateral malleolus as a continuation of the
dorsal venous arch. It continues up the calf between the gastrocnemius heads to the popliteal fossa, where it usually enters the popliteal vein.

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Figure 1.8 Traditional anatomical terms for the lower limb, posterior aspect. 1: Great saphenous vein, 2: popliteal vein, 3: tibial nerve, 4: deep fascia, 5: small
saphenous vein, 6: lateral marginal communicating veins, 7: lateral malleolus, 8: perforating veins, 9: gastrocnemius point, 10: common peroneal nerve.

The termination of the SSV is quite variable, usually occurring in the popliteal vein, as stated above. However, in 27% to 33% of the population, it terminates
above the level of the popliteal fossae, either directly into the GSV or into other deep veins. In 15.3% of patients, the SSV communicates with the popliteal vein,
then continues terminating in the GSV. In 9% to 10%, the SSV empties into the GSV or the deep veins below the popliteal fossae.9,20 The SSV may also join
the GSV in the thigh through an oblique epifascial vein (the Giacomini vein), or it may continue up under the membranous fascia of the thigh as the
femoropopliteal vein, joining the deep veins in the thigh at various locations (Fig. 1.9).21–23

Figure 1.9 Variations in the termination of the small saphenous vein (SSV). A, Termination into the saphenopopliteal junction; B, termination into the great
saphenous vein (GSV); C, termination into the gluteal vein.

Like the GSV, the SSV runs on or within the deep fascia, usually piercing the deep fascia just below the flexor crease of the knee as it passes into the popliteal
fossa.24 Gross incompetence of the SSV usually occurs only in areas where the SSV and its tributaries are superficial to the deep fascia, on the lateral calf and
lower third of the leg behind the lateral malleolus. The SSV often receives substantial tributaries from the medial aspect of the ankle, thereby communicating
with the medial ankle perforators. The SSV may also receive a lateral arch vein that courses along the lateral calf to terminate in the SSV distal to the popliteal
fossa. It may also connect directly with the GSV.

Other superficial veins and collateral veins

The superficial collateral or communicating venous network consists of many longitudinally, transversely and obliquely oriented veins. These originate in the
superficial dermis, where they drain cuticular venules. These veins are normally of lesser diameter, but when varicose they can dilate to more than 1 cm. They
are thin walled and are more superficial than the superficial fascia that covers the saphenous trunks. They drain into deep veins through the saphenous veins,
directly through perforating veins or through anastomotic veins in the abdominal, perineal and gluteal areas.25 Therefore, collateral veins may become varicose
either in combination with truncal varicose veins or independently (Fig. 1.10).15

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Figure 1.10 Schematic diagram of subcutaneous venous anatomy showing four types of flow from subcutaneous veins (SCV). SCV to GSV/SSV to SFJ/SPJ to
deep system; SCV to GSV/SSV to perforator to deep system; SCV to perforators to deep system; SCV to deep system. GSV, great saphenous vein; SSV, small
saphenous vein; SFJ, saphenofemoral junction; SPJ, saphenopopliteal junction.

(From Somjen GM, Ziegenbein R, Johnston AH, Royle JP: J Dermatol Surg Oncol 19:940, 1993.)

Although many collateral veins are unnamed, some prominent or consistent superficial veins are, for example, the Giacomini vein, which connects the proximal
GSV to the SSV. This vein has been found by duplex examination in 70% of limbs with chronic venous insufficiency.26 Other examples include the lateral
anterior accessory saphenous vein (AASV), which runs from the lateral knee to the SFJ, the anterior crural veins, which run from the lower lateral calf to the
medial knee, and the infragenicular vein, which drains the skin around the knee. Geniculate perforators, although small, may contribute significant reflux (see
Figs 1.7, 1.8).

A lateral subdermal plexus of reticular veins, first described by Albanese et al,27 has its origin through perforating veins at the lateral epicondyle of the knee
(Fig. 1.11). It has been speculated that it represents a remnant of the embryonic superficial venous system that fails to involute. This system of veins has its
importance in the development of telangiectasia. These veins may become varicose even in the absence of truncal varicosities.

Figure 1.11 Lateral subdermal plexus commonly seen on the lateral thigh arising from perforator veins from the femoral vein.

Duplex ultrasound anatomy

The venous anatomy of the leg is theoretically simple; however, its peculiarity is due to its extreme variability between individual normal subjects. Normal non-
varicose limbs show such different patterns that it is rare to see two identical anatomical arrangements in two different limbs. If we consider varicose limbs,
these differences are greatly enhanced.

The most striking progress in the knowledge of venous anatomy for phlebologists is related to the easy visibility of the fascial sheets by DUS imaging. This DUS
anatomical ‘dissection’ has offered the key for interpretation of these variations providing a simple universal language for the easy identification of veins (Fig.
1.12).28,29

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Figure 1.12 The easy visibility of the fascial sheets by ultrasound imaging offers the key for interpretation of the frequent variations of normal anatomy, providing
a simple universal language for the easy identification of the veins. Here it is the immediate recognition of the great saphenous vein on the left and the small
saphenous vein on the right.

The result is that leg veins are not just ‘deep’ or ‘superficial’, but are arranged in three levels: deep (beneath the aponeurotic fascia), intermediate (between the
aponeurotic fascia and the superficial fascia) and subcutaneous (between the superficial fascia and the skin) (Fig. 1.13).8,28

Figure 1.13 Diagrammatic representation of the compartments enclosing the saphenous and deeper veins. Ultrasound shows that lower limb veins are arranged
in three levels: deep (beneath the aponeurotic fascia), intermediate (between the aponeurotic fascia and the superficial fascia) and subcutaneous (between the
superficial fascia and the skin).

The subcutaneous space in which all superficial veins run is divided by a fascial sheet, called superficial or membranous fascia, into two layers: a superficial
layer of loculated fatty tissue (Camper’s fascia) and a deep layer of collagen and elastic tissue that provides stronger support (Scarpa’s fascia). The superficial
fascia is homologous with Scarpa’s fascia of the anterior abdominal wall and may be considered as a single unit.

In the early nineteenth century two French anatomists, Cruveilhier30 and Bayle,31 described for the first time that both saphenous veins lie in the deeper
compartment of the subcutaneous space and are covered, for their entire length, by the superficial fascia. All other superficial veins (tributaries or collaterals of
the saphenous) run into the superficial compartment, between the superficial fascia and the skin, in what is a true subcutaneous position. Despite evidence from
anatomical dissection (Fig. 1.14),32 the importance of the superficial fascia as an anatomical classification marker had been largely ignored until DUS became
an established tool for venous investigation of leg vein anatomy.29

Figure 1.14 Transverse section from the medial aspect of the thigh showing the fibrous envelope that ensheathes the great saphenous vein and holds it against
the deep fascia.

(From Thompson H: Ann R Coll Surg Engl 61:198, 1979. Copyright The Royal College of Surgeons of England. Reproduced with permission.)

It was proposed to name the interfascial compartment in which the GSV runs the ‘saphenous compartment’, and the superficial fascia that covers it, ‘saphenous
fascia’ (Fig. 1.15).28 The superficial fascia is a marker for distinguishing the two levels of superficial veins. A few constant, and named, superficial veins run
through specific intrafascial compartments (intermediated veins), covered by fascial sheet, and belong to the intermediate level. These intrafascial veins are
(Fig. 1.16):3,33

• the GSV
• the proximal part of the AASV
• the SSV and its thigh extention (Giacomini or femoropopliteal vein)
• the medial and lateral marginal veins of the foot
• the dorsal foot arch.

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Figure 1.15 The interfascial compartment in which the great saphenous vein (GSV) runs has been called ‘saphenous compartment’, and the superficial fascia
that covers it (continuous line), ‘saphenous fascia’. The interrupted line follows the muscular fascia, the dotted line underlines a type of vein ligament that fixes
the GSV inside the compartment.

Figure 1.16 The interfascial veins are: the great saphenous vein (GSV), the proximal part of the anterior accessory saphenous vein (AASV), the small
saphenous vein (SSV) and its thigh extension (TE) (Giacomini or femoropopliteal vein; GIA), the medial and lateral marginal veins of the foot and the dorsal foot
arch.

(Ricci S, Georgiev M, Goldman MP: Anatomical bases of ambulatory phlebectomy. In: Goldman MP, Georgiev M, Ricci S, editors, Ambulatory phlebectomy,
Boca Raton, 2005, Taylor & Francis)

These veins are longitudinal ‘blood transfer’ vessels of major importance in understanding varicose hemodynamics. Their position inside the close fibroelastic
ensheathing and adventitial anchoring may explain the absence of varicosity in these veins (they enlarge but do not become varicose).34 A pump mechanism
during muscular contraction can also be another explanation with caliber reduction due to the fascial compression effect enhancing blood flow8 (Fig. 1.17);
similar, but less efficient to what happens in the deep compartment.

Figure 1.17 The great saphenous vein finds a shelter from its position below the superficial fascia, but also a pump mechanism during muscular contraction can
be hypothesized, with caliber reduction due to the effect of fascial compression enhancing blood flow.

(From Franceschi C, Zamboni P: Principles of hemodynamics, Nova Science, New York, 2009. With permission from Nova Science Publishers, Inc.)

Every vein running superficially to the fascial sheet should be considered a collateral or tributary vein (Fig. 1.18). Its identification is consequently of paramount
importance when treatment must be provided in a varicose condition. Varicose veins typically belong to this superficial layer.3,8

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Figure 1.18 A, C, Under ultrasound, the apparent ‘eye’ that can be seen is the great saphenous vein (GSV). In B the prevailing vein is outside the compartment
and must be classified as a tributary vein, while inside the compartment a hypoplastic GSV may be recognised (arrow). In C two veins are visible but only the
one inside the compartment is the GSV.

With a thorough understanding of this scheme, all possible venous anatomical variations may be correctly understood.35

Duplex Ultrasound Markers for Vein Identification

The veins of the intermediate level have constant relationships with the surrounding anatomical structures – fascial sheets, muscles, bones, deep vessels –
which are easily recognized by DUS and are therefore ultrasound ‘markers’ for vein identification.3,33 It is from these markers that the following ultrasound
identification signs derive.

The ‘eye’ sign

Bailly first described, in 1993, the ‘eye’ sign as the ultrasound marker for identification of the GSV in the thigh.29 This sign is due to the fact that the superficial
fascia is echo-lucent and easily observed by USI. In transverse scan the compartment in which the GSV runs resembles an Egyptian eye, where the saphenous
lumen is the iris, the superficial fasci, the superior eyelid and the aponeurotic fascia the inferior eyelid (see Fig. 1.15). The description of the ‘saphenous eye’
could well be considered the beginning of ultrasound vein anatomy. The eye sign is always present and allows immediate and certain identification of the
saphenous vein and its separation from parallel running subcutaneous collaterals.

The ‘alignment’ sign

This sign, also suggested by Bailly,37 helps recognize and distinguish the AASV from the GSV.36,38 In the upper third of the thigh on transverse scan into the
‘eye’ there are often two veins instead of one: the GSV and the AASV. The latter lies anterior (lateral) to the GSV39–41 and is identified by its subfascial
position and by the fact that in transverse scan it lies over (is aligned with) the common femoral vessels (artery and vein) (Fig. 1.19A). In addition to the
alignment sign, in some cases the AASV has, in transverse scan, its own ‘eye’8 (Fig. 1.19B). However, it is the alignment sign that shows that in some cases
the only vein visible in the ‘eye’ is the ASV, while the GSV is not visible (absent or hypoplastic) (Fig. 1.19C).38

Figure 1.19 A, Two veins are present at the (left) groin. The GSV is medially sited, the anterior accessory saphenous vein (AASV) is lateral and aligned over the
femoral vessels. B, Same as in A but more distal. The two veins may have their own separate ‘eye’. C, Only one vein is present here, but its position over the
deep vessels suggests that it is an AASV, while the GSV is non visible (hypoplastic).

The tibia-gastrocnemius angle sign

This sign allows one to recognize the GSV below the knee, where fascial sheets are often so close to each other that the intrafascial compartment in which the
GSV runs may be difficult to recognize.36,42 In such cases the GSV is distinguished from other closely running veins by its position, on a transverse scan, in
the angle formed by tibial and medial gastrocnemius muscle (Fig. 1.20A, B). This sign allows one to demonstrate, when the angle is empty, that in this area the
GSV is absent or hypoplastic (Fig. 1.20C).

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Figure 1.20 A, At the knee level the saphenous space is very narrow and can be identified in the angle between the tibia and the gastrocnemius (T-G angle). B,
The vein inside the T-G angle is the great saphenous vein (GSV). C, If the T-G angle is empty, we can say that the GSV is hypoplastic and that a tributary has
prevailed.

(From Ricci S, Georgiev M: Ultrasound anatomy of the superficial veins of the lower limb J Vasc Technol 26:183, 2002).

The small saphenous compartment sign

The proximal portion of the SSV lies between the medial and lateral heads of gastrocnemius muscle, while its frequent thigh extension (TE) lies between the
semitendinous muscle (medially) and long head of the biceps muscle (laterally). The intermuscular grooves, along which these two veins run, are covered by a
thick fascial sheet and appears as a characteristic triangle-shaped compartment on a transverse scan (Fig. 1.21A, B).43,44 This triangle-shaped compartment
is always present and allows immediate and certain identification of the SSV/TE and distinguishes it from parallel subcutaneous and deep collaterals. Distal to
the gastrocnemius muscle the fascial sheet is still present (Fig. 1.21C), albeit less evident as it is thinner as it approaches the ankle and the marginal vein over
the foot indicating that it is the SSV. As for the GSV, it courses inside a specific compartment for its entire length.3

Figure 1.21 The intermuscular grooves along which the small saphenous vein (B) and its thigh extension (A) run are covered by a thick fascial sheet and
appear as a characteristic triangle-shaped compartment on a transverse scan. Distal to the gastrocnemius muscle the fascial sheet is still present (C), although
less evident.

(Adapted from Cavezzi A, Labropoulos N, Partsch H et al: Duplex ultrasound investigation of the superficial veins and perforators in chronic venous disease of
the lower limbs, part II: Anatomy. Eur J Vasc Endovasc Surg 31: 288–99, 2006).

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Jul 31, 2016 | Posted by admin in Dermatology | Comments Off on Anatomy

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