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Lower Extremity Venous Anatomy

Over many years, as clinical medicine caught up with classic academic anatomy, the veins of the leg acquired various names creating confusion and miscommunication. In the last several years, attempts have been made to standardize anatomical terminology of the leg veins. In 2004, the International Union of Phlebology and International Federation of Anatomical Association (IFAA) elaborated a revision of the venous nomenclature in the leg.1 The names and descriptions adopted by the IFAA are used throughout this study.

General Anatomic Considerations

Superficial veins are large, relatively thick-walled, muscular structures that lie just under the skin within the subcutaneous fascial layer. In the extremities they form a complex network of collecting veins that gather blood from the skin and superficial fascia, passively directing it into the deep system through truncal or perforating veins (see below). Among the superficial veins are the great and small saphenous veins of the leg, the cephalic and basilic veins of the arm, and the external jugular veins of the neck. The deep veins, on the other hand, are thin-walled and less muscular and lie within the deep fascia usually in close proximity to a bone. Deep veins accompany arteries (often as venae comitantes) and bear the same names as the arteries that they parallel. The cross-sectional area of these veins is roughly three times that of the adjacent artery. Within the skeletal muscles are large, thin-walled veins that sometimes are referred to as sinusoids. As part of the bellows of the muscle pump mechanism, they serve a particularly important function during exercise. In the calf, the soleal sinusoids empty into the posterior tibial vein, and the gastrocnemius sinusoids usually drain directly into the popliteal vein. In addition to the deep and superficial systems in the both the upper and lower extremities, communicating veins connect the deep and superficial systems. These short, thick-walled veins perforate through the fascia and connect the two systems in series. Also called perforators, these communicating veins allow for collateralization when normal flow channels are obstructed but they also contain valves that prevent blood in the higher-pressure deep system from refluxing back into the lower pressure superficial system. In the leg, congenital absence or damage of these valves results in abnormally
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elevated pressure in the superficial veins which can cause or contribute to the formation of varicose veins and other sequelae associated with chronic venous insufficiency. One of the most important anatomic feature Table I. Valve Distribution in the of veins, from a clinical perspective, is the Deep System of the Leg presence of venous valves. Each of these (approximate numbers) delicate, but extremely strong, bicuspid strucSuperficial femoral vein 3 tures lies at the base of a segment of vein that is 2-4 expanded into a venous sinus. This Popliteal vein arrangement permits the valves to open widely Anterior tibial veins 9 -11 without coming into contact with the wall, thus 9 -19 permitting rapid closure when flow begins to Posterior tibial veins Peroneal veins 7 reverse. There are approximately 9 to 11 valves in the anterior tibial vein, 9 to 19 in the posterior tibial, 7 in the peroneal, 1 in the popliteal, and 3 in the superficial femoral vein. In two-thirds of the femoral veins a valve is present at the upper end within 1 cm of the inguinal ligament. About one-quarter of the external iliac veins have a valve. The common iliac vein usually has no valves. Superficial veins have fewer valves - approximately seven to nine in the greater and lesser saphenous veins. Fifty-six valves are present in venules as small as 0.15 mm in diameter. Table I summarizes valve distribution in the deep veins.2 In all areas of the legs and arms, valve cusps are oriented to direct flow toward the vena cava and to prevent reflux back down the extremity. Although valves in perforating veins usually permit blood to flow only from the superficial to the deep venous system, valves in the foot allow flow from the deep to the superficial system.

Schematic representation of normal, competent venous valves.

Sonographic demonstration of normal venous valves cusps and sinus.

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Veins in the leg are traditionally named and identified based on their relationships with the deep fascia of the leg.3 This anatomic methodology separates the limb into two venous planes: superficial and deep. A third group of veins connects the two systems by piercing the deep fascia at various levels in the leg creating important hemodynamic communications. Each of these three components of the lower extremity venous system plays an important role in the efficient evacuation of blood from the gravity dependent leg.

Lower Extremity Superficial Veins

Great Saphenous Vein (GSV) The GSV (also called the long saphenous or internal saphenous vein) is a structure frequently encountered by the vascular sonographer in routine clinical practice. In many patients with a normal-sized GSV and a thin leg, it can be easily appreciated visually or by palpation, thus its name saphenous from the Greek saphe meaning clearly visible. Ultrasound can be used to map the diameter, length and integrity of the GSV prior to surgical harvesting for a variety of revascularization, or bypass, procedures. It is also routinely examined and measured sonographically prior to endovascular varicose vein ablation. Its size, tortuosity, location of major perforator insertions, and general hemodynamic patterns play an important role in planning efficacious intervention in patients with medically significant venous disease. Following laser or radiofrequency ablation, sonography can be used to confirm expected heat-induced thrombosis in the GSV and containment to a safe boundary a few centimeters caudal to the saphenofemoral junction (SFJ). The GSV is the longest vein in the body and arises from medial end of the dorsal venous arch at the foot. It ascends in the ankle in front of the medial malleolus, spirals around the medial aspect of the leg and crosses behind the femoral condyle. It continues its course up the medial aspect of the thigh within the saphenous compartment or sheath, a covering which is formed by the interlacing of subcutaneous connective sheets that descend from the inguinal ligament along the medial thigh and leg all the way to the ankle.4 The GSV terminates as it empties into the SFV about 4cm below the inguinal ligament. Throughout its course, it receives numerous tributaries as it drains the skin and superficial fascia of the medial side of the foot and leg. In the groin, the GSV is joined by a series of other superficial veins draining the upper thigh, skin and superficial fascia of most of the thigh, lower
Lower Extremity Venous Anatomy Sonographic demonstration of the saphenous sheath. Arrows at anterior and posterior connective tissue layers.

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abdominal wall, and the perineal region. These veins include the anterior accessory of the GSV and the posterior accessory of the GSV which run almost parallel to the GSV. Three additional veins enter the long saphenous usually just below its insertion into the SFV; they are the superficial external pudendal draining the pubic and genital regions, the superficial epigastric draining the area above the inguinal skin crease, and the superficial circumflex iliac veins draining the fascia in the trochanteric region . Each of these is accompanied by its corresponding artery; the arteries are branches of the femoral artery. Some of these superficial tributaries may empty directly into the femoral vein (FV) instead of the GSV. In clinical cases of iliac vein occlusion secondary to venous thrombosis, the superficial pubic collateral veins frequently dilate and present as labial varices. 5 TABLE II summarizes the frequency of site of entry of each tributary into the deep system.
Table II. Proximal Tributaries of the GSV Frequency of Insertion Site 6 Vessel inserts into: Anterior (lateral superficial) saphenous Posterior (medial superficial) saphenous veins Superficial external pudendal Superficial epigastric Superficial circumflex iliac veins. GSV 67% 82% 95% 77% 83% FV 33% 18% 5% 23% 17%

The normal diameter of the GSV is 5-6 mm in the thigh and 2-3 mm in the calf. There is considerable variation in the size, location and morphology of the GSV related to genetics, prior venous pathology in the leg, or prior venous interventional and surgical procedures. It may be surgically absent secondary to coronary artery bypass graft surgery (CABG), peripheral arterial bypass, use in hemodialysis access construction, and a myriad of other surgical procedures. In sonographic determination of GSV diameter, it is important to keep in mind that these factors as well as, patient position (supine, upright, Trendelenberg, etc.), and the amount of transducer pressure can significantly alter vein measurements. Diameter should be measured in an axial plane across the noncompressed vessel lumen. Accurate measurement of the GSV is imperative as significant clinical decisions are made from this data. In pre-operative vein mapping for peripheral arterial bypass, an AP diameter of at least 4mm throughout most of the vein is required for good surgical success rates. Laser ablation of the GSV is dependent on the amount of fluid (blood) present in the vessel. When the AP diameter exceeds 13mm, the blood acts as a heat sink and disperses the laser making successful ablation unlikely.
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Short Saphenous Vein (SSV) The SSV (also called the small saphenous vein) is the continuation of the lateral marginal vein of the dorsum of the foot. It ascends along the lateral margin of the Achilles tendon and crosses over to the middle of the back of the calf. It communicates with the deep veins of the foot, and receives numerous large tributaries as it ascends the leg. Coursing upward between the muscular and saphenous fasciae, it perforates the deep fascia in the lower part of the popliteal fossa, and terminates there in one of two common configurations. Table III summarizes the frequency of these configurations. Like the GSV, the SSV is encased by a saphenous sheath formed by subcutaneous connective tissue strands.8 The small saphenous vein possesses from nine to twelve valves, one of which is always found near its termination in the popliteal vein. Coursing over the posterior thigh through the deep fascia is a tributary, or trunk projection, of the SSV called the Directly into popliteal vein 53% Giacomini vein.9 10 It is found in about 60% of legs and connects, with frequent Termination in thigh veins: 44% Femoral vein or GSV variations, the proximal greater saphenous vein to the proximal short Termination in calf veins: saphenous vein. Valves direct blood 3% GSV below knee or flow distally gastrocnemius veins. towards the short saphenous vein. There is some evidence to suggest that valvular incompetence in the Giacomini vein may be responsible for the jump-over of venous insufficiency from one saphenous system to the other. 11 While this vein was first described by anatomist Carlo Giacomini in 1837, it remained, for the most part ignored by clinicians, until duplex ultrasound became routine in the evaluation of patients with chronic venous insufficiency (CVI) and varicose veins. After its rediscovery with ultrasound, it was postulated that incompetence of the Giacomini vein might be responsible for atypical patterns of venous pathology in the thigh and/or recurrence of manifestations of CVI after vascular intervention. Subsequent studies have concluded that abnormalities and variants of the Giacomini vein are infrequently associated with CVI and attendant sequelae.12
Table III. Short Saphenous Vein Termination Sites7

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Lower Extremity Deep Veins

The deep veins of the lower extremity can be compared to the superhighway of venous return. Within 15 minutes of standing, 15-20% of the body's blood pools in the lower extremities. It is the function of the deep system to transport this volume of blood (about 1 liter in an adult male) back to the heart against the constant pull of gravity. The configuration of the deep system lying deep within the muscular fascia; its size, valvular function, the muscle pump mechanism, all play important roles in accomplishing this goal. A proper anatomic study of the deep veins in the leg begins in the foot and progresses cephalad. The dorsal rete is a superficial network of anastomosing veins on the dorsum of the foot proximal to the transverse venous arch, draining into the great and the small saphenous veins and/or the tibial veins. Deep veins of the leg include: Anterior tibial veins Posterior tibial veins Peroneal veins Venous sinusoids in the calf: Gastrocnemius veins Soleal veins Popliteal vein Femoral vein Deep femoral Common femoral vein Iliac vein External iliac vein Internal iliac vein There can be considerable anatomic variation in the deep veins of the leg, particularly duplication variants. Since these variations are common, they pose a significant consideration in the sonographic diagnosis of deep vein thrombosis. Calf Veins The deep veins in the calf arise in the dorsal venous rete (foot), course up the leg through the soleus and gastrocnemius muscles and empty into the popliteal vein behind the knee. A set of paired tibial veins accompanies each of the three runoff arteries: anterior tibial, posterior tibial, and peroneal. The anterior tibial veins are formed by the cephalad continuation of the veins that accompany the dorsalis pedis artery. They pass between the tibia and fibula through a large opening anterior to the interosseous membrane. They join with the tibioperoneal trunk vein to form the popliteal vein behind the knee. The posterior tibial veins are formed by the internal and external plantar veins of the foot and course cephalad with the posterior tibial artery along the
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medial aspect of the tibia. In the lower popliteal space they join with the peroneal veins to form a short trunk (tibioperoneal trunk vein). This trunk in turn joins with the anterior tibial veins to form the popliteal vein. Veins that drain the major calf muscles, also referred to generically as sural veins, join the deep calf veins in the popliteal fossa. There is considerable anatomic variation in venous drainage from the calf muscles. In fact, most of these veins are not named. Generally, smaller veins draining muscle mass coalesce to form the soleal and gastrocnemius intramuscular venous plexi. There are between 2 and 12 draining veins in each gastrocnemius muscle head which, in turn, empty into a medial or lateral gastrocnemius vein. In the great majority (87%) of cases, the main gastrocnemius veins drain into a gastrocnemius trunk that then empties into the popliteal vein. 13 Alternatively, the medial and lateral gastrocnemius veins can drain individually into the popliteal vein. The soleal veins drain the soleus muscle which is a broad flat muscle located anterior the gastrocnemius muscles. Like the gastrocnemius veins, the irregularly arranged plexus veins deep within the muscle drain into one or several main trunks. These short extramuscular trunks can terminate in a number of ways: a Table IV. Incidence of Isolated Calf Vein DVT14 single common trunk may drain into the posterior tibial or peroneal veins or; the Soleal veins 39% terminal branches may create an Posterior tibial veins 37% anastomosis with the posterior tibial or 29% peroneal veins via multiple intramuscular Gastrocnemial veins 20% communications at different levels Soleal veins alone throughout the leg. Gastrocnemial veins alone 7% A familiarity with the anatomy of the veins in the proximal calf is important for the sonographer examining a patient with suspected deep vein thrombosis (DVT). While the propagation of calf DVT into the popliteal and femoral veins is uncommon (occurring in 3% of cases of isolated calf vein DVT) extension into the tibial veins happens in about 16% of cases.15 Lower extremity deep vein thrombosis is often isolated to the sinusoidal veins draining the gastrocnemius and soleus muscles. Table IV ranks the frequency of location of isolated calf DVT. 2D cross-sectional Along their course, each sural vein communicates with compression ultrasound the superficial veins by way of the perforating veins. image through soleal Each calf vein contains at least ten valves, making them veins containing an ideal location for clot formation. Edema or swelling occlusive venous thrombus. within the deep fascial tissues of the calf can compress these veins making them difficult to image sonographically.
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Popliteal Vein (PV) The popliteal vein is formed by the junction of the anterior and posterior tibial veins at the lower border of the popliteus muscle. It receives tributaries corresponding to the branches of the popliteal artery, and it also receives the small saphenous vein. It ascends through the popliteal fossa to the adductor canal where it becomes the femoral vein. In the lower part of its course, the popliteal vein runs medial to the popliteal artery. As it courses cephalad between the heads of the gastrocnemius muscles, it rises superficial to the artery and exits the popliteal space along its lateral margin. There are between two and four valves in the popliteal vein. While the popliteal vein is single most of the time (56%), duplication anomalies are be found. 16 Femoral vein (FV) Anatomic nomenclature for this vascular structure can be confusing since it is frequently referred to as the superficial femoral vein (SFV) but it is, in fact, a deep vein. To obviate this confusion, the SFV is now simply called the femoral vein. Beginning in the distal, medial thigh just above the medial condyle of the femur, the popliteal vein exits the adductor (Hunters) canal as the femoral vein. It courses up thigh medially and slightly posteriorly to the femoral artery. Just below the level of the inguinal ligament ( 4cm), it is joined by the deep femoral vein to form the common femoral vein (CFV). The CFV passes, together with the femoral artery and nerve, beneath the inguinal ligament to enter the pelvis as the external iliac vein. Along its course in the thigh, the femoral vein accommodates perforator veins arising from the GSV which joins it near its termination in the groin. The FV usually contains 2-5 valves. It may be single (62%) or duplicated. Duplication of the distal segment is more common with sequential fusing to form a single vein in mid thigh (31%). Complete duplication of the entire vein occurs about 3% of the time.17 Deep Femoral Vein (DFV) The deep femoral vein (profunda femoris v.) receives numerous muscular tributaries from the upper leg. It courses along the profunda femoris artery and joins the superficial vein to form the common femoral vein (CFV) in the groin. It receives the medial and lateral femoral circumflex veins. Iliac Veins The external iliac vein begins as the femoral veins terminate at the level of the inguinal ligament. As it courses into the pelvis, it is joined by the internal iliac vein (hypogastric v.) to form the common iliac vein (CIV) at the level of the sacro-iliac joint. The common iliac veins on each side unite to form the
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inferior vena cava (IVC). The external iliac vein receives several large tributaries that follow their adjacent arteries: the inferior epigastric vein, the deep iliac circumflex vein, and the superficial external pudenda vein all described above as superficial veins of the leg. On the right side, the CIV initially lies medial to the iliac artery but, as it courses cephalad, it gradually inclines behind it. On the left side, the CIV passes posterior to the internal iliac artery on its way to the IVC. This subtle anatomic distinction between the two sides can impact venous outflow from the leg. The compression of the vein by the artery or adjacent pathology can reduce venous flow volume resulting in mild to severe venous congestion with attendant sequelae such as deep vein thrombosis. This configuration also contributes to the increased incidence of varicoceles in the left hemiscrotum. The common iliac veins contain one, sometimes 2, valves. May-Thurner Syndrome May-Thurner syndrome is a condition characterized by impaired venous return associated with the development of symptomatic acute venous thrombosis of the left iliac vein. The cause of diminished venous flow is chronic, external compression of the left common iliac vein most commonly resulting from the normal anatomic relationships between the left iliac vein and the right iliac artery. The overlying right CIA may result in intraluminal obstruction as the vein is compressed against the vertebral body resulting in symptomatic venous occlusion of the left lower extremity.18 The impedance of flow occurs both by direct compression by the artery and by resultant intraluminal scarring and web formation inside the vein.19 The resulting venous stasis increases the risk for development of DVT in the left leg. It is a common anatomical variant; 24% of asymptomatic, healthy volunteers had compression of the left CIV of >50%; 66% had compression of >25%. The mean compression of the CIV by the right CIA in all volunteers was 35.5%20 Inferior Vena Cava (IVC) The IVC returns deoxygenated blood to the heart from all structures below the diaphragm. It is formed by the junction of the two common iliac veins at about the level of the third lumbar vertebra (L3). The IVC courses through the retroperitoneum to the right of the aorta. It perforates the diaphragm, enters the thoracic cavity and empties into the right atrium.

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Along its course, the IVC accommodates a large number of tributaries, some small and some large. These include: Lumbar veins usually paired at the level of each vertebra. Gonadal vein (ovarian or testicular) Both renal veins Both adrenal veins (suprarenal veins) Hepatic veins (right, middles and left) Inferior phrenic (diaphragm) veins. Since the IVC is not a midline structure, tributaries empty into it in an asymmetric manner. The gonadal veins and suprarenal veins drain into the IVC on the right side, but on the left side, they drain into the renal vein. The lumbar veins and hepatic veins usually drain directly into the IVC. Health problems attributed to the IVC are most often associated with its compression. Compression can occur at any level along its course usually by the mass effect of adjacent pathology. Sources of external compression include: abdominal aortic aneurysm, a gravid uterus (supine hypovolemic or aortocaval compression syndrome) and abdominal malignancies, such as colorectal cancer, renal cell carcinoma and ovarian cancer.

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Caggiati A., Bergan J. J., Gloviczki P., et al. Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. J Vasc Surg, 2002, 36: 416-22. 2 Gottlob R, and May r. Venous Valves. Spinnger-Verlag, New York. 1986. pp.17-21. 3 Caggiati A. The nomenclature of the veins of the lower limbs, based on their planar anatomy and fascial relationships. Acta chir belg. 2004, 104: 272-275. 4 Caggiati A. Fascial Relationships of the Long Saphenous Vein. Circulation. 1999; 100:2547 5 Tielliu IF, De Maeseneer MG, Tjalma WA, et al. Superficial thrombophlebitis of pubic collateral veins after gynecological surgery: a case report. Eur J Obstet Gynecol Reprod Biol. 1999 Oct; 86(2):207-9. 6 Chun MH, Han SH, Chung JW, et al. Anatomical observation on draining patterns of saphenous tributaries in Korean adults.J Korean Med Sci. 1992 Mar;7(1):25-33. 7 de Oliveira A, Vidal EA, Frana GJ, et al. Anatomic variation study of small saphenous vein termination using color Doppler ultrasound. J Vasc Br 2004; 3(3):223-30. 8 Caggiati A., Bergan J. J., Gloviczki P., et al. Nomenclature of the veins of the lower limbs : an international interdisciplinary consensus statement. J Vasc Surg, 2002, 36: 416-22. 9 Georgiev M, Myers KA, Belcaro G. The thigh extension of the lesser saphenous vein: from Giacomini's observations to ultrasound scan imaging. J Vasc Surg. 2003 Mar; 37(3):558-63. 10 Georgiev M, Myers KA, Belcaro G. Giacomini's observations on the superficial veins of the abdominal limb and principally the external saphenous International angiology 2001, 20: 3, pp. 251-264. 11 Zierau UTh, Kullmer A, Kunkel HP. Stripping of Giacomini's Vein: Is it Pathophysiologically Necessary? VASA 1996; 25:142-47. 12 Delis KT, Knaggs AL, Khodabakhsh P. Prevalence, anatomic patterns, valvular competence, and clinical significance of the Giacomini vein. J Vasc Surg. 2004 Dec; 40(6):1174-83. 13 Aragao JA, Reis FP, Pitta GB, et al. Anatomical study of the gastrocnemius venous network and proposal for a classification of the veins. Eur J Vasc Endovasc Surg. 2006 Apr; 31(4):439-42. 14 Labropoulos N, Webb KM, Kang SS, et al. Patterns and distribution of isolated calf deep vein thrombosis. J Vasc Surg. 1999 Nov; 30(5):787-91. 15 Macdonald PS, Kahn SR, Miller N, et al. Short-term natural history of isolated gastrocnemius and soleal vein thrombosis. J Vasc Surg. 2003 Mar; 37(3):523-7. 16 Quinlan DJ, Alikhan R, Gishen P, et al. Variations in lower limb venous anatomy: implications for US diagnosis of deep vein thrombosis. Radiology. 2003. Aug; 228(2):443-8. 17 Quinlan DJ, Alikhan R, Gishen P, et al. Variations in lower limb venous anatomy: implications for US diagnosis of deep vein thrombosis. Radiology. 2003. Aug; 228(2):443-8. 18 Steinberg JB, Jacocks MA. May-Thurner syndrome: a previously unreported variant. Ann Vasc Surg. 1993 Nov; 7(6):577-81. 19 Heniford BT, Senler SO, Olsofka JM, et al. May-Thurner syndrome: management by endovascular surgical techniques. Ann Vasc Surg. 1998 Sep; 12(5):482-6. 20 Kibbe R, Ujiki M, Goodwin AL, et al. Iliac vein compression in an asymptomatic patient population. J Vasc Surg. 2004 May; 39(5):937-43.

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