Anatomy of the Superficial Anatomy of the Superficial Venous SystemVenous System

Lowell S. Kabnick, MD, FACSLowell S. Kabnick, MD, FACSClinical Assistant Professor of Surgery Clinical Assistant Professor of Surgery

UMDNJUMDNJDirector of the Vein Institute of New JerseyDirector of the Vein Institute of New Jersey

Faculty Disclosure Faculty Disclosure Lowell S. Lowell S. KabnickKabnick, M.D., M.D.

I hereby disclose that I:I hereby disclose that I:

1.1. Serve as a consultant for VNUS Medical, Serve as a consultant for VNUS Medical, AngiodynamicsAngiodynamics, Inc., Johnson & Johnson, , Inc., Johnson & Johnson, Vascular Insights and Vascular Insights and BiolitecBiolitec

13th Annual MIIT Interventional Radiology 13th Annual MIIT Interventional Radiology and Endovascular Therapy Seminarand Endovascular Therapy Seminar

Vein Institute of New Jersey©

5 Levels of Veins5 Levels of VeinsDeep VeinsDeep Veins

Common Femoral, Femoral, Popliteal,and Tibial Common Femoral, Femoral, Popliteal,and Tibial VeinsVeins

Superficial VeinsSuperficial VeinsSmall Saphenous Vein (Lesser Saphenous Vein)Small Saphenous Vein (Lesser Saphenous Vein)Great Saphenous Vein (Greater Saphenous Vein)Great Saphenous Vein (Greater Saphenous Vein)

Perforators (connectors of the deep veins to the Perforators (connectors of the deep veins to the superficial veins)superficial veins)Reticular Veins (tributaries to the saphenous Reticular Veins (tributaries to the saphenous vein vein –– connecting branch veins to deep, connecting branch veins to deep, superficial or perforators)superficial or perforators)CapillariesCapillaries

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CHANGING TERMINOLOGYCHANGING TERMINOLOGY

Greater saphenousGreater saphenousSmaller or short Smaller or short saphenoussaphenous

Accessory saphenousAccessory saphenous

Great saphenousGreat saphenous

Small saphenousSmall saphenous

Anterior accessory great Anterior accessory great saphenoussaphenous

Posterior accessory great Posterior accessory great saphenous saphenous

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Varicose VeinsVaricose VeinsAnatomy and PhysiologyAnatomy and Physiology

Dominant superficial collecting veinsGreat Saphenous VeinSmall Saphenous VeinVein of GiacominiLateral subdermic venous plexus

Communicating vein connects veins in the same connects veins in the same fascialfascialplane AKA tributaries, branchesplane AKA tributaries, branches

Perforator vein connects a superficial vein to a deep vein connects a superficial vein to a deep vein (crossing (crossing fascialfascial plane)plane)

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Varicose VeinsVaricose VeinsAnatomyAnatomy

Thorough knowledge of venous of venous anatomy is important for diagnosing the anatomy is important for diagnosing the source of varicositiessource of varicositiesVaricose patterns on the leg often on the leg often indicate the source of the problemindicate the source of the problemDetermining the source of the of the varicosities is important for treatmentvaricosities is important for treatment

Varicose VeinsVaricose VeinsSuperficial Venous AnatomySuperficial Venous Anatomy

Great Saphenous Veindorsum of the foot → medial thigh →femoral veinLies in the superficial fascia –own compartmentJunctional tributariesare often the site of varicositiesSaphenous nerveclose contact with the GSV below the knee

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Tributaries at the SFJTributaries at the SFJTributary LegendAL – AnterolateralPM – PosteromedialSEP – Superficial external pudendalSE – Superficial epigastricSCI – Superficial circumflex iliac

Anterolateral branch often Anterolateral branch often demonstrates reflux alonedemonstrates reflux alone

PosteromedialPosteromedial branch when branch when dilated is called the vein of dilated is called the vein of GiacominiGiacomini

Superficial Superficial EpigastricEpigastric vein is vein is an important land mark for an important land mark for minimally invasive proceduresminimally invasive procedures

Varicose VeinsVaricose VeinsZone of Influence of GSVZone of Influence of GSV

Terminal and Terminal and subterminalsubterminalvalves at the SFJvalves at the SFJ

Leaks cause VVLeaks cause VVOften causes varicosities in Often causes varicosities in the tributariesthe tributaries

Zone of influenceZone of influenceGSV medial aspectGSV medial aspect

Varicose VeinsVaricose VeinsGSV RefluxGSV Reflux

Varicose VeinsVaricose VeinsAnterior Anterior Circumflex(ATLCircumflex(ATL) Reflux) Reflux

Varicose VeinsVaricose VeinsPudendalPudendal RefluxReflux

Varicose VeinsVaricose VeinsSuperficial Venous AnatomySuperficial Venous AnatomySmall Saphenous Small Saphenous vein vein runs along the runs along the posterolateralposterolateral aspect of aspect of the calfthe calfStarts along the the Starts along the the posterolateralposterolateral aspect of aspect of the anklethe ankleThe vein of Giacomini The vein of Giacomini connect the SSV to the connect the SSV to the GSVGSVSSV is closely SSV is closely associated with the associated with the SuralSural nervenerve

Varicose VeinsVaricose VeinsZone of Influence of SSV and Zone of Influence of SSV and VGVG

The The saphenopolitealsaphenopolitealjunction is often the origin junction is often the origin of reflux in the SSVof reflux in the SSVThe excess blood volume The excess blood volume entering the SSV from the entering the SSV from the deep system causes deep system causes varicosities to form in varicosities to form in tributary braches that tributary braches that course along the posterior course along the posterior calfcalfReflux in the VG often leads Reflux in the VG often leads into the GSV and varicosities into the GSV and varicosities often occur in the posterior often occur in the posterior thighthigh

Varicose VeinsVaricose VeinsSmall Saphenous RefluxSmall Saphenous Reflux

Varicose VeinsVaricose VeinsVaricosities of the Vein of GiacominiVaricosities of the Vein of Giacomini

Varicose VeinsVaricose VeinsSuperficial Venous AnatomySuperficial Venous AnatomyLateral SubdermicVenous System is a is a system of small caliber system of small caliber veins extending above veins extending above and below the knee on and below the knee on the lateral legthe lateral legNormal venous flow is Normal venous flow is paradoxically downward paradoxically downward to perforators in the to perforators in the region of the kneeregion of the knee

Varicose VeinsVaricose VeinsZone of Influence of LSVSZone of Influence of LSVS

The network of abnormal The network of abnormal reticular vein reticular vein demonstrate refluxdemonstrate refluxA focal source of reflux A focal source of reflux often often can notcan not be found be found with ultrasoundwith ultrasoundSpider veins often occur Spider veins often occur along the lateral aspect along the lateral aspect of the thigh and calfof the thigh and calfLarge varicosities can Large varicosities can occur occur

Varicose VeinsVaricose VeinsLateral Lateral SubdermicSubdermic Venous SystemVenous System

Varicose VeinsVaricose VeinsVenous PerforatorsVenous Perforators

HunterianHunterian perforatorsperforatorsCommon cause of Common cause of medial thigh medial thigh varicosities in patients varicosities in patients with competent SFJwith competent SFJ

DoddsDodds perforatorsperforatorsBoyd perforatorsBoyd perforators

Connect small Connect small saphsaph to to cruralcrural veinsveinsCommon site for Common site for primary varicose veinsprimary varicose veins

Cockett’sCockett’s perforatorsperforators

Vein Institute of New Jersey©

Boyd’s PerforatorBoyd’s Perforator

Vein Institute of New Jersey©

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Treatment of SVI is entirely based on Treatment of SVI is entirely based on defining the pathologic anatomydefining the pathologic anatomyThrough knowledge of the superficial and Through knowledge of the superficial and deep venous system of the lower extremity deep venous system of the lower extremity is essential before embarking upon the is essential before embarking upon the treatment of SVI treatment of SVI Ultrasound evaluation of the extremity is Ultrasound evaluation of the extremity is the the gold standardgold standard way to define the way to define the superficial venous anatomysuperficial venous anatomy

ConclusionConclusion

Welcome to theWelcome to the

1313thth Annual MIIT Interventional RadiologyAnnual MIIT Interventional Radiologyand Endovascular Therapy Seminarand Endovascular Therapy Seminar

October 28-30, 2004

Chicago Westin River North HotelDowntown Chicago