Anatomy and Terminology

Zygmunt 2010
Anatomy and Terminology
Joseph A. Zygmunt., Jr. RVT, RPhS
Disclosure
Covidien Vascular Therapies
Cardiovascular Credentialing International
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Mis-diagnosed – 2nd Opinion??
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Venous Insufficiency, Reflux
 Definition: a leaky state of one or more of the venous valves, the valve not closing tightly and blood therefore regurgitating through it, thus valvular incompetence
 Reflux = > 0.5 seconds
 Positioning: hydrostatic pressure is the key: the patient should standing (90 mmHg for a 6’ tall person) – 71% false negative if done supine
img 4
 Color Flow: normal antegrade flow is BLUE
abnormal retgrograde flow is RED i.e. RED = REFLUX
normal antegrade flow is toward the heart: from the right side of screen to the left side of the screen
Time scale important for grading ‐ !!!
Image courtesy of Olivier Pichot, MD
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Nomenclature
Older Term
New Term
Greater Saphenous or
Long saphenous vein (LSV)
Great Saphenous Vein (GSV)
Lesser Saphenous Vein(LSV)
Small Saphenous Vein (SSV)
Giacomini Vein
Cranial Extension of the SSV
SFJ or Crosse
Confluence of the superficial
inguinal veins
Dodd or Hunter Perforators
Femoral Canal Perforators
Sherman and Boyd Perforators
Paratibial Perforators
Posterior Arch Vein
Posterior Accessory GSV
Cockett Perforators
Posterior Tibial Perforators
Communicating veins
intersaphenous veins
Nomenclature of the veins of the lower limbs: An international interdisciplinary consensus
statement, Alberto Caggiati,MD, John Bergan,MD, Peter Gloviczki,MD, Georges Janetet,MD, Colin P.
Wendell-Smith MD, and Hugo Partsch, MD
Journal of Vascular Surgery Journal of Vascular Surgery August 2002, Volume 36 Number 2, August 416‐‐422 422 *revision 2005
*revision 2005
Zygmunt
20112002, Volume 36 Number 2, 416
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Confluence of superficial inguinal veins
“Crosse”
Posterior Accessory
Saphenous vein
Anterior Accessory
Saphenous vein
Great Saphenous Vein
Posterior accessory great
Saphenous vein
Anterior accessory great
Saphenous vein
** perfs here!!!
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The “most” significant landmark:
The Saphenous Compartment
Hyper-echoic saphenous fascia –”eye”
Contains:
saphenous
veins,
and
C t i
h
i
d nerves
NOTE: Saphenous tributaries, collateral
and communicating veins
lie external to this compartment
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Duplex –– Mickey Mouse View of SFJ
Duplex Zygmunt 2011
Anatomic Location
Red Line : Deep System
Black Dotted Line: Saphenous System
Open Circles: Perforators
Sample for reflux at multiple sites
narrow down location
you are a “detective”
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1 O’clock
Location, Location,
Location
4 O’clock
1pm
GSV orientation changes
as it moves distally from the
groin to the ankle
4pm
2 O’clock
2pm
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ASV
GSV
Lymph node
Anatomy at
Anatomy at
the Junction
FA
use the lymph node to help identify id tif
structures
Deep System
FV
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Anterior Saph
Anterior Saph
Location
Landmark:
Alignment Sign
FA
FV
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GSV Variations – Sheath and Tributaries
Anterior Saph
“h” vein
Ricci and Georgiev - Journal of Vascular Technology
Multi-level investigation
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Mapping of a GSV Tributary
leaving the sheath
Trib
GSV GSV in “eye”
US image
to diagram
Tracing the Reflux : Clues
Diameter of a saphenous vein may
decrease distal to a major
incompetent tributary
Diameter of a saphenous vein may
increase at the level where major
reflux enters the vein
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Other Vein Patterns
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Perforating Veins





Connect Superficial to Deep
Normal flow is IN and UP‐ “pump”
Estimated 206 Perforators in the leg
SFJ and SPJ are PV’s by definition
Fascia is your landmark
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Anterior Thigh PV’s
Posteromedial Thigh
g PV’s
PV’s of the Femoral Canal
Sherman’s PV
Paratibial PV’s
Posterior Tibial PV’s
Medial Ankle PV’s
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SSV Anatomy
 Begins behind the lateral malleolus as a ti
ti f th l t l i l f t continuation of the lateral marginal foot vein
 Ascends the posterior aspect of the calf and frequently terminates at the popliteal vein‐ Saphenopopliteal Junction (SPJ)
( )
 Lies in an interfascial compartment
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Imaging: Where to Start?
Not here
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SSV at mid calf – w/ fascial
compartment
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SSV at pop fossa – no compartment
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SSV – 2 main reflux patterns
A)Reflux transmitted
from GSV to SSV
B) Primary SPJ and SSV
incompetence
check 2 sites
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SSV Anatomic Variations
 SSV joins the popliteal vein at the Saphenopopliteal Junction (SPJ) and joins deep veins at a higher l l h
h
l
level through its cranial extension of the SSV or joins GSV via the vein of Giacomini
2-4cm
above
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers
K, Nicolaides A, and Smith PC. Duplex Ultrasound Investigation
of the Veins in Chronic Venous Disease of the Lower Limbs- UIP
Consensus Document. Part II. Anatomy. Eur J Vasc Endovasc
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Surg 2006; 31:288-299
SSV Anatomic Variation

SSV has no connection to deep veins‐ it continues upward as the cranial extension of the SSV or vein of Giacomini
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound
Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J
Vasc Endovasc Surg 2006; 31:288-299 Zygmunt 2011
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Other Variations
 Gastrocnemius veins j i th lit l may join the popliteal vein, proximal SSV, or their confluence at the SPJ
 SSV may merge with the gastrocnemius veins before joining the popliteal vein (10‐30%)
Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, and Smith PC. Duplex Ultrasound Investigation of
the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part II. Anatomy. Eur J Vasc Endovasc Surg
2006;31:288-99
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Nerves in the Popliteal Fossa
The nerve is a round
structure, more
echogenic than the
surrounding tissue,
containing small
yp
g
hypoechogenic
areas
corresponding to the
nerve fibers.
Ricci S. Ultrasound Observation of the Sciatic Nerve and its Branches at the Popliteal Fossa: Always Visible, Never Seen. Eur J
Vasc Endovasc Surg 2005;30:659-63
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When the SSV is
dilated, the sciatic
nerve may appear
slightly irregular in
shape due to the
compression of the
vein.
Ricci S. Ultrasound Observation of the Sciatic Nerve and its Branches at the Popliteal Fossa: Always
Visible, Never Seen. Eur J Vasc Endovasc Surg 2005;30:659-63
Incompetent Giacomini Vein
dumping into SSV
 Transmits reflux from GSV or thigh perforators and pelvic veins to SSV through the intersaphenous anastomosis (IA)
SSV
Georgiev M, Myers K, and Belcaro G. The thigh extension of the lesser saphenous vein: From Giacomini’s observations to
ultrasound scan imaging. J Vasc Surg 2003;37:558-63
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Incompetent Giacomini Vein
dumping from SPJ to GSV
 Transmits reflux from SPJ to GSV or thigh varicose veins through the intersaphenous anastomosis (IA)
 Retrograde reflux
SSV
Georgiev M, Myers K, and Belcaro G. The thigh extension of the lesser saphenous vein: From Giacomini’s observations to
ultrasound scan imaging. J Vasc Surg 2003;37:558-63
Th k f Thank you for your attention
joseph.zygmunt @ covidien.com
Zygmunt 2011
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