Venous drainage of lower limb

Contents
Veins – An introduction
Veins of the lower limb
Factors responsible for venous return.
Superficial veins, perforators and deep
veins .
Venous drainage from foot to thigh.
Summary
Development of lower limb veins.
Clinical highlights.
References

VEINS
 Return the deoxygenated blood from
the capillary beds to the heart.
 The pulmonary veins are atypical in
that they carry well oxygenated blood
from lungs to the heart .
 Because of the lower blood pressure in
the venous system , the walls of the
veins are thinner than those of their
companion arteries.

 Normally, veins do not
pulsate or squirt blood when
severed.
 There are three sizes :
Venules
Medium
veins,
Large veins.

Veins Of Lower Limb
 The veins of lower limb are divided into
three groups :
i. Superficial veins
ii. Deep veins
iii. Perforating veins.

Factors Responsible for Venous Return
from lower limb
 General factors :
Negative intra thoracic pressure( Recumbent
position ).
The pulsations of accompanying arteries help
in propelling the blood in the veins.
The valves in superficial and deep sets of
veins allows the blood to flow in upward
direction only.
The deep veins of the leg lie in the tight fascial
compartment along with the arteries. ( upright

 Local factors:
1. Venous : Veins of lower limb are more
muscular.
Greater number of valves
2. Muscular : When the limb is active, Muscular
contraction compresses the deep veins and
drives the blood in them upwards.
3. Fascial : Tight sleeve of deep fascia makes the
muscular compression of the veins much more

Musculovenous Pump
 Soleus is regarded as the peripheral
heart.

Superficial Veins
 Lie in superficial fascia.
 Drain into deep veins at their termination.
 Connected to deep veins through perforating
veins that pass through deep fascia.
Superficial Veins are:
 Great or long saphenous vein.
 Small saphenous vein
 Dorsal Venous arch.

Great Saphenous Vein
 Longest
Vein of the
body .

Structures Accompanying the Great Saphenous
Vein
 In the thigh : Medial Femoral
cutaneous nerve.
 At the Knee : Saphenous branch of
descending genicular artery.
 In the leg and foot : Saphenous nerve.

Tributaries
 Just below the knee:
Posterior arch vein ( Vein of Leonardo da Vinci):
Consists of series of venous arcades
connecting the three medial ankle
perforators
Collects blood from posteromedial
aspect of calf
Posterior arch vein

Other tributaries are :
Anterior leg veins – extend across the shin.
Few veins from calf – communicate with
small saphenous vein.

 In the thigh :
Anterolateral vein :
Commences from venous plexus
on lower part of front of thigh
Crosses the apex of femoral
triangle
Joins great saphenous vein in
upper part of thigh.

Posteromedial Vein : Accessory saphenous vein
Drains the posterior and medial aspects
of thigh.
 Just before piercing the cribriform
fascia: Superficial Epigastric
vein
Superficial Circumflex
iliac vein
Superficial external
pudendal veins.

 Superficial epigastric and superficial
circumflex iliac veins: Drain the lower part of
abdominal wall below the umbilicus.
 Superficial external pudendal veins:
Passes superficial to spermatic cord.
Thoracoepigastric vein :
 Anterolateral wall of trunk.
 Connects superficial epigastric vein with the
lateral thoracic vein.
 Establishes a connection between femoral and
axillary veins.

 Deep to the Saphenous opening :
Deep external pudendal vein :
Deep to
spermatic cord
Drains blood
from anterior
part of perineum
Great
Saphenous vein

Valves in the Great Saphenous vein
 10 -20 valves .
 Saphenofemoral
valve is functionally
important.

Surface marking of the
Great Saphenous Vein

Small Saphenous vein
Small
Saphenous
vein
Lateral
malleolus
Lateral end of
dorsal venous
arch
Middle of
back of leg
Middle of popliteal
space, terminates
into the popliteal
vein

 Valves : 7 - 13.
 Termination :
In the upper 1/3rd of
thigh : Great
saphenous vein.
Bifurcates to drain
into :
•Great saphenous
vein
•Popliteal vein
Fails to reach the
knee:
Great Saphenous
vein
Deep Veins of the
leg.

 Lies on the distal parts of
metatarsal bones.
 Receives dorsal digital and
dorsal metatarsal veins.
 Communicates with proximally
located dorsal venous
network.
 Medial end of the arch along
with the medial marginal vein
continues as great saphenous
vein.
 Lateral end of arch along with
the lateral marginal network

Perforators
 Perforate through the deep fascia.
 Connect the superficial and deep veins.
 Contain unidirectional valves.
 5 perforating veins.

Perforating veins or Perforators
Valves : From
superficial to
deep .

 Show a predilection for
intermuscular septa occuring
on :
i. Either side of Sartorius.
ii. Either side of peroneal
group .
iii. Along the anterior border of
soleus.
 Two types :
Direct
Indirect

Position of Perforators
 Perforators of Cockett :
Three ankle perforators.
Between medial malloelus
and mid calf.
Connect posterior arch
vein to the venae
comitantes around the
posterior tibial artery.
Upper : At the junction of
middle and lower third of
tibia.
Lower : Below and behind
the medial malleolus.
Middle : Midway between

 Knee perforator or
Boyd’s Perforator or
Tibial tubercle
perforator:
Connects great saphenous
vein with the venae
comitantes of the posterior
tibial artery.
Below the knee .
Close to medial border of

 Hunterian Perforator or Perforator of
Dodd :
 In the intermediate third of thigh.
Connects great saphenous vein to femoral
vein in subsartorial canal.
Passes through the fascial roof of the canal.
• Lateral Ankle Perforator: one
At the junction of middle and lower third of the
leg.
Communicates Short saphenous vein with the

Deep veins
 Placed subjacent to the deep fascia and run along
the arteries.
 Deep veins of the lower limb are:
Femoral vein
Popliteal vein
Anterior and posterior tibial veins
Medial and lateral plantar veins
Plantar venous arch
Metatarsal veins
Digital veins

Femoral vein  Accompanies
femoral artery.
 Begins : At adductor
opening
 Continuation of
popliteal vein.
 Terminates :
Posterior to inguinal
ligament as external
iliac vein.

 Tributaries : Long Saphenous
vein
Profunda femoris
vein
Valves:
4 – 5 valves .
2 are constant :
1. Distal to entry of profunda femoris vein.
2. Near the inguinal ligament.

Surface Marking Of
Femoral Vein

Profunda femoris vein /Deep Vein of thigh
 Lies anterior to profunda
femoris artery.
 Connects distally with:
Popliteal vein .
 Proximally with : inferior
gluteal veins.
 Drains medial and lateral
circumflex femoral veins.
 Presents valve before its
termination.
 Enters femoral vein :
 8cm inferior to inguinal
ligament.
 5cm inferior to termination
of great saphenous vein.

Popliteal vein
 Begins : Distal border of
popliteus.
 Continuation of posterior tibial
vein.
 As it traverses the adductor
hiatus,it becomes femoral
vein.

Anterior and Posterior tibial veins

Medial and Lateral Plantar veins
Four plantar
metatarsal
veins
Deep plantar
venous arch
formed
Medial and
lateral plantar
veins run
along with the
arteries.
Communicate
with Great and
small
saphenous
vein
Form Posterior
tibial veins
behind the
medial
malleolus

 Both superficial and deep sets of veins in the foot.
 Deep Veins : Interanastamosing paired veins
accompanying all the arteries internal to deep fascia.
 Superficial veins : subcutaneous, unaccompanied by
arteries.
Venous drainage in foot is primarily to the major
superficial veins.

 Superficial Venous Drainage : Small
Saphenous vein.
 Deep Venous Drainage :
Anterior Tibial Veins
Peroneal veins
Posterior Tibial Veins
Small Saphenous Vein

 Superficial Veins :
Long and short
saphenous veins.
 Deep Vein: Popliteal
vein

Gluteal Region
 Tributaries of internal iliac veins drain blood from
the gluteal region.
 Superior and inferior gluteal veins accompany the
corresponding arteries through the greater sciatic
foramen – Superior and inferior to piriformis.
 Communicates with tributaries of femoral vein.

External genitalia and pudendum: Internal
pudendal veins accompany the artery, joins to
form a single vein which drains into the internal
iliac vein.
Perforating veins : drain blood from posterior
compartment into the deep veins.
Inferiorly : popliteal vein.
Superiorly : inferior gluteal vein.

 Medial and lateral
superior genicular
veins.
 Medial and lateral
inferior genicular
veins.
Descending
Genicular vein
Femoral Vein

 Superficial veins: Long saphenous vein
receives many tributaries :
1.Posteromedial tributaries.
2. Anterolateral tributaries.
3. Peri inguinal tributaries.
Superficial epigastric and circumflex iliac
veins : Drains the inferior abdominal wall.
Superficial external pudendal vein : drains
part of scrotum/labia , one joined by the
superficial dorsal vein of penis/ clitoris.
Deep external pudendal vein : joins with long
saphenous vein at saphenous opening.

 Deep Veins :
Femoral vein
Profunda femoris vein

 Primitive capillary plexus of flattened limb bud –
Peripheral border vein.
 Cranial margin of limb bud : Vein is smaller and
disappears.
 Caudal margin : Permanent vessels.
 Appears in the leg : 8th week.

 Tibial continuation of primitive border vein
disappears, fibular persists.
 Great saphenous vein : Posterior cardinal veins.
 Gives off : Femoral vein and posterior tibial veins.
 At the level of knee : Annexes with fibular border
vein.
 Anterior tibial , Small saphenous and inferior
gluteal veins – Fibular border vein.

Saphenous vein Grafts
 Great saphenous vein commonly used for
coronary arterial bypasses because: 1.
Readily accessible.
2. Usable lengths can be
harvested.
3. Walls contain higher
percentage of muscular and elastic fibers
than do other superficial veins.
 Used to bypass obstructions in blood
vessels.
 Vein is reversed, valves do not obstruct the
blood flow.

Saphenous Cut Down
 Exposure of the great saphenous vein through a skin is
usually performed at the ankle.
 Disadvantage : Phlebitis.
 Great saphenous vein can be entered at the groin.
 Advantage : 1. Phlebitis is rare.
2. Permits the use of large diameter
catheters.
 Anatomy of ankle vein cutdown:
Procedure: Saphenous nerve branches blocked with
local anaesthesia.
 Transverse incision is made through the skin and
subcutaneous tissue.
 Vein is easily identified and saphenous nerve should

 Groin vein cut down:
Branches of ilioinguinal nerve and
intermediate cutaneous nerve of thigh are
blocked with local anaesthetic.
A transverse incision is made through skin
and subcutaneous tissue on a point 11/2
inches below and lateral to pubic tubercle.

Saphenous Varix
 Localized dilatation of terminal part of the great
saphenous vein.
 May lead to edema.
 May be confused with other groin swellings such as
psoas abscess.
 Can also be consfused with femoral hernia.
 Diagnosis : Presence of varicose veins elsewhere
in the leg .

Location of Femoral Vein
 Femoral vein is not usually palpable.
 In thin people , femoral vein may be mistaken for
great saphenous vein.
 Fermoral vein has no tributaries at this level except
great saphenous vein.
 In varicose vein operations, precautions should be
taken not to tie off the femoral vein instead of great
saphenous vein.

Femoral Vein Catheterization
 Rapid access to large vein.
 Constant relation to the femoral artery just below the
inguinal ligament .
 Easily cannulated.
 Once the patient is stabilized the cannula should be
removed – Pulmonary embolism.
 Anatomy of the procedure:
 Genitofemoral nerve is blocked by a local anaesthesia.
 Femoral pulse palpated between ASIS and symphysis
pubis .
 Femoral vein is medial .
 Two fingers breadth below the inguinal ligament,
needle is inserted into femoral vein.

A 28 year old woman was seen by her family
practitioner for a routine pregnancy check up at 36
weeks gestational age. Neither the patient nor the
family physician had any concerns about the
pregnancy. However , the patient did complain of
unilateral swelling of left leg, which had gradually
increased over the previous two days.
Furthermore, the evening before her visit she
developed some sharp chest pain ,which was
exacerbated by deep breaths.

 Also known as
phlebothrombosis.
 Acute thrombosis of
deep veins.
 Affects the venous
sinuses in soleal
muscles.

Causes Of Deep Vein
Thrombosis :
Trauma : Trauma to vessel wall
Hormones : Increased
Coagulability
Road traffic accidents
Operations – Cholecystectomy
Malignancy : Sluggish blood
flow
Blood disorders : Polycythemia
Orthopaedic surgery, obesity
,Old age

 Clinical features :
 2nd to 5th day in post
operative period.
 Oedema, dilated veins of leg.
 Dull aching pain in calf
muscles.
Signs :
Homan’s test
Moses test
Investigations:
Doppler study
Contrast venography

 Treatment :
 Bed rest and elevation of limbs.
 Low dose heparin
 Intermittent pneumatic
compression.
 Inferior vena caval filters
 In chronic venous
cases :
Surgery is done
 Palma
 May – Husni
operation

Case Discussion
 Duplex ultrasound scan of left leg
venous system.
 Probe was placed over left
femoral vein and no flow was
demonstrated.
 Right femoral venous system
however showed excellent flow.
 A diagnosis of left sided deep vein
thrombosis was made :
1. Gently massaging the calf
muscle, augmentation to venous
flow was noted.
2. Alteration of flow – respiratory
excursion

 Result :
In this patient :
There was compression of left external iliac
vein.
Chest pain was due to pulmonary emboli.
Patient was administered anticoagulant and
had an uneventful delivery 

Varicosity is the penalty for
verticality against gravity.

 Dilated ,tortuous superficial veins
of the limb are called varicose
veins.
 Primary varicose veins.
 Secondary varicose veins.
Clinical symptoms:
1. Dilated veins in the leg.
2. Dragging pain in the leg.
3. Night cramps.

Palpation:
1. Morrissey’s test.
2. Trendelenburg test
3. Multiple torniquet
test
4. Modified Perthe’s
test

Investigations
 Doppler ultrasound
 Duplex ultrasound imaging
 Venography

Treatment
 Conservative line of
treatment
 Injection line of
treatment /Compression
Sclerotherapy
 Surgery

Trendelenburg’s Operation  Saphenofemoral
incompetency.
 Juxtafemoral
Flush Ligation.

Subfascial endoscopic Perforator Surgery (SEPS)
 For below the knee perforators.
 Small port incisions are made in the skin of the
calf region.

Complications Of Varicose Veins
 Eczema and Dematitis
 Lipodermatosclerosis
 Haemorrhage
 Thrombophlebitis
 Venous ulcer

Venous Ulcers  Gravitational
ulcer

References
Gray’s Anatomy , The Anatomical Basis of Clinical Practice –
Susan Standring ,40th Edition.
Cunningham’s manual of Practical Anatomy ,Vol.1,15th Edition
-G.J . Romanes.
Clinically Oriented Anatomy ,5th Edition – Keith.L.Moore.
Gray’s Anatomy for Students – Richard.L.Drake
Essentials Of Human Anatomy ,4th Edition – A.K.Datta
Clinical Anatomy For Students –Neeta .V .Kulkarni
Clinical Anatomy For Medical Students ,6th Edition – Richard .
S.Snell
Grant’s Atlas of Anatomy,12th Edition – Anne.M.R.Ague,
Arthur.F.Dalley
Current Surgical Diagnosis and Treatment,11th Edition –
Lawrence. W.Way,Gerard .M.Doherty
Lee Mc Gregor’s Synopsis Of Surgical Anatomy ,12th Edition .
Arey Embryology
A Short practice of surgery, Edition - Bailey and Love

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