Imaging and investigations
The venous system of the lower limb is categorized into 3 groups according to their relationship to the muscular fascia
that surrounds the muscles of the lower limb:
1. Veins that pass under the muscle fascia and drain from the lower muscles are deep veins;
2. Those that lie above the muscle fascia and drain above the fascia are superficial veins;
3. Those that cross the muscle fascia and connect superficial and deep veins are called perforating veins.
In contrast to arteries, veins have a thin muscular layer with less wall elasticity and therefore complete collapse occurs when the vein is compressed by the transducer. The compressibility of the veins and the pulsation of the arteries is a method followed in Doppler ultrasound. In addition, veins have valves that play an important role in preventing venous blood reflux. Normal blood flow through veins is from distal to proximal and from superficial to deep. Normally, the vascular flow cannot be seen on Doppler ultrasound, sometimes it can be seen as an echogenic image due to reflection due to the aggregation of red blood cells, not to be confused with thrombosis. This occurs more frequently in conditions of decreased venous flow.
Anatomy of the venous system
The important deep veins of the lower limb have a similar direction to the corresponding arteries. The deep venous system of the leg includes the anterior tibial vein, posterior tibial vein and peroneal veins. In the calf, these veins are present in pairs on either side of the arteries. The posterior tibial vein receives blood flow from the medial and lateral plantar veins and drains the posterior compartment as well as the plantar surface of the foot. The veins run behind the tibia and anastomose with the popliteal vein at the back of the knee.
The anterior tibial vein is the continuation of the vein on the dors dorsal aspect of the foot. It runs along the anterior compartment of the limb, just above the interosseous membrane between the tibia and the fibula, and joins with the posterior tibial vein and the popliteal vein.
The peroneal vein runs along the posteromedial surface of the fibula and joins the posterior tibial vein.
The polyteal vein is formed from the junction of the anterior and posterior branches of the tibial veins and ascends posterior to the knee and distally, anteromedial to the thigh. The popliteal vein is located medial to the artery in the lower part of the knee, superficial to the artery in the posterior part of the knee and lateral to it above the knee. The popliteal vein runs into the adductor hiatus where it will be called the femoral vein. In the lower part of the thigh, it lies lateral to the artery, at mid-thigh it is behind the artery and in the upper part, medial to the artery.
The deep femoral veins run along the deep femoral artery, join with the femoral veins and form the femoral common venous trunk which is located medial to the femoral common arterial trunk. The inguinal ligament is the marker that divides the femoral venous trunk, originating from the external iliac vein.
Doppler ultrasound technique
The conventional Doppler ultrasound examination starts with the patient in supine or semi-fowlling position. The reverse Trendelenburg position is postponed to facilitate visualization of the veins due to their dilation. External rotation of the hip and slight flexion of the knee helps to decrease muscle tension and is good for exposing deep veins at the medial thigh, posterior knee and calf as well as for the compression maneuver.
Venous circulation runs from the periphery to the heart. Normally the venous system is examined from proximal to periphery because proximal veins are larger in diameter and easier to visualize. At the level of the inguinal ligament, in the transverse image, the examiner can see the common femoral venous trunk medial to the femoral artery. Following the common femoral venous trunk, it will bifurcate into the deep femoral vein and the femoral vein. In the most distal part of the thigh, only the femoral vein is visible. When we approach the popliteal fossa in the posterior knee with the transducer, the popliteal vein becomes visible. By following the popliteal vein downward, two posterior venous branches are visualized in the posteromedial aspect of the calf. The vein that lies next to the tibia is the posterior tibial vein and the vein that lies posteromedially to the tibia is the peroneal vein. In standard Doppler ultrasonography, the cortices of the tibia and fibula can be used as landmarks. Paired veins are present on either side of the artery. After the patient extends the leg, the anterior tibial vein can be visualized anaterolaterally above the interosseous membrane between the fibula and tibia, near the tibial artery. If the posterior tibial veins cannot be visualized proximally, they are best seen posterior to the medial malleolus where the vein is superficially located. If the popliteal and calf veins are not well visualized in supine position, then pronation and recumbency may help. The distal femoral vein, at the level of the adductor hiatus, can sometimes be difficult to assess due to its deep localization.
Anatomy
Two important superficial venous branches belong to the lower limb and they are: the great saphenous vein and the small saphenous vein. The great saphenous vein originates in the medial area of the leg, runs anterior to the medial malleolus and passes posteromedially at the knee, then ascends medially to the thigh, pierces the muscular fascia and joins the common femoral venous trunk at the level of the sapheno-femoral junction, a few centimeters below the inguinal ligament.
The lesser saphenous veins originate from the dors dorsal venous arch of the leg and ascend posterolaterally from behind the lateral malleolus, ascend medially in the calf and terminate in the popliteal vein at the posterior knee. Before penetrating the muscular fascia, a branch extends proximally and joins the great saphenous vein.
Technique
Superficial venous insufficiency can be assessed with the patient in orthostasis, and in supine position sometimes the venous reflux cannot be visualized on Doppler ultrasound. The reverse Trendelenburg position may be used when the orthostatic position is not possible. The leg to be examined should not be supported on the ground. The saphenofemoral junction is visible in the anteromedial aspect of the common venous trunk with the transducer held in a transverse position. The longitudial image of the saphenofemoral junction is useful to visualize the reflux of the terminal valve. Normally, the terminal valve of the saphenofemoral junction prevents venous reflux back into the great saphenous vein. After performing a provocative test, such as the Valsalva maneuver, retrograde flow in the great saphenous vein that persists for more than 0.5 seconds is referred to as pathologic reflux.
There is an echogenic fascia that surrounds the great saphenous vein which is delimited in depth by a musclary fascia and superficially by the saphenous fascia. The saphenous compartment can be well visualized by Doppler ultrasound and appears as an “Egyptian eye”. The saphenous compartment can also be visualized at the knee, above the tibia and medial to the gastrocnemius muscle.
The superficial saphenous veins are visible in the middle of the gastrocnemius muscle. Proximally, the superficial saphenous veins continue with the popliteal veins. The longitudial image of the saphenopopliteal junction as at the saphenofemoral junction of the greater saphenous vein is useful for the assessment of superficial saphenous vein insufficiency. Retrograde flow occurs at the saphenopopliteal junction by tightening of the calf muscles.
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Anatomy
Perforating veins connect the deep veins to the superficial veins and maintain the direction of blood flow from the superficial to the deep system. There are numerous perforating veins in the lower limb, which are named according to their location. A major classification divides them according to their longitudinal location into perforating veins of the ankle, leg, knee and thigh. Subclassification indicates the anterior, posterior, medial and lateral position, so the full name of the perforating veins are a combination depending on their level and position, such as the medial perforating vein of the foot or the anterior perforating vein of the thigh.
Technique
Normally, the perforating veins are not very well visualized by Doppler ultrasound, but when blood circulation is impaired in the deep or superficial veins, then the perforating veins become ineffective, are dilated and can be well visualized ultrasonographically. If varicose veins occur due to insufficiency of the perforating veins, it is important to localize the point of reflux to correct it.
The perforating veins of the leg and the medial thigh are the most important. The medial perforating veins of the leg include the posterior tibial and parotibial perforating veins.
The posterior tibial perforating veins, also known as Cockett’s perforating veins, connect the posterior great saphenous vein to the posterior tibial vein in the distal portion of the leg.
Parotibial perforating veins connect the greater saphenous vein to the posterior tibial vein. The proximal paratibial perforating vein is known as the Boyd’s perforating vein.
In the thigh, the perforating vein of the femoral canal, called the Hunterian (in the proximal part of the thigh) or Dodd (in the distal part of the thigh) connects the large superficial vein with the femoral vein or the proximal popliteal vein.
The insufficiency of these perforating veins can lead to varicosities of the medial calf and thigh, even in the absence of saphenofemoral reflux.
The venous system of the lower limbs is divided into 3 groups: deep, superficial and perforating veins.
In Doppler ultrasound examination of the lower extremity, knowledge of the venous anatomy, the optimal position of the patient, as well as the placement of the transducer, are very important for obtaining optimal images and an accurate diagnosis.
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