Key words
anatomy - perforating veins - 3D modeling - duplex US
Schlüsselwörter
Anatomie - Perforansvenen - 3-dimensionale Modellierung - Duplex-Sonografie
Introduction
A perforating vein (PV) – vena perforantis – is defined by a vein joining the deep
to the superficial venous system, which perforates the deep fascia, also called aponeurosis.
Perforating veins are provided with one-way valves along the whole limb, and are physiologically
oriented from superficial to deep, except for the foot PVs. (see paragraph 2)
Anatomical landmarks of the lower limbs
Anatomical landmarks of the lower limbs
The knowledge of limb’s divisions and reference points is essential for anatomical
description [1]. Among the latter, we have to mention the following (red dots in [Fig. 1]):
Fig. 1 Lower limb’s anatomical landmarks. Reference points and regions (Source: Gillot C.
Atlas of the superficial venous network of the lower limbs. Editions Phlébologiques
Françaises; 1980) 1 = Malleolar apex, 2 = apex of the gastrocnemius, 3 = knee joint,
4 = femoral condyle. FOOT below the malleolar apex, ANKLE from malleolar apex to line
A, LEG between lines A & B. KNEE between lines B & C, THIGH between lines C & D.
1 – Malleolar apex, 2 – Apex of the gastrocnemius muscle, 3 – Knee joint, 4 – femoral
condyles.
The divisions of the limb are shown by straight lines:
A: 4 cm above the malleolar apex, B: 4 cm below the knee joint (soleus arch level),
C: 12 cm above the knee joint (adductor’s hiatus level), D: Scarpa’s triangle apex
level.
These four lines allow us to recognize 5 anatomical regions: foot, ankle, leg, knee
and thigh.
FOOT below the malleolar apex, ANKLE from malleolar apex to line A, LEG between lines
A and B, KNEE between lines B and C, THIGH between lines C and D
GENERAL DESCRIPTION [1]
[2] of perforating veins (PVs)
We will describe successively, according to Gillot’s Atlas: ANKLE, LEG (numbers 1
to 5), CALF (numbers 6 to 9), KNEE, femoral THIGH PVs. (numbers 10 to 12) and other
thigh PVs (numbers 13 to 15) see [Fig. 2].
Fig. 2 Location of the main perforating veins (PVs) of the limb (Source: Gillot C. Atlas
of the superficial venous network of the lower limbs. Editions Phlébologiques Françaises;
1980). ANKLE, LEG (numbers 1 to 5), CALF (numbers 6 to 9), THIGH PVs (numbers 10 to
12). 1 = Lower posterior tibial, 2 = Higher posterior tibial 3 = Inferior paratibial,
4 = lower superior paratibial, 5 = higher superior paratibial, 6 = Anterior calf PV,
7 = central calf PV, 8 = Posterior calf PV, 9 = Inferior (polar) calf PV 10 = PV of
the Hunter canal 11 = Lower PV of femoral canal, (formerly Dodd’s PV), 12 = Higher
PV of femoral canal, 13 = PV of the apex of the scarpa triangle, 14 = PV of the adductor
magnus, 15 = Direct femoral vein PVs (connected to the lymph node venous networks
of the groin [6]).
The perforating veins have been renamed for a better international understanding in
an UIP consensus document in 2002. The old and new terminology [4]
[5] is shown on [Table 1].
Table 1
Terminologies of the Perforating veins of the lower limb [4]
[5].
|
old eponyms
(English)
|
new terminology
(English)
|
latin
vena perforans
|
german
Perforansvene
|
french
veine perforante
|
|
Cockett
|
posterior tibial
|
posterior tibialis
|
Posteriore tibiale
|
Tibiale postérieure
|
|
Sherman
|
inferior paratibial
|
paratibialis inferior
|
Inferiore paratibiale
|
Paratibiales inférieures
|
|
Boyd
|
superior paratibial
|
paratibialis superior
|
Superior paratibiale
|
Paratibiales supérieures
|
|
May
|
inter gemalar
|
intergemellaris
|
Intergemelläre
|
inter gémellaire
|
|
Bassi
|
para achilean
|
para achilean
|
Paraachilläre
|
Para achilléenne
|
|
Gillot
|
medial gastrocnemius
|
Gastrocnemius medialis
|
Gastrocnemius medialis
|
Polaire du gastrocnémien médial
|
|
Thierry
|
popliteal fossa
|
fossa poplitea
|
Der Fossa poplitea
|
Externe de la fosse poplitée
|
|
Dodd
|
femoral canal
(femoral canal)
|
Femoralis
|
Des Femoralkanals
|
du canal fémoral
|
|
Hunter
|
adductor canal
|
Hunter
|
Des Addukotrenkanals
|
Huntérienne
|
|
Hach
|
posterolateral thigh
|
V femoris posterior
|
Posterolaterale PV des Oberschenkels
|
postéro-latérale de cuisse
|
A more detailed anatomical topography of the leg including the distances from the
floor is shown in scheme [Fig. 3], based on a tibial length of 35 cm. Since the perforators relate to the anatomy
and function of muscular veins, their location is quite constant, and predictable.
This is related to the hemodynamical levels of the limb, explained in more details
on paragraph 3. Therefore, the landmarks and distances displayed in this figure become
useful not just for skin mapping but for treatment as well, according to tibia’s length.
In clinical practice, sonographers can use these landmark distances, according to
the tibia length, for a quicker assessment of the leg PVs
Fig. 3 Locations of the leg and calf PVs for a tibia length of 35 cm. (Source: Gillot C.
Atlas of the superficial venous network of the lower limbs. Editions Phlébologiques
Françaises; 1980). Lower leg perforator’s measurements are taken from the malleolus.
Upper leg perforators measurements are taken from the knee joint. 1 = Lower posterior
tibial (5 to 9 cm), 2 = Higher posterior tibial (from 10 to 16 cm), 3 = inferior paratibial
(from 17 to 21 cm), 4 = lower superior paratibial (from 15 to 23 cm), 5 = higher superior
paratibial (from 6 to 14 cm), 6 = Anterior calf PV, 7 = central calf PV, 8 = Posterior
calf PV, 9 = Inferior (polar) calf PV.
The perforating veins of the foot [6]
[7]
[8]
[9]
The perforating veins of the foot [6]
[7]
[8]
[9]
Hemodynamical key features of Foot PVs [9]
Perforating veins of the foot show a distinctive feature, which is unique in the venous
system of the lower limbs. Some of them are either valveless – allowing bidirectional
flow – or have valves in the inverted position, enabling “inverted” flow: from deep
towards superficial veins. So, from a hemodynamic point of view, foot veins should
not be classified as deep and superficial, but considered as medial and lateral anatomical/functional
units instead.
THE MEDIAL FOOT PVs
-
Located at the forefoot, the perforator of the first intermetatarsal space is usually
the largest. It connects the medial marginal vein (MMV) to the plantar veins. On the
opposite end, over the anterior surface of the medial malleolus, the MMV gives the
main root, out of 3, to form the GSV.
-
At the medial side of the foot, there are 3 main perforators:
-
inframalleolar or inframalleolar PV: considered to be the second root for the GSV
origin.
-
navicular PV: running close to the navicular bone at midfoot.
-
cuneiform PV, which courses near to the medial cuneiform bone.
-
the third root for the GSV origin is the medial dorsal PV of the ankle, which connects
to the anterior tibial veins
The dorsal foot and ankle PVs originate from the venous network of the dorsal foot and gives birth to the peroneal
and anterior tibial veins ([Fig. 4])
Fig. 4 The lateral foot PVs (Scheme from right foot, lateral view). Cuboid intertendinous
(I) and infratendinous (Cu) perforators join in a common trunk (C), which is the 3 rd
root for the SSV (SS) trunk origin. F = fibula, MP = lateral malleolar plexus, d = superficial
dorsal venous arch, P = lateral dorsal PV of the ankle, which connects to the anterior
tibial veins, s = lateral inframalleolar perforator, which connects to the peroneal
veins.
The lateral foot PVs. The intertendinous and infratendinous PVs are cuboid perforators that share a common
trunk. This trunk is the 3rd root for the SSV since it joins the 2nd and 1st roots (lateral malleolar plexus & plexiform lateral marginal vein respectively) to
form the SSV trunk. The infratendinous and intertendinous perforators are so called
because of their path: below the peroneus longus tendon and between the latter and
the peroneus brevis tendon respectively ([Fig. 4]).
The posterior foot PV: At the posterior part of the foot we find the calcaneal PV, which originates from
the calcaneus plexus and is usually connected to the Achillean tributary of the SSV.
The Achillean tributary runs medially to the Achille’s tendon to drain into the SSV
at the lower third of the calf ([Fig. 5], [7]).
Fig. 5 Calcaneal PV and Achillean tributary of the SSV. Drawing from anatomical dissection
(right limb, medial view)1 = achillean tributary, 2 = SSV, 3 = calcanean PV, 4 = infra
malleolar PV, 5 = PV connecting with the AT veins, 6 = posterior tibial PVs (superior),
7 = posterior tibial PVs (middle), 8 = posterior tibial PVs (inferior), 9 = inferior
paratibial PV, 10 = Polar calf PV 11 = anterior accessory saphenous of the GSV, 12 = medial
marginal vein, GS = GSV.
Fig. 7 Medial PVs and hemodynamic levels. Anatomical dissection (right limb, medial view).
On the medial surface of the leg, PVs are displayed together with their hemodynamic
levels at 10, 14 and 20 cm from the medial malleolus. 1 = GSV (in light blue) Tributaries
of the GSV (in dark blue) give origin to the main PVs. 2 = posterior tibial (PT) veins
3 = Popliteal vein 4 = inferior posterior tibial PV 5 = Superior posterior tibial
PV 6 = Inferior paratibial PV, 7 = Superior paratibial PV. Two groups of veins drain
the soleus muscle (S): medial soleal veins (MSVs) and lateral soleal veins. MSVs are
shown (in green) in this figure. Please note how they converge towards specific points
(red circles), corresponding to the draining points of perforating veins.
During the systolic phase of the calf pump, extrinsic muscular compression of posterior
tibial and peroneal veins blocks venous return through this path. Flow coming from
the foot is then shunted to alternative superficial routes, mainly the GSV and the
SSV.
Leg & ankle perforating veins [11]
Leg & ankle perforating veins [11]
At different levels, horizontal or oblique anastomoses (deep communicating veins)
between posterior tibial, anterior tibial and fibular veins may be present ([Fig. 6]). These are not randomly distributed, but located at several levels, which define
the hemodynamic levels, explain the fixed location of the leg perforator veins, and
allow for venous blood flow exchange when needed.
Fig. 6 Lower leg and ankle Anatomical dissection (left limb, lateral view, after removing
the fibula). This outstanding dissection by C. Gillot shows several transverse connections
between the venous axes displayed: an information that – to the best of my knowledge
– cannot be found in anatomy books. This unique final result was possible only after
having removed the fibula. 1 = anterior tibial (AT) veins, 2 = peroneal veins, 3 = posterior
tibial (PT) veins, 4 = Achillean tributary, 5 = SSV, 6 = dorsal PV of the ankle which
gives origin to the AT veins, 7 = dorsal PV of the ankle which gives origin to the
peroneal (peroneal) veins, 8, 9 and 10 = deep communicating veins between peroneal
and PT veins, 11 = deep communicating veins between peroneal and AT veins, 12 = perforators
from the SSV system into the peroneal veins.
Leg PVs landmarks and theory of hemodynamic levels by Gillot [1]
The anatomic and functional interaction between leg’s muscular veins and PVs, allows
us to know in advance the location of perforators, which is quite steady when related
to the tibia’s length ([Fig. 3]). This is according to the theory of the hemodynamical levels of C. Gillot: PVs
are closely connected to the muscular veins which represent the active part of the
pumps. Their fixed location is explained by anatomy of the muscular veins.
Leg PVs can be divided into 2 groups: medial ([Fig. 7], [8]) and lateral ([Fig. 9])
Fig. 8 Medial PVs of the leg A and their deep connections B. Gillot’s dissection of a left limb (medial view) after dissection of the skin and
fascia A and after dissection of deep plan B. The patient had a refluxing SPJ and insufficient SSV trunk, which is found dilated
(2). A transverse superficial communicating vein (5) shunted reflux towards the GSV
trunk (1) and the superior posterior tibial PV (8) in the lower leg. Deep dissection
displays connections between medial gastrocnemius (12) and soleal (4) veins, and to
superficial veins through perforators as well. 3 = popliteal vein, 6 = superior paratibial
PV, 7 = lower paratibial PV, 8 = superior posterior tibial PV9 = inferior posterior
tibial PV, 10 = central calf PV, 13 = posterior tibial veins.
Fig. 9 Lateral PVs and hemodynamic levels. Anatomical dissection (right limb, lateral view).
Lateral soleal veins, shown on the lower half of the picture, are colored in green.
They converge towards specific points, to receive the peroneal PVs (in yellow) at
the hemodynamic levels displayed on yellow labels: 11,17 cm from the lateral malleolus
and 11, 13 and 16 cm from the knee joint.
Medial lower leg perforator’s measurements [1] are taken from the malleolus, including the following groups on the medial surface:
ankle PVs (–2 to 4 cm), inferior posterior tibial PVs (5 to 9 cm), superior posterior
tibial PVs (10 to 15 cm) and inferior paratibial PVs (16 to 20 cm).
Upper leg perforator’s measurements are taken from the knee joint. These are the superior
paratibial PVs (6 to 14 cm), the inferior paratibial PVs (15 to 23 cm). The superficial
connection of the medial PVs is variable, according to the anatomy of the superficial
communicating veins of the leg
On the lateral surface of the leg, peroneal PVs, in yellow ([Fig. 9]) are located on the same level than the medial leg PVs (in red). They drain into
the peroneal veins.
Calf perforating veins [1]
[12]
Calf perforating veins [1]
[12]
They can be divided into 4 groups: anterior, posterior, central and inferior perforators.
The latter, formerly known as Gillot’s perforator, is also called the “polar” PV since
it is located at the apex of the calf (lower end of the medial gastrocnemius muscle,
see [Fig. 1, ]Point 2).
The central and anterior PVs usually drain into the soleal veins. To do so, they have
to run through the gastrocnemius muscle. Thus, they are also known as trans-gemellar
PVs of the soleus.
The polar PV of the calf is frequently present and plays an important functional role,
due to its direct connection (end-to-end anastomosis) to the powerful pump of the
medial gastrocnemius muscle. This key anatomical feature allows SSV reflux to re-enter
the popliteal vein through the gastrocnemius veins. White arrows in (A) indicate the
direction of the reflux circuit.
The posterior or dorsal (D) calf PV. At the level where the leg reaches its maximum
diameter, the posterior PV connects to the dorsolateral component (DLC) of medial
gastrocnemius veins through an end-to-end anastomosis. Likewise, through and end-to-end
anastomosis, the inferior (polar or Gillot’s) PV ends either in the DLC or in the
ventromedial component (VMC) of medial gastrocnemius veins, as shown in [Fig. 10], [11].
Fig. 10 The calf PVs and their connections with gastrocnemius veins (saphenogemellar arcade).
A Schematic presentation of the polar PV (3). The direction of venous flow is indicated
by white arrows. 1 = popliteal vein, 2 = SSV, 3 = polar PV, 4 = ventromedial component
(VMC) of medial gastrocnemius veins, 5 = dorsolateral component (DLC) of medial gastrocnemius
veins, PV 6 = dorsal veins of the Soleus muscle. B Anatomical dissection of a right leg (posterior view) showing the SSV (1) and its
posterior PV of the calf., 2 = popliteal vein 3 = tibial nerve 4 = medial common gastrocnemius
venous trunk 5 = posterior PV of the calf M = medial gastrocnemius muscle L = lateral
gastrocnemius muscle.
Fig. 11 The calf PVs and their connections with gastrocnemius veins. Po = Polar calf PV,
P = Posterior calf PV, C = Central calf PV, A = Anterior calf PV, SPT = superior paratibial
PV. IPT = inferior paratibial PV, 1 = popliteal vein, 2 = SSV, 3 = GSV, VM = Ventromedial
component of medial gastrocnemius veins, DL = dorsolateral component of medial gastrocnemius
veins.
The central (C) calf PV drains into the DLC of medial gastrocnemius veins at the same
level than the posterior calf PV.
The anterior (A) calf PV drains into the VMC of medial gastrocnemius veins and into
soleal veins as well. To do so, it splits into 2 or more subfascial connections. One
of them terminates as an end-to-end anastomosis with the VMC. The other one runs through
the gastrocnemius muscle to drain into the soleal veins. It is known as the “transgemellar”
PV of the soleus muscle.
Leg perforating veins by CTV [2]
[14]
[15]
[16]
[17]
Leg perforating veins by CTV [2]
[14]
[15]
[16]
[17]
3D reconstruction from CT Venography is made possible through virtual rendering technique
(VRT) [Fig. 12], [13], [14], [15].
Fig. 12 Virtual dissection by CTV showing medial leg PVs. 1 = PT veins; 2 = Calcaneal crossroad;
3 = Superior paratibial PV (upper Boyd) located at 23.5 cm from the medial malleola;
4 = Superior paratibial PV (lower Boyd) located at 20 cm from the medial malleola;
5 = Inferior paratibial PV (Sherman) located at 17 cm from the medial malleola; 6 = Posterior
tibial PV (upper Cockett) located at 11 cm from the medial malleola; 7 = Posterior
tibial PV (lower Cockett) located at 5 cm from the medial malleola; 8 = AT veins;
9 = Fibular veins C = Medial femoral condyle I = knee joint level M = Medial malleola.
Fig. 13 Ankle & lower leg PVs. 3D reconstruction from CTV through virtual rendering technique
(VRT). 1 = PT veins; 2 = Peroneal veins; 3 = AT veins; 4 = GVS; 5–6 = Posterior tibial
PV (Cockett) at 9.6 cm from the medial malleolus. Formerly superior posterior tibial
PVs were known as Cockett III, while mid posterior tibial PVs were known as Cockett
II. The latter are currently called inferior posterior tibial PVs, while formerly
known Cockett I is now included within the perforators of the ankle group).
Fig. 14 Anterior and lateral leg PVs. 3D reconstruction from CTV through virtual rendering
technique (VRT) PT = PT veins, F = peroneal veins, Ta = anterior tibial veins, S = soleal
veins, 1–2–3–4 = peroneal PVs (draining into the lateral group of soleal veins), 5–6 = lower
anterior tibial PVs, 7–8 = higher anterior tibial PVs, AC = anterior compartment of
the leg (in yellow), LC = lateral compartment of the leg (in green). Please note that
the soleus muscle is drained by two groups of veins: medial soleal and lateral soleal
veins, the latter being the largest ones.
Fig. 15 Leg perforators and gastrocnemius veins. Virtual dissection from CTV. 1 = upper superior
paratibial PV, 2 = lower superior paratibial PV, 3 = inferior paratibial PV, 4 = superior
posterior tibial PV, 5 = middle posterior tibial PV 6 = inferior posterior tibial
PV. PVs are in red. The SSV is colored in purple, the medial GV in green and the PT
veins in blue.
Interperforator anastomoses (IPA)
Interperforator anastomoses (IPA)
The rate of after surgery recurrent leg’s PVs insufficiency is very high (about 76 %
after 3 years follow-up) according to André Van Rij [17], and usually underestimated.
In our dissection series of non-embalmed cadavers, after latex injection and color
segmentation, multiple deep connections between perforators are visible in a significant
(60 %) number of cases. We call them the interperforator anastomoses (IPA).
They may result in a complex network of venous connections, usually more apparent
on the medial aspect of the leg (close to the tibial bone), difficult to assess by
ultrasound and potentially accountable for treatment’s failures. Two types of IPA
can be differentiated: horizontal and vertical, the latter being more frequent ([Fig. 16], [17], [18], [19], [21], [22], [23], [24]).
Fig. 16 Horizontal interperforator anastomoses (IPA). Dissection by C. Gillot after latex
injection and segmentation (right leg, medial view). Transverse anastomosis (1, in
yellow) at midleg, linking an inferior paratibial (3) to a medial gastrocnemius perforator
(2). 4 = superior posterior tibial PV (in red), 5 = superior paratibial PV (in red),
6 = medial gastrocnemius vein, 7 = medial soleal vein, 8 = GSV, 9 = para-achillean
(formerly Bassi’s PV), 10 = transverse superficial communicating vein of the lower
leg, 11 = SSV. Please note that neither the superior (5) nor the inferior (3) paratibial
PVs spring from the GSV trunk in this particular case. Numbered labels indicate PVs
hemodynamic levels.
Fig. 17 Longitudinal and horizontal interperforator anastomoses. Anatomical dissection by
C. Gillot, after latex injection and color segmentation (right leg, medial view).
Longitudinal interperforator anastomosis joining several (4 to 7) medial PVs at the
upper leg. This case clearly shows the connection of most medial PVs through a long
uninterrupted anastomosis (in yellow). Both PVs and anastomosis run below the aponeurosis
of the Soleus muscle (S) which was detached from the tibial bone. The superficial
origin of perforators, from the GSV trunk (1) and tributaries, is clearly visible.
The yellow labels indicate PVs hemodynamic levels: at 9,12,15,16 cm from the medial
malleolus and 8,11,12 cm from the knee joint. A horizontal IPA (9) is also displayed,
linking a lower posterior tibial perforator (3, in red) to the polar perforator (8)
at the apex of the calf, 2 = ankle PV, 4 = higher posterior tibial PV, 5 = inferior
paratibial PV, 6–7 = superior paratibial PVs, 8 = polar calf PV, G = gastrocnemius
muscle.
Fig. 18 Longitudinal anastomosis of paratibial PVs. Dissection of a left leg (medial view).
1 = popliteal vein, 2 = PT veins, 3 = peroneal veins, 4 = medial soleal veins, 5 = upper
superior paratibial PV, 6 = lower superior paratibial PV, 7 = inferior paratibial
PV, 8 = posterior tibial PV, 9 = GSV tributaries, S = Soleus muscle, G = gastrocnemius
muscle.
Fig. 19 Complex PVs anatomical pattern. Anatomical dissection by C. Gillot after latex injection
and color segmentation (right leg, medial view). This case illustrates the anatomical
complexity that PVs connections can reach. Perforating veins subfascial links should
not be understood as a single joining between superficial and deep veins but, instead,
as a complex (occasionally plexiform) network composed of multiple bonds. Medial PVs
of the leg (in red) form a plexiform network extended between the GSV (1) and its
accessories (2) on one end, and convergent medial soleal veins (3) on the opposite
side. Yellow labels indicate PVs hemodynamic levels: at 10,12,18 cm from the medial
malleolus and 9, 13 and 16 cm from the knee joint. 4 = ankle PV 5 = lower posterior
tibial PV 6 = upper posterior tibial PV 7 = inferior paratibial PV 8 = superior paratibial
PVs S = Soleus muscle G = partially resected gastrocnemius muscle.
Fig. 21 Longitudinal IPA. Anatomical dissection by C. Gillot of a right leg (below the knee,
medial view) (medial below-knee view of a right leg) PVs are colored in red, IP anastomosis
(A1 & A2) in yellow. A vertical anterior IPA is displayed (A1), between superior (5)
and inferior (6) paratibial PVs. An additional oblique posterior IPA (A2) is shown.
PVs are colored in red. 1 = popliteal vein, 2 = GSV, 3 = anterior accessory GSV, 4 = posterior
accessory GSV, 5 = superior paratibial PVs, 6 = inferior paratibial PVs, 8 = superior
posterior tibial PV, 9 = oblique superficial communicating vein of the calf, 10 = calf
PVs.
Fig. 22 Longitudinal IPA. Anatomical dissection by C. Gillot of a right leg (below the knee,
medial view). Vertical IPA (in yellow), connecting superior (4) and inferior (5) paratibial
PVs, PVs are colored in red, 2 = GSV, 3 = anterior accessory GSV, 6 = superior posterior
tibial PV, 7 = PT veins, 8 = calcaneal confluence of plantar veins, 9 = soleus muscle.
Please notice the hemodynamic levels (yellow labels) 9 and 15 cm from the medial malleolus
and 7 and 12 cm from the knee joint.
Fig. 23 Accompanying arteries of the leg PVs. Anatomical dissection after double (arterial
and venous) latex injection and color segmentation. Arteries are shown in red, while
veins are displayed in green. Left lower leg (medial view). Following the course of
PVs (in yellow), several tiny arteries are visible on the posteromedial aspect of
the lower leg. Yellow labels indicate PVs hemodynamic levels: posterior tibial perforators
at 5, 7 and 10 cm from the medial malleolus and inferior paratibial PV at 17 cm from
the same anatomical landmark.
Fig. 24 Accompanying arteries of the leg PVs. Enlarged from previous figure, these pictures
display greater anatomical detail. Running close to their accompanying arteries (in
red), PVs are shown in yellow.
Vertical IPA usually connect paratibial perforators in the upper half of the leg, although they
may extend downwards to include posterior tibial PVs as well. Since IPA arches run
below the muscular fascia, they are overlooked and consequently not treated when there
may be a need to.
Horizontal IPA are a less frequent finding, at the lower leg connecting posterior tibial perforators,
occasionally including calf perforators as well ([Fig. 27]). In a way, also soleal veins could be considered as deep intramuscular connections
between PVs, since they converge towards their draining points ([Fig. 20]).
Fig. 20 Longitudinal IPA Anatomical dissection of upper left leg (medial view). A vertical
IPA is shown (5), linking superior paratibial perforators (1,2 in blue). The longitudinal
anastomosis (5) has a double connection (3,4) to the GSV trunk. The saphenous network
(GSV and tributaries) are painted in green.
Fig. 27 Primary PFP insufficiency. 3D reconstruction from CTV through virtual rendering technique.
1 = higher femoral canal PVs, 2 = lower femoral canal PV connected to the GVS, 3 = Hunterian
PV, 4 = competent GSV, 5 = popliteal vein, 6 = calf varix fed by the PFP (white arrows
show popliteal origin), 7 = medial GV.
Accompanying arteries of leg PVs ([Fig. 25])
Accompanying arteries of leg PVs ([Fig. 25])
Fig. 25 Posterior tibial artery branches. Anatomical dissection of a right leg (medial view).
Ankle is on the left of the picture while upper leg is on its right. In this case,
arterial red latex injection was performed prior to the dissection. Many tiny arteries
are shown, branching from the posterior tibial artery. (The red and blue plastic tubes
are used to enhance the tributaries connections).
This interesting, previously unpublished, anatomical study by C. Gillot enable us
to learn the risk of potential harm during insufficient PVs treatment. At the transfascial
segment of their course, PVs run closer to their accompanying artery and nerve. Facing
the risk of arterial injection, ultrasound-guidance is a must.
Popliteal fossa perforating vein (PFP)
Popliteal fossa perforating vein (PFP)
With a prevalence of about 4 % in chronic venous disease patients [19], the popliteal fossa perforating vein (PFP formerly named Thierry’s [18] vein) is identified as an insufficient large tortuous vessel, running along the
posterior surface of the knee and upper leg, and feeding a regional varicose cluster
without connections to the saphenous trunks. The odds ratio for a PFV after SPJ disconnections
is 5.7 as reported by Delis [19].
The PFV usually ends in the lateral surface of the popliteal vein 2 cm above the saphenopopliteal
junction ([Fig. 26], [28], [29], [30], although its draining point can be either higher or lower (1–2 cm below the popliteal
crease).
Fig. 26 Skin map of politeal fossa perforator.
Fig. 28 Skin maps of popliteal fossa perforators. Interrupted line: SSV. Left high connection
to the popliteal vein (> 3 cm above the sapheno-popliteal junction) Right low connection
to popliteal vein.
Fig. 29 Primary insufficiency of PFP. Skin map and virtual dissection from CTV. 1–2 = higher
femoral PVs, 3 = lower PV connected to the GVS, 4 = GSV trunk 5 = calf varix fed by
the PFP (white arrows indicates the connection between PFV and popliteal vein), 6 = competent
SSV.
Fig. 30 Differential diagnosis of insufficient PFP: Skin map and virtual dissection from
CTV. Yellow arrows show the reflux path. This clinical case illustrates a differential
diagnosis that must be considered. Rather than an insufficient PFV, this is an upper
calf varix (1) fed by SPJ (3) reflux. 2 = competent SSV trunk 3 = SPJ on the lateral
surface of the popliteal vein, 1 cm above the femoral condyle 4 = thigh extension
of the SSV 5 = deep communicating vein draining upwards into DFV 6 = popliteal vein
a–b = competent high hunterian PVs. Please note the femoral vein permanent occlusion
(broken line following a thrombosis), starting at level of the adductor’s hiatus (white
arrow). Due to the obstruction, a SPJ ligation would probably lead to popliteal fossa
recurrence.
Mainly 3 conditions must be differentiated from the PFV [19]:
-
a dystrophic insufficient upper SSV
-
popliteal component of sciatic nerve varices (also called sciatic-peroneal varices)
-
a long SPJ stump after SPJ surgical ligation.
Thigh perforating veins
They could be classified into 5 groups[1]: ([Fig. 31])
Fig. 31 THIGH PVs (Source: Gillot C. Atlas of the superficial venous network of the lower
limbs. Editions Phlébologiques Françaises; 1980). Femoral PVs (black circles): 10 = Hunterian
PV, 11 = lower femoral canal PV, 12 = higher femoral canal PV. Other thigh PVs (white
circles): Vm = PV of the vastus medialis muscle, S = PV of the apex of Scarpa’s triangle,
Am = PV of the adductor magnus muscle, G = LNVN. Scheme on the bottom left represents
the deep connection of the femoral PVs: FV = femoral vein, Cc = Collateral canal of
the FV, S = PV of the apex of Scarpa’s triangle Sm = PV of the semimembranosus muscle.
-
Femoral PVs: the main PVs of the thigh including Hunter’s PV and 2 PVs of the femoral
canal (higher and lower – formerly Dodd PVs)
-
muscular PVs (Sartorius, vastus medialis, vastus lateralis, biceps, semimembranosus)
-
PV of the apex of the Scarpa’s triangle
-
Lymphnode venous networks (LNVN) PVs
-
posterior thigh muscular PVs:
Case reports of thigh PVs shown by 3d reconstruction from CTV ([Fig. 32], [33], [34]).
Fig. 32 Thigh PVs. Virtual dissection by CTV (VRT). Left thigh, medial view and axial slice.
1 = femoral canal PV feeding the varix, 2–3 = femoral canal PVs perforating the vastus
medialis muscle and connected with its muscular veins, a = femoral vein, b = popliteal
vein, A = femoral artery, S = soleus muscle. The slice on the right also shows the
course of the main PV (1) behind the Sartorius. Postoperative CTV: the GSV is not
visible (removed by stripping).
Fig. 33 Thigh PVs. Virtual dissection by CTV (VRT). Left thigh, posterior view. Notice that
both femoral canal PVs and Hunter’s PV are direct PVs connected to the GSV trunk.
The calf varix is fed by a non saphenous lateral network of the knee. 1 = femoral
canal PV; 2 = Hunter’s PV; 3 = GSV trunk: a = femoral vein; b = popliteal vein.
Fig. 34 Thigh PVs. 3D reconstructions from CTV and axial images. Lower thigh PVs (p1, p3)
and their origins from the GSV trunk (d) are shown, c = anterior accessory GSV, a = femoral
vein, b = popliteal vein, f = deep femoral vein.
Abbreviations used
AAGSV:
anterior accessory of GSV
AT:
anterior tibial vein
CDU:
color duplex ultrasound
CFV:
common femoral vein
CT:
computed tomography
CTV:
CT venography
CVD:
Chronic venous disorder
DUS:
Duplex ultrasound
DV:
Deep femoral vein[
**]
EIV:
external iliac vein
FV:
femoral vein
GSV:
great saphenous vein
GV:
gastrocnemius veins
IPA:
interperforator anastomosis
LNVN:
lymph node venous networks
Po:
popliteal vein
PT:
posterior tibial vein
PV:
perforating vein
SFJ:
saphenous femoral junction
SM:
semimembranosus muscle
SPJ:
sapheno-popliteal junction
SSV:
small saphenous vein
TE[
*]
:
thigh extension (of the SSV)
VRT:
Volume rendering technique
