Chapter 1

ANATOMY OF THE VENOUS SYSTEM

The blood supply of the skin of the lower limb derives from
perforating vessels. The arteries pass through the investing fascia to
intercommunicate in the subcutaneous tissues and the venous blood is
collected into a network which drains back alongside the arteries into the deep
veins. The venous system, however, differs from the arterial in possessing a
series of longitudinally disposed channels under the skin-the saphenous
system. Valved for centripetal flow, it too empties deeply. Dilatation and
tortuosity of saphenous tributaries presents as varicose veins, and
incompetence of certain of their perforating communications accounts for
venous ulcer. The first condition is one of the most common of human
ailments to present for treatment, the second one of the most difficult to cure.
A sound knowledge of the anatomy is necessary for the management of both.

The most notable feature was the rich diversity, no two limbs
exhibiting the same superficial venous arrangement. Nonetheless, certain
features occurred with sufficient frequency to constitute a pattern. The
appearances are best considered under separate headings. The surgical
anatomy of the superficial and perforating veins of the lower limb

LONG SAPHENOUS VEIN (LSV)

A normal LSV was present in whole or in part lay from ankle to groin on the
deep fascia. It was found, in the thigh particularly, to be enclosed in a loose
compartment of fat and areolar tissue by a thin, glistening sheet of
transversely disposed fibrous tissue arching over it from the deep fascia on
either side (Fig. I). In 2 cases it pierced the deep fascia in the middle of the
thigh to lie in an intrafascial plane for several centimetres before emerging
again on the surface. In 9 cases, however, only the lower and upper parts of
the LSV lay on the deep fascia. In the upper part of the leg and lower half or
so of the thigh it lay superficially, separated from the fascia by subcutaneous
fat, and in 5 of these legs the superficial part was replaced by two or three
intercommunicating channels. In 3 further specimens a corresponding
segment of the LSV was narrow and underdeveloped (although lying in the
correct position on the deep fascia), the main stream being carried by a
parallel, superficially-lying trunk communicating with it above and below.
 Diagram of LSV tributaries. A = LSV; B = infragenicular vein; C =
intersaphenous vein; D = posterior arch complex; E = anterior crural vein.

True duplication of the LSV, its splitting into two channels both lying
on the deep fascia and later rejoining, was uncommon. It occurred in only 4
cases (8%), was confined to the thigh, and involved only a short segment. So
frequent as to be almost the rule, however, was the occurrence of a parallel,
superficially-lying, thin-walled vein communicating with the LSV above and
below through channels of similar calibre and lying either directly over it or
more posteriorly. It will be described later.

The course of the anterior accessory great saphenous

vein (dotted line) is parallel and more anterior to the great saphenous
vein (black line). B, The course of the posterior accessory
great saphenous vein (dotted line) is parallel and more posterior
with respect to the great saphenous vein (black line). C, The cranial
 extension of the small saphenous vein (black line) ends in the
inferior gluteal vein (IGV) and can be connected to a sciatic
perforator (ScP) or to the great saphenous vein via the posterior
thigh circumflex vein (CV). One or more intersaphenous veins
(IV) connect the small and great saphenous veins at the calf. D,
The anterior thigh circumflex vein (dashed line) ascends obliquely
in the anterior thigh to reach the anterior accessory great saphenous
vein (AA) or the great saphenous vein. E: The posterior thigh
circumflex vein (dashed lines) originates from the lateral venous
plexus (1), or from the cranial extension of the small saphenous
vein (2) or directly from the small saphenous vein (3). It courses

obliquely in the posterior thigh toward the great saphenous vein.

SHORT SAPHENOUS VEIN (SSV)

The SSV was present in all 20 dissections and in each case ran
normally on and then within the deep fascia from the lateral malleolus to that
ensheaths the LSV (arrowed) and holds it against the deep fascia. The more
superficial position of its tributaries is clearly seen.

the popliteal fossa. In I9 legs it entered the fossa, but in one its main
flow was directed to the LSV while its continuation, much attenuated, sank
into the gastrocnemius. It often received substantial tributaries from the
medial aspect of the ankle, thereby communicating with the medial ankle
perforators.

Diagram of perforating veins associated with short saphenous system.

A = SSV; B = intersaphenous vein (with calf perforator); C = paraperoneal
perforators

SAPHENOUS TRIBUTARIES

The thigh tributaries were not dissected unless they arose from below
the knee; furthermore, no attempt was made to display the three classic
terminal tributaries. The saphenous tributaries in the leg were found to fall
into four main groups:

I) Posterior arch complexes The medial ankle perforating veins usually

communicated with the LSV by means of a vessel which passed up the leg in
a plane posterior and superficial to it. In only 17 legs (3470), however, did it
join the LSV directly (sometimes at the knee, at others several centimeters
above or below it). In another 2I legs (42 7o) it joined the venous arcade
referred to earlier, a vessel which arched in a superficial plane from one part
of the LSV to another, sometimes in the leg only, at others across the knee
joint into the thigh. In a further I o legs the medial ankle perforating veins
drained either directly from the LSV or from a tributary of the SSV or from
both, and in 2 final legs there were no ankle perforators of sufficient size to
trace. In these I2 cases the posterior arch complex could be aid to have no
substantial communication with the medial ankle perforators.

2) Anterior crural veins ascended diagonally across the shin towards

the LSV in every leg. Some of them, particularly from the upper part, joined
directly (occasionally not until the upper thigh), while the majority crossed
superficial to the LSV to join the posterior arch complex.

3) Infragenicular vein A vein draining the skin around the knee and
circling medially below it to join the LSV was a common finding.

4) Intersaphenous vein In every case communications passed upwards

and medially from the SSV across the gastrocnemius to join either the
posterior arch complex or the LSV directly.

Finally it is worth recording that the LSV and its tributaries often
received vessels from the tibial periosteum, from the knee joint, and from the
sartorius.
 Diagram of perforating veins springing from long saphenous system.
A = Hunterian perforator; B = post-tibial perforator; C = calf perforator; D =
medial ankle perforators.

PERFORATING VEINS

Vessels connecting the superficial veins with the deep through

apertures in the investing fascia were found in every limb examined. The
average number between ankle and groin in the 2 limbs in which they were
counted was 64. They were scattered over the limb but showed a predilection
for intermuscular septa, occurring particularly on either side of the sartorius,
between the vastus lateralis and the hamstrings, on either side of the peroneal
group, and along the anterior border of the soleus. They were almost
invariably accompanied by an artery. Inasmuch as a rich anastomosis exists
among the superficial veins there is no strict qualitative or functional
difference between their perforating branches. Nonetheless, two fairly distinct
types exist. The first consists of the small number of relatively wide vessels
which arise from the saphenous system. The second is composed of the
numerous, scattered, slender communications between the subcutaneous

The surgical anatomy of the superficial and perforating veins of the

lower limb

i) The 'Hunterian' perforator A vessel left the LSV in the thigh and
passed deeply behind the posterior border of the sartorius to join the femoral
veins or their muscular tributaries in 24 limbs (48%). Usually a long slender
vein (although a substantial vessel was found on occasion), it frequently
received muscular twigs from the sartorius.

2) The post-tibial perforator In almost every limb examined (46 limbs;

92 To) a substantial vessel arose a hand's breadth or so below the knee from
the LSV (30 limbs) or from either its posterior arch complex or anterior crural
tributary. It passed through the tibial attachment of the soleus, joining the
posterior tibial veins deep in the calf. Characteristically, it passed downwards
at first from the parent trunk before piercing the fascia at the tibial border.
One or two similar vessels were sometimes found a few centimetres below it.

3) Calf perforators Substantial perforators stemmed from the SSV or

the inter-saphenous vein to sink into the gastrocnemius in most of the 20
limbs in which the short saphenous system was examined. 4) Paraperoneal
perforators In every limb four or five (and sometimes many more) veins
perforated the deep fascia in a line from knee to ankle both in front of and
behind the peroneals (Fig. 4). They were mainly slender and thin-walled, but
occasionally a more substantial postperoneal perforator communicated with
the SSV either directly through a moderate- sized vessel near the ankle or
through a slender lateral tributary.

5) Medial ankle perforators There is an elongated triangle on the

medial aspect of the lower half of the leg. It is bounded by the subcutaneous
border of the ibia, the anterior border of the soleus and elongated space
between the subcutaneous tibial border and soleus, showing the medial ankle
perforators in their short and unsupported course from the posterior arch
complex to the posterior tibial venae comitantes. elow by the flexor
retinaculum (Fig. 5). Piercing its fascial roof in every case were veins which
communicated directly with the posterior tibial venae comitantes. Their size,
number, and origin varied. In the 8 detailed dissections as many as five were
found, but this number is somewhat misleading. In each of the 6o legs in the
series only one (usually about a hand's breadth above the ankle) or two were
of substantial size. They almost invariably stemmed from the posterior arch
complex, but in 3 cases one arose from the LSV itself and in a few others they
arose from a tributary of the SSV. Their length depended on their position in
the triangle. Inferiorly they were shortest, about I cm long, the posterior tibial
vessels lying immediately beneath the fascial roof. Towards the apex, midway
up the leg, they travelled 3-4 cm inwards between the soleus and flexor
digitorum longus to reach their destination. Valves in the perforating veins
Competent valves were readily demonstrated in each of the normal-looking
perforators studiect and segments of vein submitted for histological
examination showed the slender valve cusps clearly.
Diagram of the 'venous triangle', the elongated space between the subcutaneous tibial
border and soleus, showing the medial ankle perforators in their short and unsupported
course from the posterior arch complex to the posterior tibial venae comitantes.

Thomson H. The surgical anatomy of the superficial and perforating veins of

the lower limb. Annals of the Royal College of Surgeons of England. 1979
May;61(3):198.

DEEP VEINS

The nomenclature of the deep veins proposed in 2002 (Table I) was

not criticized. The main terminology recommendations, such as the
designation of the deep veins of the thigh as common femoral, femoral, and
deep femoral, have been accepted and commended in important journals of
several medical, surgical, and radiologic specialties. 4,5

The names of a few deep veins have been changed from those in the
TA, and the list has been extended by adding the names of a few anatomically
and clinically relevant veins (Table II).

The common femoral vein (vena femoralis communis) runs from the
confluence of the femoral vein and the deep femoral vein to the external iliac
vein at the inguinal ligament. The femoral vein originates from the popliteal
vein at the upper margin of the popliteal fossa and courses in the femoral
canal. The unauthorized term “superficial femoral vein” should not be used
for this vein because it is a deep vein2 and is not in the official TA.1

The profunda femoris vein (vena profunda femoris, alternative term

deep femoral vein) originates from the confluence of veins draining the
muscles of the posterior and lateral thigh, the deep femoral communicating
veins. The term deep vein of thigh listed in TA must be abandoned because it
is nonspecific and misleading.
 The deep femoral communicating veins (venae comitantes arteriae
perforantium; formerly the perforating veins), are the venae comitantes
(accompanying veins) of the perforating arteries that originate from the deep
femoral artery. The term “perforating” veins should not be applied to these
veins because it is reserved for veins connecting superficial and deep veins.9

The sciatic vein (vena ischiadica) is the main trunk of the primordial
deep venous system (the axial vein of embryo). It courses close to the sciatic
nerve and may assume an important role as a collateral pathway for the
femoral vein.21

The term “sural veins” is not sufficient to appropriatelydesignate the

complex venous system of the calf. Thisshould be designated a s soleal veins
(venae solealis), the veins of the soleus muscle22 and gastrocnemiu s
veins(venae gastrocnemii).23 The latter are divided in medial gastrocnemius
vein (vena medialis gastrocnemii), lateral gastrocnemius vein (vena
lateralis gastrocnemii), and intergemellar vein (Vena intergemellaris), the
vein ascending between the two heads of the gastrocnemius, just below the
SSV.24 (Fig 4, D).

The term genicular venous plexus (plexus venosus genicularis)

should replace the term genicular veins. At the knee, deep veins do not
correspond exactly to the branches of the popliteal artery (articular arteries).
They are arranged in a complex plexus of interconnecting veins.25

The deep veins of the foot are the medial plantar veins, lateral plantar
veins, deep plantar venous arch, deep metatarsal veins (plantar and dorsal),
deep digital veins (plantar and dorsal), and the pedal vein.

PERFORATING VEINS

The perforating veins (PV; or “perforators”) are numerous and very

variable in arrangement, connection, size, and distribution.26 In clinical
practice, perforating veins have been associated frequently with names of
authorities, often incorrectly from a historical point of view, and some times
misleading. Instead, descriptive terms designating location are preferred.
Perforators are grouped on the basis of their topography, as in Table III and in
Fig 5. The perforators of the foot (venae perforantes pedis) are divided into
dorsal foot perforators, with their equivalent term intercapitular veins,
medial foot perforators, lateral foot perforators, and plantar foot
perforators, according to their location.27

The ankle perforators (venae perforantis tarsalis) are designated in

medial ankle perforators, anterior ankle perforators, and lateral ankle
perforators, according tp their topography.27

The perforators of the leg (venae perforantes cruris) are divided

infour main groups. The perforators of the medial leg are designated as
paratibial and posterior tibial.

Paratibial perforators connect the main trunk or tributaries of the

GSV with the posterior tibial veins and course close to the medial surface of
the tibia. These correspond to the so-called Sherman PV (at the lower and mid
leg) and Boyd PV (at the upper leg).

Posterior tibial perforators (Cockett perforators)28connect the

posterior accessory great saphenous vein with the posterior tibial veins. These
correspond to the so-called Cockett PV. They should not be named first,
second, and third. As recommended by Frank Cockett,29 they can be
indicated topographically as upper, middle, and lower.

The anterior leg perforators pierce the anterior tibial ompartment

and connect the anterior tributaries of the GSV to the anterior tibial veins. The
lateral leg perforators connect veins of the lateral venous plexus with the
fibular veins.

The perforators of the posterior leg are divided into medial

gastrocnemius perforators (in the medial calf), lateral gastrocnemius
perforators (in thelateral calf), intergemellar perforators (connecting the
SSV with the calf veins, also called “mid-calf perforator of May”), para-
Achillean perforators (connecting the SSV with the fibular veins; also called
“perforator of Bassi”).

The perforators of the knee (venae perforantes genus) are designated

as medial knee perforators, suprapatellar perforators, lateral knee
perforators, infrapatellar perforators, popliteal fossa perforators,
according to their location.

The perforators of the thigh (venae perforantes femoris) are grouped

on the basis of their topography. On the medial thigh are the perforators of
the femoral canal (Dodd) and the inguinal perforators, which connect the
GSV (or its tributaries) with the femoral veinat the groin The anterior thigh
perforators pierce the quadriceps femoris. The lateral thigh perforators
pierce the lateral muscles of the thigh. On the posterior thigh, Perforators are
designated as posteromedial thigh perforators (those piercing the adductor
muscles), sciatic perforators (lying along the midline of the posterior thigh),
posterolateral thigh perforators (those piercing the biceps femoris and
semitendinosus muscles, also called “perforator of Hach”),and pudendal
perforators.

The perforators of the gluteal muscles (venae perforantes glutealis)

are divided in superior, mid, and lower perforators.29

SUPERFICIAL VEINS

The names of a few superficial veins have been changed from

those in the official Terminologia Anatomica, the list of which has been
extended by adding the names of a few anatomically and clinically
relevant veins (Table I). The term great saphenous vein (vena saphena
magna), abbreviated as GSV should be used instead of terms such as long
saphenous vein (LSV), greater saphenous vein, and internal saphenous
vein. The omission of long saphenous vein is recommended so as to
remove confusion caused by the abbreviation LSV, which could represent
either the long saphenous vein or the lesser saphenous vein.3 Similarly,
the term small saphenous vein (vena saphena parva) abbreviated as SSV,
should be used instead of the terms short, external, or lesser saphenous
vein. The term confluence of superficial inguinal veins (confluens venosus
subinguinalis) corresponds to the veins of the saphenofemoral junction
(SFJ). This is termed Crosse by many clinicians. It also corresponds to the
Venenstern unter dem Leistenband of German anatomists.10 The term
anterior accessory great saphenous vein (vena saphena magna accessoria
anterior) indicates any venous segment ascending parallel to the GSV and
located anteriorly, both in the leg and in the thigh.11(Fig 3, A). The term
posterior accessory great saphenous vein (vena saphena magna accessoria
posterior) indicates any venous segment ascending parallel to the GSV
and located posteriorly, both in the leg and in the thigh.12 (Fig 3, B). The
leg segment corresponds to the so-called Leonardo’s vein or Posterior arch
vein.

The term superficial accessory great saphenous vein (vena

saphena magna accessoria superficialis) indicates any venous segment
ascending parallel to the GSV and located more superficially above the
saphenous fascia, both in the leg and in the thigh.13(Figs 4, A and B). The
cranial extension of the small saphenous vein (extensio cranialis venae
saphenae parvae) courses in the groove between the biceps femoris and
semimembranosus muscles (Fig 3, C). This vein has been called
“femoropopliteal vein.”14 A cranial extension of the SSV that
communicates with the GSV via the posterior thigh circumflex vein is
often termed the vein of Giacomini. The superficial accessory small
saphenous vein (vena saphena parva accessoria superficialis) ascends
parallel to the SSV and is located more superficially, above the saphenous
fascia15 (Fig 4, C).

The anterior thigh circumflex vein (vena circumflexa femoris

anterior) is a tributary vein of the GSV (or of the anterior accessory great
saphenous vein) ascending obliquely in the anterior thigh.16 It may
originate from the lateral venous system (Fig 3, D).

The posterior thigh circumflex vein (vena circumflexa femoris

posterior) is a tributary vein of the GSV (or of the posterior accessory
great saphenous vein), which ascends obliquely in the posterior thigh.
This vein may originate in the SSV, in its cranial extension, or in the
lateral venous system.17(Fig 3, E). One or more intersaphenous vein(s)
(vena(e) intersaphena( e)) course obliquely at the calf to connect the SSV
with the GSV18 (Fig 3, C). The lateral venous system (systema venosa
lateralis membri inferioris) is extended on the lateral thigh and eg.19 It
represents the remnant of the embryonic vena marginalis lateralis.

In TA, all the veins of the foot were listed as superficial veins.
They should be identified according to their topographic location. It is
important to note that the dorsal Fig 1. The saphenous compartment
(SaphC) is bound superficially by the saphenous fascia (SF) and deeply
by the muscular fascia(MF) and contains the saphenous veins (SV)
accompanied by the saphenous nerve (SN). The accessory saphenous
veins (ASV) lie external to this compartment, close to the dermis (D). SC,
Superficial compartment; DC, deep compartment.

In the consensus document of 2002,3 main innovations regarding the

nomenclature of the superficial veins regarded (1) the subdivision of the
superficial veins according to their relationships to the saphenous fascia (Fig
1); (2) the designation of the saphenous veins as great and small* and, (3) the
designation of nonsaphenous veins regarding their topography and path. The
criticisms and suggestions the committee received were used to refine and
extend the list of the superficial veins (Table II). In particular:
 A, Axial computed tomography scan of the thigh. The greater saphenous vein (*) and the
saphenous accessories (arrows) course in different planes, separated by the saphenous fascia
(arrowheads). B, Axial section from a cadaveric limb showing the close relationships of the great
saphenous vein (*) with the saphenous fascia (arrowheads) and the underlying muscular fascia (MF).
SL, Saphenous ligament

Schematic representation of the topography of the main groups of perforating veins (PVs). Foot PVs: 1.1,
dorsal foot PV; 1.2, medial foot PV; 1.3, lateral foot PV. Ankle PVs: 2.1, medial ankle PV; 2.2, anterior ankle PV; 2.3,
lateral ankle PV. Leg PVs: 3.1.1, paratibial PV; 3.1.2, posterior tibial PV; 3.2, anterior leg PV; 3.3, lateral leg PV; 3.4.1,
medial gastrocnemius PV; 3.4.2, lateral gastrocnemius PV; 3.4.3, intergemellar PV; 3.4.4, para-achillean PV. Knee PVs:
4.1, medial knee PV; 4.2, suprapatellar PV; 4.3, lateral knee PV; 4.4, infrapatellar PV; 4.5, popliteal fossa PV. Thigh PVs:
5.1.1, PV of the femoral canal; 5.1.2, inguinal PV; 5.2, anterior thigh PV; 5.3, lateral thigh PV; 5.4.1, posteromedial
thigh PV; 5.4.2, sciatic PV; 5.4.3, posterolateral thigh PV; 5.5, pudendal PV. Gluteal PVs: 6.1, superior gluteal PV; 6.2,midgluteal PV; 6.3, lower
gluteal PV.

Sapheno-femoral junction, sapheno-popliteal junction.

The terms sapheno-femoral junction (SFJ) and saphenopopliteal

junction (SPJ) and their valves (Fig 2) have been included in the official
 nomenclature because they are anatomically correct, clinically appropriate,
and not misleading. However, there is no agreement in the literature with
regard to the anatomic extent of the SFJ and SPJ, because a clear anatomic
definition is lacking. From the strict anatomic sense of the word junction, SFJ
and SPJ would correspond only to the saphenous openings with the terminal
valve† contained in them. The role of these valves is to prevent reflux from
the femoral or popliteal veins, and they can also be located a few millimeters
distal to the opening (subterminal location of the terminal valve).8 However,
since the terms SFJ and SPJ have been introduced, 9 they have been
considered to be more extended than indicated by the anatomic concept of
“junction” (Fig 1). From classic9-11 and more recent papers on the anatomy,
physiology, and pathophysiology of these junctions,12-15 it can be
determined that both the SFJ and the SPJ extend distally along the saphenous
trunks to the penultimate preterminal valve.‡ This valve is located 3 to 5 cm
below the terminal valve—distal to the termination of the saphenous
junctional tributaries—to prevent reflux from these veins into the saphenous
trunk when the terminal valve is closed.12,13 The proximal level of the SFJ
and SPJ corresponds to the valve located proximal to the saphenous opening
(suprasafenic valve), because it has a pivotal role in junctional
hemodynamics.16 The distal limit of the SFJ and SPJ has never been
established, but it was proposed that it corresponds to the valve placed distal
to the saphenous opening (infrasaphenic valve),17 whose possible
hemodynamic role is still to be defined.

Schematic representation of the hemodynamic role of the sapheno-femoral junction (SFJ) valves (modified
from Pieri et al, 1995). B, The first exhaustive representation of the SFJ with its valves. Modified from the De Venarum
Ostiolis, of Jeronimus Fabricius Ab Acquapendente, Venice, 1603. TV, Terminal valve; PTV, preterminal valve; SSV, suprasaphenic valve; ISV,
infrasaphenic valve.

Caggiati A, Bergan JJ, Gloviczki P, Jantet G, Wendell-Smith CP, Partsch H,

International Interdisciplinary Consensus Committee on Venous Anatomical
Terminology. Nomenclature of the veins of the lower limbs: an international
interdisciplinary consensus statement. Journal of vascular surgery. 2002 Aug
.1;36(2):416-22

Caggiati A, Bergan JJ, Gloviczki P, Eklof B, Allegra C, Partsch H. Nomenclature of

the veins of the lower limb: extensions, refinements, and clinical application. Journal
.of vascular surgery. 2005 Apr 1;41(4):719-24