Niels BÆkgaard
•
FABRIZIO Fanelli
•
Gerard J. O’Sullivan
NEW HORIZONS IN
DEEP VENOUS DISEASE MANAGEMENT
EDIZIONI MINERVA MEDICA
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ISBN: 978-88-7711-893-6
© 2017 – EDIZIONI MINERVA MEDICA S.p.A. – Corso Bramante 83/85 – 10126 Turin (Italy)
www.minervamedica.it / e-mail: [email protected]
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means.
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Preface
This book is intended for vascular specialists, who wish to learn more about deep venous disease. Our authors have
delivered chapters on anatomy, physiology, pathology, state of the art diagnosis and multiple different treatment options, each written by an acknowledged expert in that field. We have targeted the current best in class for each aspect
of venous disease.
We hope the readers learn as much from this book as we did!
We are deeply grateful to all the sponsors for making this book possible – without their support we would not have
been able to publish it. Finally, we wish to thank the staff at Edizioni Minerva Medica for providing excellent assistance.
The Editors
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AUTHORS
Carsten W.K.P. Arnoldussen
Department of Radiology, VieCuri Medical Centre, Venlo, The Netherlands; Maastricht University Medical Centre,
Maastricht, The Netherlands
Raazi Bajwa
Faculty of Radiology, Royal College of Surgeons, Ireland
Niels Bækgaard
Vascular Clinic, Gentofte Hospital and Rigshospitalet, Copenhagen, Denmark
Stephen A. Black
Department of Vascular Surgery, Guy’s and St Thomas’ Hospital, London SE1 7EH, UK TomasBreslin
Department of Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
Alessandro Cannavale
NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, Glasgow, United Kingdom
Anthony J. Comerota
Jobst Vascular Institute, The Toledo Hospital, Toledo, OH, USA; University of Michigan, MI, USA
Fabrizio Fanelli
Department of Radiological, Oncology and Anatomo-Pathology Sciences, “Sapienza” University
of Rome, Rome, Italy
Rick
de
Graaf
Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
Marianna Gazzetti
“Villa Stuart” Medical Center, Rome, Italy
Emma Groarke
Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
Houman Jalaie
European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH Aachen University
Hospital, Aachen, Germany
Julian Javier
Naples Cardiac and Endovascular Center, Naples, FL, USA
Barry Kevane
School of Medicine, University College Dublin (UCD), Dublin; UCD Conway SPHERE Research Group, UCD,
Dublin, Ireland
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VI
NEW HORIZONS IN DEEP VENOUS DISEASE MANAGEMENT
Lotte Klitfod
Department of Vascular Surgery, Rigshospitalet and Gentofte University Hospital, Copenhagen, Denmark
Hong Kuan Kok
Department of Interventional Radiology, Beaumont Hospital, Dublin; Royal College of Surgeons, Ireland
Michael J. Lee
Department of Interventional Radiology, Beaumont Hospital, Dublin; Royal College of Surgeons, Ireland
Michael Lichtenberg
Vascular Centre Arnsberg, Arnsberg, Germany
DanielLyons
Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
Sara Azhari Mohamed
Galway University Hospitals, Galway, Ireland
Peter Neglén River Oaks Hospital, Jackson, MS, USA
Fionnuala Ní Áinle
School of Medicine, University College Dublin (UCD), Dublin; UCD Conway SPHERE Research Group, UCD,
Dublin; Department of Haematology, Rotunda Hospital, Dublin; Department of Haematology, Mater Misericordiae
University Hospital, Dublin, Ireland
Jørn Dalsgaard Nielsen Centre of Excellence for Anticoagulant Therapy; Department of Cardiology, Bispebjerg-Frederiksberg Hospital,
Frederiksberg, Denmark
Gerard J. O’Sullivan
Department of Interventional Radiology, Galway University Hospitals and National University of Ireland, Galway,
Ireland
Leandro Perez
Naples Cardiac and Endovascular Center, Naples, FL, USA
Rodrigo Ruiz-Gamboa
Jobst Vascular Institute, Toledo, OH, USA
Elizabeth Ryan
Department of Interventional Radiology, Beaumont Hospital, Dublin; Royal College of Surgeons, Ireland
Mariangela Santoni
Department of Radiological, Oncology and Anatomo-Pathology Sciences, “Sapienza” University of Rome, Rome, Italy
Cees H.A. Wittens
Department of Vascular Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular
Research Institute Maastricht, Maastricht, The Netherlands; Department of Vascular Surgery, University Hospital Aachen,
Aachen, Germany
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CONTENTS
PREFACE ................................................................................................................................................................  III
AUTHORS ..............................................................................................................................................................  V
I
Introduction
1
ANATOMY .....................................................................................................................................  2
M. Gazzetti, M. Santoni, A. Cannavale 
2
IMAGING 
Ultrasonography: an updated review .................................................................................  8
J. Javier, L. Perez 
Computed tomography venography ...............................................................................  15
G.J. O’Sullivan, S.A. Mohamed
Magnetic resonance venography .......................................................................................  22
C.W.K.P. Arnoldussen
Case report ...............................................................................................................................  29
Intravascular ultrasound ...........................................................................................................  32
S.A. Black, P. Neglén
D-dimer as biomarker for venous thromboembolism ..................................................  36
J.D. Nielsen
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VIII
NEW HORIZONS IN DEEP VENOUS DISEASE MANAGEMENT
II
3
Clinical assessment
Deep venous thrombosis 
Acute deep venous thrombosis ............................................................................................  42
R. Bajwa, G.J. O’Sullivan 
Causes of venous thrombosis.The European perspective ........................................  50
L. Klitfod 
Causes of venous thrombosis.The North American perspective ...........................  54
A.J. Comerota 
Clinical presentation of DVT in pregnancy .....................................................................  57
A.J. Comerota 
Clinical severity scores and quality of life assessment tool ......................................  59
M. Lichtenberg 
4
Clinical presentation of deep vein thrombosis 
Classification of deep venous thrombosis .......................................................................  65
N. Bækgaard 
Risk factors .....................................................................................................................................  68
L. Klitfod 
DVT predictors .............................................................................................................................  73
J. Javier, L. Perez 
Diagnostic strategies for DVT management ....................................................................  79
C.W.K.P. Arnoldussen 
III
5
Therapeutic options
Management of deep venous thrombosis 
Prevention ......................................................................................................................................  86
N. Bækgaard, J.D. Nielsen 
Medical therapy .........................................................................................................................  95
E. Groarke, B. Kevane, F. Ní Áinle 
Case report .............................................................................................................................  106
Minimally invasive therapy ..................................................................................................  109
G.J. O’Sullivan 
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CONTENTS
IX
Medical therapy in pregnancy ..........................................................................................  118
B. Kevane, D. Lyons, F. Ní Áinle 
Case report .............................................................................................................................  125
Catheter-based management of DVT in pregnancy .................................................  127
A.J. Comerota, R. Ruiz-Gamboa 
Inferior vena cava filters ........................................................................................................  131
H.K. Kok, E. Ryan, M.J. Lee 
Challenging cases ...................................................................................................................  140
J. Javier, L. Perez 
6
Management and treatment of occluded large veins 
Medical therapy .......................................................................................................................  150
N. Bækgaard 
Open surgery .............................................................................................................................  155
H. Jalaie, C.H.A. Wittens 
Endovascular management .................................................................................................  160
R. de Graaf 
Surgery in deep venous incompetence ..........................................................................  172
H. Jalaie, C.H.A. Wittens 
What to do with occluded iliac venous stents? ..........................................................  176
S.A. Black 
IV
7
Setting up a dedicated venous service
Vein clinic 
Inpatient management ...........................................................................................................  182
S. Black 
Outpatient endovascular centers: an alternative to hospitalization ...................  185
J. Javier, L. Perez 
Establishing a multidisciplinary venous thromboembolism service .....................  190
F. Ní Áinle, T. Breslin 
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Introduction
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I
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Ultrasonography: an
ANATOMY
updated review
M. Gazzetti, M. Santoni, A. Cannavale
Although perceived in the past as less important,
nowadays the venous anatomy of the lower extremities is
considered substantially more variable and complicated
than the corresponding arterial anatomy. Also there is
an increasing interest in the lower limbs venous anatomy
due to the advancement in diagnostic and treatment options of the related pathology.
Pathology of the vein system is commonly caused by
an interaction of anatomical and hemodynamic changes.
For this reason a true understanding of the highly variable venous anatomy is essential to identify the underlying pathophysiology as well as in planning treatment.1-8
Microscopic anatomy
of the veins and physiology
I
The microscopic structure of the vein is based on a
three-layered organization, as well as arterious vessels,
even if each layer is thinner in proportion to the size
of the lumen. Nevertheless the connective tissue in the
outer layer, mainly composed of elastic and muscular elements, provide strength and endurance.
The venous wall is divided in three layer: the intima,
media and adventitia. The inner layer is defined tunica
intima and consists of the endothelium, which rest on
the basement membrane, and a thin amount of connective tissue. The first one is actively antithrombogenic,
producing prostaglandin, glycosaminoglycan cofactors
of antithrombin, thrombomodulin, and tissue-type plasminogen activator (t-PA) in order to prevent improper
coagulation. Nevertheless, endothelial perturbation may
lead to the induction of procoagulant and suppression of
anticoagulant activity.
The connective tissue in the intima layer lacks a proper functional internal elastic membrane or if present it
is a really delicate one: in this case the fibres run mainly
longitudinally.
The intermediate layer, tunica media, consists of three
smooth muscle layers interspersed with collagen and
elastic fibres. The tunica media of the veins is relatively
thin, when compared with that of the arteries; the only
exception of the veins of the lower extremities; the difference is mainly related to the different pressure in the
lower vessels than in the upper extremities.
The tunica adventitia, the outer coat, is the thickest
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2
1
one of the vein wall. It contains more collagen, elastic
fibres and smooth muscle cells, brought togheter into
small bundles that run chiefly longitudinally, providing
the vessels with stiffness.
There may also be robust vasa vasorum penetrating
throughout the venous wall, up to the intima.
In some body regions, in particular the lower limbs, the
veins over 2 mm in size, are provided with bicuspid valves
that prevent the blood in flowing back usually arranged
in pairs opposite to another. Valves are most numerous
in the distal leg and decrease toward the hip: they divide
the hydrostatic column of blood into small segments,
and play an important role in maintaining flow direction
(from superficial to deep and from caudal to cephalad).
The bicuspid valves in the lower extremity remain
open during rest in the supine position, and their closure
is a passive event initiated by reversal of the resting antegrade transvalvular pressure gradient. As the pressure
gradient is reversed, there is a short period of retrograde
flow (<0.5 seconds in the upright position) that ensure
the blood to reach a sufficient velocity to close the cusps
completely. For this reason reflux lasting less than 0.5
seconds is a normal and expected finding, on the other
hand retrograde flow persisting for more than 0.5 seconds is usually defined as pathologic reflux.
Venous drainage
of the lower limb
The veins of the lower extremity are classified according to their relationship to the muscular fascia, that divides a superficial, from a deep compartment. The deep
veins lie beneath the muscular fascia and drain the lower extremity muscles. The superficial veins, which are
above the deep fascia, drain the cutaneous microcirculation. Then there are perforating veins (providing connections between the deep and superficial vessels) and
the communicating veins connecting veins within the
same system (i.e. deep to deep, superficial to superficial).
The superficial veins
of the lower extremity
The superficial venous system includes the reticular
veins, the great and small saphenous veins and their trib-
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1. ANATOMY
Figure 1.2
Figure 1.1
External iliac artery (1), external Iliac vein (2), great saphenous vein
(3), superficial circumflex iliac vein (4), superficial epigastric vein
(5), accessory saphenous vein (6), inguinal ligament (7).
Superficial venous system of the lower extremities: great saphenous
vein (1) and small saphenous vein (2).
utaries (Figure 1.1). The great saphenous vein, the longest vein in the body, arises from the medial portion of
the dorsal pedal arch and ends in the common femoral
vein about 3 cm after perforating the deep fascia, distal to the inguinal ligament. The anatomic site of the
sapheno-femoral junction is 3-4 cm inferior and lateral
to the pubic tubercle. It ascends anterior to the medial
malleolus and pass along the medial side of the leg in
relation with the saphenous nerve (which lies anterior to
the great saphenous vein in the calf and may be injured
by procedures extended into the calf). Then the great
saphenous vein crosses the tibia at the junction of the
distal and middle third of the calf to pass posteromedial
to the knee, runs upward behind the medial condyles
of the tibia and femur and along the medial side of the
thigh and, passing through the fossa ovalis, ends in the
femoral vein (Figure 1.2). The great saphenous vein, in
the most comon situation, lies directly on the muscular
fascia in the saphenous compartment, which is that part
of the superficial compartment located between the hyperechoic saphenous fascia superficially and by the muscular fascia, deeply.
The saphenous vein and associated arteries and nerves
lie within the saphenous compartment, and the reticular
veins, accessory veins, and tributary veins are external
to the compartment. The importance of this anatomical
detail is due to the possibility to visualize it using ultrasound: it has been described as having the appearance of
an “egyptian eye” (Figure 1.3).
Some rare anatomic variants have been described in
literature, the most important is the great saphenous
vein duplication, identified by the presence of two dif-
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3
Figure 1.3
The three compartments of the venous system of the lower limb: the
skin (4), the saphenous fascia (5), the muscular fascia (6). The deep
venous system (3) is located in the deep layer, beneath the muscular
fascia. Tributaries (1) of the great saphenous vein (2) are found
under the skin. The great saphenous vein is recognized by ultrasound
between the the muscular fascia and the saphenous fascia forming
the “Egyptian eye”.
I
ferent veins, both lying on the muscular fascia and the
saphenous fascia, has been described in 8% of the cases
in the thigh and in 25% of cases in the calf.
Other cause of anatomical variation is the level where
the great saphenous vein may perforate the saphenous
fascia: this may be at the level of the middle or distal
thigh. This particular behaviour is supposed to be im-
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4
NEW HORIZONS IN DEEP VENOUS DISEASE MANAGEMENT
Table 1-I – Tributaries of the great saphenous vein.
Level
I
Tributaries
Calf
Anterior branch vein
Posterior arch (Leonardo’s) vein
Intersaphenous vein
Thigh
Anterior accessory saphenous vein
Posterior accessory saphenous vein
Sapheno-femoral
junction
Superficial external pudendal vein
Superficial circumflex iliac vein
Superficial epigastric vein
portant because some theories postulate that the lack of
connective tissue support in these areas may cause varicose veins, explaining why they occur more frequently
above the level of the superficial fascia.
There are many triburaries of the great saphenous
vein, that at different levels join the main trunk: they
have been summarized in the Table 1-I. In the calf are
commonly observed an anterior branch and a posterior
arch (Leonardo’s) veins. The latter drains a network of
medial ankle veins and is particularly important due to
its connections, via perforating branch, with the posterior tibial vein. At the same level, intersaphenous veins
have also been observed, crossing obliquely the calf between the great and small saphenous veins’ compartments. In the thigh it communicates with the femoral
vein and receives numerous tributaries; those from the
medial and posterior parts of the thigh frequently unite
to form a large accessory saphenous vein which joins the
main vein at a variable level. Near the fossa ovalis, at the
saphenous femoral junction it is joined by the superficial epigastric, superficial iliac circumflex, and superficial external pudendal veins providing drenaige to the
pelvis and lower abdominal wall. The valves in the great
saphenous vein have been reported ranging from ten to
twenty in number, the majority located in the calf.
The main trunk of the great saphenous vein has at
least six valves: some observation highlight that varicose
great saphenous veins have slightly fewer valves (mean
6.0) than normal veins (7.3), even if the value of this
data has never been confirmed.
A valve is commonly present at the sapheno-femoral
junction in 94% to 100% of individuals. Moreover 81%
of the observed people have at least one valve in the external iliac–common femoral segment above the junction.
The small saphenous vein begins behind the lateral
malleolus as a continuation of the lateral marginal vein,
providing dreinage to the dorsal pedal. It ascends along
the lateral compartment and subsequently reach the
middle of the back of the calf. The sural nerve ascends
immediately lateral to the vein. About 60% of small
saphenous veins join the popliteal vein within 8 cm of
the knee joint; further 20% of the small saphenous veins
join the great saphenous vein via anterior or posterior
FANELLI IMPAGINATO.indd 4
tributaries, and 20% join the femoral, profunda femoris,
or internal iliac veins.
In the thigh, the main connection with the great
saphenous vein (via the posterior thigh circumflex vein) is
provided by the vein of Giacomini, which is a cranial extension of the small saphenous vein, that arises before the
small saphenous vein pierces the deep fascia in the popliteal fossa and is located in the posterior compartment.
The lateral arch vein is the major tributary of the
small saphenous vein and communicates with the peroneal vein through the lateral calf perforators. The small
saphenous vein may also communicate with the medial
ankle perforators through several tributaries. Running
directly upward, it perforates the deep fascia in the lower part of the popliteal fossa, and ends in the popliteal
vein, between the heads of the gastrocnemius muscle.
The small saphenous vein possesses from nine to twelve
valves, one of which is always found near its termination
in the popliteal vein.
The deep veins
of the lower extremity
The major veins of the deep system in the lower extremity follow the course of the associated arteries: the
only exception is the femoral vein. Nevertheless, there is
an high incidence of variability and the classic anatomy,
as reported in the atlas may be present in as few as 16%
of limbs (Figure 1.4).4 The deep venous system of the calf
includes the tibial and peroneal veins as well as the soleal
Figure 1.4
Deep venous system of the lower extremities:external iliac vein (1),
internal iliac vein (2), common femoral vein (3), femoral circumflex
vein (4), profunda femoris vein (5), femoral vein (6), popliteal vein
(7), anterior tibial vein (8), fibular vein (9), posterior tibial vein (10).
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1. ANATOMY
Medial
plantar veins
Digital veins
Metatarsal
veins
Dorsal veins
Figure 1.5
Plantar
venous arch
Posterior
tibial veins
Lateral
plantar veins
Lower limb venous drainage: the posterior tibial veins.
and gastrocnemial veins. The plantar digital veins (vv.
digitales plantares) arise from plexuses on the plantar surfaces of the digits, and, after sending intercapitular veins
to join the dorsal digital veins, unite to form four metatarsal veins; these run backward in the metatarsal spaces,
comunicate via perforating veins, with the veins on the
dorsum of the foot, and unite to form the deep plantar
venous arch which lies alongside the plantar arterial arch.
From the deep plantar venous arch the medial and
lateral plantar veins arise and run backward close to the
corresponding arteries and, after communicating with
the great and small saphenous veins, unite behind the
medial malleolus to form the posterior tibial veins (Figure 1.5).
The fibular veins run with the namesake arteries to
join the posterior tibial veins. Fibular veins drain the lateral compartment of the leg.
The anterior tibial veins (vv. tibiales anteriores) arise
as venae commitantes of dorsalis pedis and carries blood
from the anterior compartment of the leg to the popliteal vein. They leave the front of the leg by passing between the tibia and fibula, posteriorly and over the interosseous membrane, and unite with the posterior tibial,
to form the popliteal vein.
The popliteal vein is formed by the junction of the
anterior and posterior tibial veins at the lower border of
the popliteus; it goes through the popliteal fossa to the
adductor canal, where it forms the femoral vein. Nowadays the deep vein extending from the popliteal to the
common femoral vein is named femoral vein, instead of
superficial femoral vein: it has been changed in order to
avoid this vessel to be considered as part of the superficial venous system.
In the lower part of the popliteal fossa the popliteal
vein is located medial to the artery then, between the
heads of the gastrocnemius muscle, it is superficial; finally, above the knee-joint, it is close to its lateral side.
In the popliteal fossa, laterally to the artery and vein,
there is also the sciatic nerve, which at this level spleets
in the tibial nerve, located in the centre of the fossa (providing the medial sural cutaneous nerve) and the common fibular nerve located in the lateral compartment
(Figure 1.6).
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5
Figure 1.6
The popliteal fossa: artery, veins and nerves. Popliteal artery and
vein (1), supero-medial genicular artery and vein (2), inferior-medial
genicular artery and vein (3), supero-lateral genicular artery and vein
(4), infero-lateral genicular artery and vein (5), small saphenous
vein (6), sciatic nerve (7), tibial nerve (8), fibular nerve (9), sural
nerve (10).
The popliteal vein receives tributaries corresponding
to the branches of the popliteal artery, and it also receives the small saphenous vein (Figure 1.7). The valve
in the popliteal vein are usually reported to be four in
number.
The femoral vein accompanies the superficial femoral
artery through the upper two-thirds of the thigh. In the
lower part, it lies lateral to the artery while in the higher
part it is behind it. At the inguinal ligament, it lies on
its medial side, and on the same plane of the arterious
vessel.
Medial superior gemellary v.
Lateral superior gemellary v.
I
Popliteal
Medial inferior gemellary v.
Lateral inferior gemellary v.
Small saphenous vein
Figure 1.7
Tributaries of the popliteal vein.
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6
NEW HORIZONS IN DEEP VENOUS DISEASE MANAGEMENT
Figure 1.8
I
Inferior vena cava (1), common iliac vein (2), internal iliac vein (3),
external lliac vein (4), common femoral vein (5), inferior epigastric
vein (6), deep circumflex iliac vein (7), lateral sacral vein (8), middle
sacral vein (9).
It receives: numerous muscular tributaries, the profunda femoris vein (4 cm below the inguinal ligament)
and the great saphenous vein (near its termination). The
valves in the femoral vein are three in number. The femoral vein, after it passes under the inguinal ligament, is
named external iliac vein.
The profunda femoris vein receives tributaries corresponding to the perforating branches of the profunda
artery, and through these establishes communications
with the popliteal vein below and the inferior gluteal
vein above. It also receives the medial and lateral femoral circumflex veins. It is a large deep vein that drains
the blood from the inner compartment of the thigh,
running superiorly and medially the profunda femoris
artery up to the ischial tuberosity, where it joins the superficial femoral artery.
The femoral vein continues upward into the the external iliac vein behind the inguinal ligament, and enters
the lesser pelvis, ending opposite the sacroiliac articulation, by uniting with the hypogastric vein to form the
common iliac vein (Figure 1.8). On the right side, it lies
at first medial to the artery: but, as it passes upward,
gradually inclines behind it. On the left side, it lies altogether on the medial side of the artery. It frequently
contains one, sometimes two, valves.
The tributaries of the external iliac veins are: the inferior epigastric, deep iliac circumflex, and pubic veins.
The inferior epigastric vein is formed by the union of
the venae commitantes of the inferior epigastric artery,
which communicate above with the superior epigastric
FANELLI IMPAGINATO.indd 6
vein; it joins the external iliac about 1.25 cm above the
inguinal ligament.
The deep iliac circumflex vein is formed by the union
of the venae commitantes of the deep iliac circumflex
artery, and joins the external iliac vein about 2 cm above
the inguinal ligament.
The pubic vein communicates with the obturator
vein in the obturator foramen, and ascends on the back
of the pubis to the external iliac vein. The internal iliac
vein begins near the upper part of the greater sciatic
foramen, passes upward behind and slightly medial
to the hypogastric artery and, at the brim of the pelvis, joins with the external iliac to form the common
iliac vein. A single internal iliac trunk usually drains
into the external iliac vein to form the common iliac
vein. However, a duplicated internal iliac vein may be
present in up to 27% of extremities. The internal iliac
veins drain both parietal (superior and inferior gluteal,
sacral, sciatic, lumbar, obturator, and internal pudendal) and visceral (hemorrhoidal, vesicoprostatic, uterine, gonadal, and vesicovaginal plexuses) tributaries
that have extensive, valveless interconnections. These
collateral pathways may become important in cases of
iliocaval obstruction. It receives a) the gluteal, internal
pudendal, and obturator veins, which have their origins
outside the pelvis; b) the lateral sacral veins, which lie
in front of the sacrum; and c) the middle hemorrhoidal, vesical, uterine, and vaginal veins, which originate
in venous plexuses connected with the pelvic viscera.
The common iliac veins are composed of the external iliac and hypogastric veins, in front of the sacroiliac
joint: they unite on the right side of the fifth lumbar vertebrae to form the inferior vena cava. The right common
iliac vein ascends longwise, on the other hand the left
common iliac vein runs obliquely upward the right side,
forming an acute angle. The left common iliac vein is
usually longer than the right one: at first it is located on
the medial side of the corresponding artery, and then behind the right common iliac artery. This anatomic location represents the reason of the May-Turner syndrome,
where the left common iliac vein may be compressed by
the overstanding right common iliac artery. Each common iliac receives the iliolumbar, and sometimes the lateral sacral veins. The left receives, in addition, the middle sacral vein. No valves are found in these veins.
Inferior vena cava
The inferior vena cava (IVC) is formed by the confluence of the two common iliac veins at the L5 vertebral
level and has a retroperitoneal course, ascending along
the front of the vertebral column, on the right side of the
aorta. Once reached the liver, continues in a groove on
its posterior surface and then perforates the diaphragm
between the median and right portions of its central
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1. ANATOMY
tendon at T8 level; it subsequently inclines forward and
medialward for about 2.5 cm, and, piercing the fibrous
pericardium, passes behind the serous pericardium to
open into the lower and back part of the right atrium.
Schematically the IVC has four segments: the infrarenal IVC, renal, suprarenal and the hepatic. Anatomical variants of the IVC may be present in up to 4% of
the populations and they are the result of abnormal embryologic development involving the vitelline, posterior
cardinal, subcardinal, and supracardinal veins. They can
occur alone or in combination. Most common abnormalities are:
1.abscence of whole or segment of the IVC: prominent
venous collateralization may be a finding: patients
may develop lower limbs venous insufficiency or idiopathic deep vein thrombosis or have large lumbar
collateral vessels, that resemble paraspinal masses;
2.duplication of IVC (0.2‑0.3%): It consists in elongation of the left common iliac vein that forms the left
sided IVC that joins the left renal vein and drains into
a normal suprarenal IVC. This variation is asymtpomatic, but relevant in case of interventional/surgical
treatments and IVC filter insertion;
3.left-sided IVC (0.2‑0.5%): it is due to the regression
of the right supracardinal vein and persistence of the
left supracardinal vein. This IVC, similarly to the absence of IVC variant, drains in the suprarenal IVC;
4.anomalous continuation of the IVC: the IVC continuation of azygos and hemiazygos is often associated
with other variations such as the absence of segments
IVC, retroaortic left/right renal vein and double IVC.
In this variant, generally the azygos and hemiazygos
appear prominent due to the increased draining flow
and drain in the usual veins;
5.IVC webs: it is thought to be a congenital anomaly
or the result of sebsequent episodes of thrombosis
and it is far more common in the Eastern Countries. It appears as a fenestrated membrane in the
intrahepatic IVC or a segment of fibrotic occlusion
that may be of variable length, often associated with
prominent intrahepatic and extrahepatic collateral
vessels.
The perforating veins
Small anatomic series in cadavers have described a
huge number of perforating veins between the ankle and
the groin (up to 64).
Moreover the anatomy of perforating vessels is incredibly variable: for instance this vessels not only reach the
deep veins (as proper direct perforators do), but sometimes they empty into the venous sinus of the calf and
are consequently named indirect perforators.
FANELLI IMPAGINATO.indd 7
7
In order to make the situation clear, perforators have
been classified into four classes of different clinical significance: foot, medial and lateral calf, and thigh.
The foot perforators are characterized by a unique
property: they are the only ones that, in physiologic conditions, direct flow toward the superficial veins, while all
others normally direct flow to the deep system.
The major perforators of the medial calf and thigh
have one to three valves that direct flow from the superficial to the deep veins.
The perforators of the calf are clinically the most important: they are furtherly divided into four groups of
perforators: the paratibial perforators: connecting the
great saphenous and posterior tibial veins; the posterior tibial perforators: connecting the posterior accessory great saphenous (posterior arch) and posterior tibial
veins; the lateral and anterior leg perforators.1
Eponyms associated with the paratibial (Sherman and
Boyd perforators) and posterior tibial perforators (Cockett perforators) should no longer be used.
The direct perforators are localized into five groups
7‑9 cm, 10‑12 cm, 18‑22 cm, 23‑27 cm, and 28‑32 cm
proximal to the medial malleolus. The indirect perforators, in contrast, tend to be randomly distributed.
The perforators of the femoral canal connect the great
saphenous vein 15 cm proximal to the knee with the distal superficial femoral or proximal popliteal vein. This
perforator may give rise to medial thigh varicosities in the
presence of a competent proximal great saphenous vein.
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Phlebology 2010;25:113‑23.
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