lower limb

1. THE VEINS OF THE LOWER LIMB
Dr M Idris Siddiqui

2. THE VEINS OF THE LOWER LIMB
• The veins of the lower limb can
be divided into three groups:
1. Superficial
2. Deep
3. Perforating .

5. The superficial veins
The superficial veins consist of the
great and small saphenous veins and
their tributaries, which are situated
beneath the skin in the superficial
fascia.
– Having relatively thicker muscular
walls.
• The constant position of the great saphenous vein in front of the medial malleolus
should be remembered for patients requiring emergency blood transfusion.

6. The Superficial Veins
• The most important superficial veins are the great and
small saphenous veins, which originate from the medial
and lateral sides, respectively, from a dorsal venous
arch in the foot.
• The great saphenous vein passes up the medial side of
the leg, knee, and thigh to pass through saphenous
opening in deep fascia covering the femoral triangle
and join with the femoral vein.
• The small saphenous vein passes behind the distal end
of the fibula (lateral malleolus) and up the back of the
leg to penetrate deep fascia and join the popliteal vein
posterior to the knee.

8. The deep veins
The deep veins are
• The venae comitantes to the anterior and
posterior tibial arteries,
• The peroneal veins,
• The popliteal vein, and
• The femoral veins and their tributaries.
– Lie (deep to deep fascia) amongst & supported by
powerful muscles.
– Deep veins generally follow the arteries.
• The major deep vein draining the limb is the femoral vein. It
becomes the external iliac vein when it passes under the
inguinal ligament to enter the abdomen.

9. Deep veins of leg
• Perforating veins penetrate the deep fascia, forming
and continually supplying an anterior tibial vein in the
anterior leg.
• Medial and lateral plantar veins from the plantar aspect
of the foot form the posterior tibial and fibular veins.
• All three deep veins from the leg flow into the
popliteal vein posterior to the knee, which becomes the
femoral vein in the thigh.
• Veins accompanying the perforating arteries of the
deep artery of the thigh drain blood from the thigh
muscles and terminate in the deep vein of the thigh
(vena profunda femoris), which joins the terminal
portion of the femoral vein.

11. The perforating veins
• The perforating veins are communicating vessels
that run between the superficial and deep veins.
• Many of these veins are found particularly in the
region of the ankle and the medial side of the
lower part of the leg.
• They possess valves that are arranged to prevent
the flow of blood from the deep to the superficial
veins.
• It enables musculovenous pump to propel blood
toward the heart against the pull of gravity.

14. Flow of veous blood in lower limb
• The direction of flow of venous
blood is dictated by valves so that
blood flow is from superficial to
deep and from below upward.
•But in foot between superficial &
deep.

16. LOCATION OF PERFORATORS
• A) An adductor canal perforator:
• It attaches the great saphenous vein together with the femoral
vein in the lower part of the adductor canal.
• B) A knee perforator (Boyd’s perforator):
• It attaches the great saphenous vein together with the posterior
tibial vein just below the knee and close to the medial border
of tibia.
• C) A lateral ankle perforator:
• It interacts the short saphenous vein together with the peroneal
vein. It is situated in the junction of middle and lower third of the
leg.
• D) Three medial ankle perforators (of Cockett):
• All these are situated near the medial border of the lower third
of tibia between the medial malleolus and mid-calf and attach the
great saphenous vein together with the posterior tibial veins.

20. Femoral vein
The vein enters the lower angle of the femoral triangle,
where it lies posterior to the artery. It ascends through
the femoral triangle and comes to lie on the medial
side of the artery.
• It receives the profunda femoris vein posteriorly and
just below the femoral sheath the great saphenous vein
joins it anteriorly. Within the sheath it passes under
the inguinal ligament and run along the brim of the
pelvis as the external iliac vein.
• It has four or five valves, the most constant ones being
just above the junctions with the profunda and great
saphenous veins. Absence of these valves could
contribute to varicosity of the great saphenous vein.

21. Location of femoral vein
• In the living body the position of the
femoral vein below the inguinal ligament
is found by feeling the pulsations of the
femoral artery, which is immediately
lateral to the vein.
• In thin people the femoral vein may be
surprisingly near the surface even
though it is within the femoral sheath.

22. The popliteal vein
The popliteal vein lies, at all levels, between the
artery and the tibial nerve.
It is formed by the union of the venae comitantes of
the anterior and posterior tibial arteries; as it
acends through the aperture in the adductor
magnus it becomes the femoral vein.
It receives tributaries that accompany the branches of
the popliteal artery and the small saphenous vein.
The popliteal vein may take the form of venae
comitantes on either side of the artery.

23. The great (long) saphenous vein
The great (long) saphenous vein, the longest vein in the
body, begins as the upward continuation of the medial
marginal vein of the foot, drains the medial end of the
dorsal venous arch of the foot and passes upward
directly in front of the medial malleolus.
It ascends in company with the saphenous nerve in the
superficial fascia over the medial side of the leg. The
vein passes behind the knee and curves forward around
the medial side of the thigh.
It passes through the lower part of the saphenous
opening in the deep fascia and joins the femoral vein
about 1.5 in. (4 cm) below and lateral to the pubic
tubercle.
Cont.

24. The great (long) saphenous vein
• The great saphenous vein possesses
numerous valves and is connected to the
small saphenous vein by one or two
branches that pass behind the knee.
• Several perforating veins connect the
great saphenous vein with the deep
veins along the medial side of the calf.
Cont.

25. The great
(long)
saphenous
vein

26. The great (long) saphenous vein
• At the saphenous opening in the deep fascia,
the great saphenous vein usually receives
three tributaries variable in size and
arrangement :
1. The superficial circumflex iliac vein,
2. The superficial epigastric vein, and
3. The superficial external pudendal vein.
– These veins correspond with the three branches of the
femoral artery found in this region.

27. VALVES IN THE GREAT SAPHENOUS VEIN
• There are around 10 to 20 valves in the great
saphenous vein, outside of which the location of 2
are important:
• (a) one, which is located just before it pierces the
cribriform fascia
• (b) the other, which is located at its junction together
with the femoral vein (saphenofemoral valve).
• The saphenofemoral valve is of great functional
importance. It is located about 3.5 to 4 cm
inferolateral to the pubic tubercle.
• In about 80% people, the external iliac vein possesses a valve,
which shields the saphenofemoral valve against high venous
pressure.

28. SURFACE MARK OF THE GREAT SAPHENOUS VEIN
• At ankle, it is located 2.5 cm anterior to the medial
malleolus.
• In leg, it ascends by crossing the medial surface and
medial border of the tibia.
• At knee, it is located about a hand’s width posterior
to the medial margin of the patella.
• In thigh, it ascends obliquely on the medial aspect
of the thigh to reach a stage 3.5-4 cm inferolateral
to the pubic tubercle (saphenofemoral junction).

29. The small (short) saphenous vein
• The small (short) saphenous vein, draining the lateral side of the
dorsal venous arch and the lateral margin of the foot, lies with the
sural nerve behind the lateral malleolus.
• It passes upwards in the subcutaneous fat to the midline of the calf
and pierces the deep fascia anywhere from midcalf to the roof of
the popliteal fossa.
• It usually runs within and then beneath the deep fascia for some
distance before it enters the popliteal vein.
• It communicates by several perforators with the great saphenous
vein.
– The posterior femoral cutaneous nerve accompanies the upper
part of the vein, while going from deep to superficial.
– The small saphenous vein includes 7-13 valves.

30. The small (short) saphenous vein
• Tributaries:
– Numerous small veins from the back of the leg
– Communicating veins with the deep veins of the foot
– Important anastomotic branches that run upward and
medially and join the great saphenous vein.
• The mode of termination of the small saphenous
vein is subject to variation:
– It may join the popliteal vein;
– It may join the great saphenous vein; or
– It may split in two, one division joining the popliteal and
the other joining the great saphenous vein.

32. Venous Pump of the Lower Limb
• Within the closed fascial compartments of the lower limb,
the thin-walled, valved venae comitantes are subjected to
intermittent pressure at rest and during exercise.
• The pulsations of the adjacent arteries help move the blood
up the limb. However, the contractions of the large muscles
within the compartments during exercise compress these
deeply placed veins and force the blood up the limb.

33. Varicose Veins
• A varicosed vein is one that has a larger diameter
than normal and is elongated and tortuous.
• Varicosed veins have many causes:
–Hereditary weakness of the vein walls and
incompetent valves;
–Elevated intra-abdominal pressure as a result of
multiple pregnancies or abdominal tumors;
–Thrombophlebitis of the deep veins, which
results in the superficial veins becoming the main
venous pathway for the lower limb.

34. Varicose veins
There are typical points where incompetent valves occur
between the superficial and the deep veins. In these regions
the varicosities tend to become marked.
1. At the saphena varix-the saphenofemoral junction where
the femoral vein is joined by the great saphenous vein.
2. In the mid-thigh perforating vein between the great
saphenous vein and the femoral vein.
3. In the calf the three sites where perforators occur, 5, 10,
and 15 cm above the medial malleolus between the great
saphenous vein and the deep veins of the calf.
4. At the junction of the small saphenous vein and the
popliteal vein.
– A saphena varix, or a saphenous varix is a dilation of the saphenous vein at
its junction with the femoral vein in the groin.

35. Great Saphenous Vein Cutdown
• Exposure of the great saphenous vein through a
skin incision (a cutdown•) is usually performed at
the ankle . This site has the disadvantage that
phlebitis (inflammation of the vein wall) is a
potential complication.