Veins

calf vessels best seen w posterolateral approach

peroneal

A: PTV
B: Peroneal vein
C: ATV

vein that receives blood from DFV & GSV

CFV

spontaneous flow vs nonspontaneous flow

spontaneous: actively moves w/out external maneuvers

• normal vein

nonspontaneous: flow only moves w maneuvers (valsalva)

LE veins w normal nonspontaneous flow

GSV & calf veins

*may need distal augment to see

start & end of GSV

@dorsum, ant to medial malleolus TO FV (3cm below inguinal ligament)

how breathing affects LE venous return

inspiration:

• low intrathoracic P

• increases P gradient

• INCREASE VEIN FLOW TO HEART

expiration:

• high intrathoracic P

• decreases P gradient

• DECREASE VEIN FLOW TO HEART

total blood volume vein vs artery

vein: 70%

artery: 30%

veins w/out valves

IVC, SVC

brachiocephalic

PV

CIV

only vascular structure post to IVC

RRA

vein along posteromedial fibula

pero v

normal venous blood flow goes…

superficial-to-perforator-to-deep

SSV location

from lat dorsal venous arch of foot

ascends post to lat malleolus & along midline of post leg

runs w sural nerve

SSV empties at…

saphenpopliteal junction (SPJ) into pop vein

vein w greatest threat to PE

CFV

*large, closer to heart, in LE

• UE PE less common bc no soleal sinuses

venous return from deep vs superficial

deep: 90%

superficial: 10%

• only drains skin & subcutaneous tissue

• role in thermoregulation

venous return against gravity depends on muscle pumps in the…

foot & calf

prothrombin time (PT)

how long it takes for blood to clot

normal: 10-13s

international normalized ratio (INR)

*asses risk of bleeding or coagulation status

• blood’s clotting ability

normal: <1

UE veins w pulsatile flow & spontaneous flow

brachiocephalic

IJV

subclavian

*axillary may or may not

normal CFV

*phasic & lil pulsatile

# of valves below knee

GSV: 10-12

SSV: 6-12

ATV, PTV, PERO: 9-12 each

# of valves in perforators

# of valves in soleal

1

0

# of valves above knee

POP V & SFV: 1-3 each

CFV: 1

% of EIV w valves

25%

# of IJV valves

1

peroneal veins

posterior tibial veins

anterior tibial veins

peroneal: empty lateral leg into tibioperoneal trunk

posterior tibial: empty post leg into tibioperoneal trunk

• btwn medial malleolus & achilles

anterior tibial: empty ant leg & joins tibioperoneal trunk to form pop v

• btwn tib/fib

• from dorsalis pedis v

LEV visual

deep veins & superficial veins

deep veins:

• muscles surround

• push blood back to heart (90%)

superficial:

• no muscles around; above fascia

• feed into deep veins

• slower flow bs NO muscles to squeeze/pump

perforator veins

superficial-to-deep

w valves

• cockett

• boyd

• hunterian

• dodd

   

perforator that connects GSV to PTV

boyd perforator

*common site for primary vv

perforator to connect GSV to SFV

hunterian

sinuses

brain

• space btwn dura mater & periosteum

• receive venous return

LEV (soleal)

• dilation superior to valve cusp in calf

• accumulates venous blood & drains into PTV/PERO

• helps valve close

SSV & Giacomini V

SSV:

• back of leg into PopV

• <3mm

Giacomini:

• continuation of SSV into thigh

• drains into GSV

gatier area

posterior arch veins connect w 3 ankle perforators

mc for stasis ulcers

gastroc veins & soleal veins

*superficial*

gastroc empties into PopV

soleal empties into PTV/PERO

UE veins

IJV+subclavian…brachiocephalic (innominate)

RT innominate +LT innominate…SVC

……

cephalic joins axillary

basilic+brachial…axillary

PV facts

MPV<13mm

hepatopetal

intrasegmental (w/in liver)

low V (20-40cm/s)

respiratory phasicity

portal HTN can lead to…

ascites, splenomegaly, GI bleeding, jaundice

cirrhosis (w intrahepatic obstruction) mc

UEV diagram

IVC & AO diagram

what determines cross sectional shape of vessel?

transmural P

• difference btwn intraluminal P (inside) & interstitial P (outside)

is venous P high or low?

low

15-20mmHg in venules

0-6mmHg in RA

transmural P in supine

LOW transmural P

• dumbbell shape

• low volume

venous resistance & vein shape

veins have higher resistance bc not completely full

• partially empty: dumbbell shape (more resistance)

intraluminal pressures when…

standing: 80mmHg

walking: 25mmHg

lying: 10mmHg

breathing affects on venous flow

inspiration…decreases thoracic P & increases abdominal P

• less flow from LE

expiration…increases thoracic P & decreases abdominal P

• less flow from UE

calf veno pump

*gastrocnemius & soleus muscles

w muscle contraction…venous valves open & perforator valves close

w muscle relaxation…venous valves close & perforator valves open

**to reduce P

primary vs secondary venous insufficiency

valves dont work & blood flows back down in muscle relaxation

primary venous insufficiency:

• congenital absence of valves

secondary venous insufficiency:

• valve damage bc DVT

valsalva maneuver & LE flow

LE flow will cease w competent valves; NO retrograde flow

if damaged valves…retrograde flow

*never do w severe CAD or acute MI

venous stasis/insufficiency S&S and RF

S&S:

• recurrent calf & ankle swelling

• ankle ulcers

• varicose veins

RF:

• vessel trauma, post op

• MI, CHF, hypotension

• stasis

venous stasis/insufficiency

incompetent valves allow back flow deep-to-superficial

high P in veins causes damage

allows blood pooling [stasis]

w discolored skin & ulcers @ medial malleolus

lymphedema

“ant farm” on US

obstruction of lymph vessels

may mimic DVT

edema

sign of high peripheral venous P

bc obstruction & unable to reabsorb fluid bc high capillary P

virchows triad

DVT development based on…

• vessel trauma

• venous stasis

• hypercoagulability

paget-schroetter syndrome

‘stress/effort thrombosis’

thrombosis of subclavian/axillary w intense, repetitive activity

mc place for thrombosis to form

valve cusps

soleal sinuses

what does positive D-dimer indicate?

DVT

DVT pain is usually located…

in posterior or medial calf

**2-3wks of pain or in anterior leg…not DVT

mc cause of UE DVT

PICC line

acute vs chronic DVT

acute:

• <4wks

• loose thrombus-vein wall attachment

• hypoechoic; free floating tail

• distended lumen; spongy/non-compressible

chronic:

• firm wall attachment

• echogenic; no tail; calcs

• small lumen; incompressible

• w collaterals

recanilization

w chronic DVT

body naturally tries to restore flow

w heparin & vitamin K inhibitors

often produces incompetent valves

primary vs secondary vv

primary vv:

• hereditary

• bc high venous P…not obstruction

secondary vv:

• bc DVT

varicose veins

tortuous & dilated; >4mm

bc venous insufficiency…then damaged, leaky valves

flow is reversed w standing

pressure ulcers are located on…

bony prominence

causes of venous & arterial ulcers

venous: blood pools; cant pump out

arterial: inadequate blood suppled in

mechanisms of ulcers

tissue breakdown bc lack of O2 & nutrients

incompetent perforators that carry blood GSV-to-deep system

**near medial malleolus (where 3 perforators meet)

neuropathic skin ulcers

‘diabetic’

little to no sensation in feet bc DM nerve damage

venous ulcers

medial/lateral malleolus

mild pain

shallow, irregular shape

venous ooze

stasis changes (brawny discoloration, vv)

arterial ulcers

tibial, toes, bony prominences

severe pain

deep, regular shape

little ooze

trophic changes (shiny skin, hair loss, thick toenails)

phlegmasia alba dolens

arterial spasms bc acute iliofemoral DVT

severe LE swelling

• pale

• absent pulses

pregnancy

phlegmasia cerulea dolens

severely reduced venous & arterial flow

• cyanotic

• extreme pain

massive iliofemoral DVT bc obstruction

may thurner syndrome

L iliac v compressed by R iliac a

higher risk of DVT in LT LE

-<20yo females

-L leg pain & edema

-oral contraceptives, pregnancy

superior venous thrombophlebitis

“trousseau syndrome”

in UE bc IV/cath

in LE above knee…high DVT risk

vv, pain, warm & red skin

treat w NSAIDS & warm compress or heparin

photoplethysmography PPG

measures capillary blood volume

evaluates venous insufficiency (reflux)

*infrared light

*not w acute DVT

PPG technique

place sensor on medial malleolus (seated patient w feet dangling)…

pt dorsiflexions (move blood to heart)…

record VRT

normal VRT: >20s

if VRT >20s w/out cuff…

normal venous filling

if VRT <20s w/out cuff & then >20s w cuff below knee…

SSV reflux

if VRT <20s w/out cuff & >20s w cuff above knee…

GSV reflux

if VRT <20s w & w/out cuff…

deep & superficial reflux

if VRT <20s w cuff on thigh…

deep reflux

retrograde flow times for reflux

perforator: >0.35s

superficial: >0.5s

deep: >1-1.5s

*>1.5s means superficial & deep reflux

minimum artery & vein diameter to create AV fistula or AV graft

artery: 2mm

vein: 2.5mm

which UE vein is mc taken for CABG?

non-dominate radial v

gold standard for venous exams

contrast venography

• NOT used often now

varicose veins

dilated, tortuous, >0.4mm

mc in calf bc incompetent GSV or SSV

RF:

• age, female, pregnant

anticoagulants

help prevent clot formation

• by reducing vitamin K in clotting process

mc is coumadin

acute anticoagulation»heparin

chronic anticoagulation»warfin

another name for internal iliac v

hypogastric v

PICC line locations

mc subclavian

• lowest clot risk

IJV

FV

• highest clot risk

• highest arterial injury

most common & least common DVT locations for PE

most common: prox iliofemoral v

least common: calf v

superficial thrombophlebitis

bc IV vessel wall injury

mc w varicose veins & IV therapy

pain, redness, swelling, fever

PE S&S

tachycardia

low PCO2

chest pain

dyspnea

IVC filters

reduce risk of PE

placed below renal v to trap large clots

• thru neck or groin

patients not on anticoagulants

extrinsic compression of iliac vein results in…

continuous CFV flow w no DVT

AVF

common after catheter insertion

high V w/in neck

bruit

vv ablation

vein is heated to seal the vein off

vv stripping & ligation

incision in groin area w thin wire inserted into vein

vein is stripped & ligated (tied off) at both ends

hydrostatic P when standing

(below heart) + hydrostatic P

• measured P will be higher than true circulatory P

(above heart) - hydrostatic P

• measured P will be lower than true circulatory P