The hemodynamics and diagnosis of venous disease

Development of the inferior vena cava and iliac veins (adopted from Avery LB. Developmental Anatomy, revised 7^th ed. Philadelphia: WB Saunders, 1974.)

Relationship between the fascia and veins of the lower extremity. The fascia covers the muscle and separates the deep from the superficial compartment. Superficial veins (a) drain the subpapillary and reticular venous plexuses and they are connected to deep veins through perforating veins (b). The saphenous fascia invests the saphenous vein. The saphenous compartment is a subcompartment of the superficial compartment. From Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc Endovasc Surg 2004;38:367-374.¹²¹

Superficial and perforating veins of the leg. From Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc Endovasc Surg 2004;38:367-74.¹²¹

Deep veins of the leg. From Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc Endovasc Surg 2004;38:367-74.¹²¹

Relationship of the posterior tibial perforators to the deep and superficial posterior compartments (SPC) of the calf (PTVs, posterior tibial veins). From Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc and Endovasc Surg 2004;38:367-74.¹²¹

Pressure/volume relationships in the distensible venous lumen are reflected in this diagram. Considerable volume is introduced before pressure rises; pressures begin to rise as the vein becomes elliptical and increase further as a circular configuration is reached. Katz AI, Chen Y, Moreno AH. Flow through a collapsible tube; Experimental analysis and mathematical model. Biophysical J 1969;9:1261-79.¹⁴

Relative venous hydrostatic (HP) and dynamic (DP) pressures at various heights (Ht) and distances from the right atrium (RA) in the upright individual. Dynamic pressure derive from the activity of the cardiac pump while hydrostatic pressures are related to position and gravity. The figure has been standing motionless with the dependent veins filling by gravity. Upper extremity pressures vary with the position of the arm.

The pressure and volume changes with activation of the calf muscle pump are demonstrated. Beginning in the standing posture, the hydrostatic pressure baseline is demonstrated in a dependent, but non-weight bearing limb. The subject then performs 10 tip-toe (heel-raising) maneuvers and resumes the non-weight bearing posture. A, This schematic compares the pressure and volume changes along a concomitant timeline. Note the efficiency of the calf pump in rapidly reducing either volume or pressure upon commencement of muscle activity. Although volume filling begins within 5 to 7 seconds, pressure does not rise substantially for 30 to 40 seconds. Alterations in these relationships can generate chronic, sustained venous pressure elevations, the end products of which are the symptoms and findings of chronic venous insufficiency. B, Pressure changes during these maneuvers are illustrated in this recording from cannulation of a dorsal foot vein reported in mm Hg. C, Volume changes during these maneuvers are illustrated in this air plethysmographic examination. The volume remaining in the limb after exercise divided by the venous volume standing still is reported as the residual volume fraction (RVF, %).

A, Zones of reference for upper extremity venous scanning: midline = 1.0, acromion = 3.0, elbow = 5.0, wrist = 8.0, fingertips = 9.0. B, Zones of reference for lower extremity venous scanning: femoral vessels at the inguinal ligament = 1.0, midpatella to popliteal crease = 5.0, midmedial malleolus to midlateral malleolus = 8.0, tips of the toes = 9.0.