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Perforator Veins of the Leg (13)

Communicating (perforator) Veins
Communicating veins (perforators) play an important role in the complex and
varied hemodynamic states found in the leg. As the check-valves between the
high-pressure deep and the low-pressure superficial systems, perforators
activated by the muscle pump mechanism help maintain even and efficient
evacuation of blood from the leg. Contraction of muscle bundles surrounding
the deep fascial veins and perforators massages blood inward and upward,
creating a pressure gradient that pulls blood from the superficial tributaries
through the perforators into the deep system. Maintenance of this normal flow
pattern is dependent on fragile valve leaflets present in each of the three
anatomical components of the venous system in the leg. These leaflets, or
cusps, are easily damaged, particularly by venous thrombosis. Approximately
30% of patients with varicose veins have incompetent perforators.
1
They are
also implicated in exacerbating chronic venous disease and contributing to
venous ulcerations.
2
In addition to valvular insufficiency secondary to venous
thrombosis, clinical manifestations of chronic venous insufficiency may also
appear with congenitally absent or malformed valves.
In the lower extremity, there are numerous connections between the
superficial and deep venous systems. These communicating veins
frequently referred to in clinical practice as perforating veins perforate the
muscular aponeuroses throughout the leg linking the two systems anatomically
and hemodynamically. This linkage is a critical component of normal venous
outflow from the leg.
Perforators are found everywhere in the leg. Autopsy studies have revealed
that each leg can contain as many as 80 140 communicating veins. They are
disbursed topographically at the level of the ankle, calf, knee, thigh, and groin.
Each vein contains at least 2 valves, that makes for a lot of perforator valves in
the leg that can go bad and upset the normal venous hemodynamic relationships
in the leg.
Flow direction in normal
communicating veins in the leg.
Sonographic correlation.
Normal perforator flow.
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Perforator Veins of the Leg (14)
Communicating veins have several configurations.
Type I
Single, direct connection between a deep and a superficial vein.
Type II
Several branches connecting two superficial veins to a single
deep vein.
Type III
Two deep vein branches connecting to a single superficial vein.
Type IV
Ascending within the muscular compartments of the leg.
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Perforator Veins of the Leg (15)
General Topographical Anatomy
There are several anatomical approaches to
studying perforator veins in the leg. The
topographical approach marks locations of
communicating veins based on external leg
landmarks using the popliteal space as a north-south
boundary. Specific groups of veins found above and
below the popliteal space are listed in Tables V and
VI.
Alternatively, communicating veins can be
grouped into functional categories; those participating
in hemodynamic equilibrium along the great
saphenous and those along the short saphenous
veins. Some anatomists make a distinction between
communicating veins and perforator veins. They
would categorize those veins that connect superficial
vein to superficial vein as communicating veins and
those that connect superficial to deep as perforator
veins. The anatomical approach or taxonomic
language a vascular ultrasound laboratory takes is
less important than sharing that approach with the
vascular surgeons and interventionalists who will be using the information to plan
treatment for their patients.
Table V. Communicating veins Above the Popliteal Space
Connects
External
Landmarks
Name Superficial Deep
Upper 1/3 third
of thigh
Proximal
terminal
Terminal portion of the
long saphenous
Femoral vein
Perineum Perineal
Long saphenous trunk
and its posterior
branches via a
Giacomini vein
Uterine and ovarian
veins of the hypogastric
network
Middle 1/3 of
thigh
Distal terminal
Long saphenous
network
Femoral vein
Lower 1/3 of
thigh,
adductor canal
Dodd's
Long saphenous
network
Femoral vein
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Perforator Veins of the Leg (16)
Typically, the diameter of a normal, competent communicating vein is <2mm,
therefore, many of them are not routinely recognized during routine duplex
imaging of the leg. They have to be searched for. With the highly sensitive
Doppler imaging methods now in use, even normal perforators can frequently be
found and evaluated. As one would expect, based on knowledge of myriad
anatomical configurations, these veins have an equally varied sonographic
appearance.
Several observations on the size, appearance, and expected flow direction
within perforator veins (PV) can help the vascular sonographer sort things out.
Perforators less than 3 mm in diameter regardless of flow direction on
color Doppler Imaging (CDI) are probably normal.
3
Vein diameter >3.9 mm = 95% chance of valvular incompetence.
PV incompetence is most often associated with reflux in the superficial
veins.
4
Incompetent PVs have outward flow alone (77%).
5 6
When ultrasound system levels and examination protocols are optimized
to evaluate perforator veins, the accuracy of triplex imaging is equal to that
of contrast venography without the potential risks. Low-threshold, low
velocity flow detection should be maximized for CDI of perforator veins.
Flow direction can be more easily be determined and documented using
CDI, however, the operator must be well versed in CDI interpretation.
7
Table VI. Communicating veins Below the Popliteal Space
Connects
External
Landmarks
Name Superficial Deep
Medial
subcondylar
region
Boyd's
Saphenous network of the
subcondylar region
Popliteal or tibioperoneal
trunks
Heads of
gastrocnemius
muscles
Medial
gastrocnemius
Saphenous network
around knee
Gastrocnemius veins
Medial
supramalleolar
region
Cockett's
Posterior saphenous
branches
Posterior tibial veins
Lateral lower
calf
Peroneal
Anterior saphenous
branches
Peroneal veins
Retromalleolar
and submalleolar
regions
Saphenous and marginal
branches
Plantar veins
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Perforator Veins of the Leg (17)
Clinical Anatomy
The ones of most frequent locations of
clinical manifestations of perforator vein
incompetence, especially in the setting of
concomitant superficial venous insufficiency,
is an area along the medial, distal calf.
Coursing beneath the superficial fascia are a
series of veins, usually six in number, that
join the posterior tibial vein to the greater
saphenous system. These stubby
communicating veins are known as
Cocketts perforators and are found along
the medial-posterior aspect of the tibial crest.
They course through the deep fascia of the
calf connecting the deep tibial veins to the
great saphenous vein through a series of
interconnected posterior arch veins. There
are usually three sets of Cocketts perforating veins (labeled 1, 2, and 3 in the
schematic) and they lie between 10 15 cm above the lower margin of the
medial malleolus.
Insufficient Cockett perforators are usually easily demonstrable with duplex
ultrasound and frequently can be palpated with the fingertips as indentations, or
divits along the tibial crest. Commonly, in patients with stasis changes in the
ankle, the area most obviously affected lies directly above an incompetent
perforator vein. Using these clinical pearls can help the vascular sonographer
localize the level and number of incompetent perforator vein before beginning the
duplex examination.
2-D sonographic image of a
dilated, incompetent medial tibial
perforator vein.
PTV: post. Tibial v.
VV: varicose GSV tributary
CDI demonstration of perforator
incompetence. With compression
of the calf, blood refluxes out of the
PTV and into a perforator vein
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Perforator Veins of the Leg (18)
1
Wills V, Moylan D, Chambers J. The use of routine duplex scanning in the assessment of
varicose veins. Aust N Z J Surg. 1998 Jan; 68(1):41-4.
2
Labrpoulos N, Leon M, Geroulakos G. et al. Venous hemodynamic abnormalities in patients
with leg ulceration. Am J Surg. 1995 Jun; 169(6):572-4.
3
Phillps GW, Cheng LS. The value of ultrasound in the assessment of incompetent perforating
veins. Australas Radiol. 1996 Feb; 40(1):15-8.
4
Stuart WP, Lee AJ, Allan PL, et al. Most incompetent calf perforating veins are found in
association with superficial venous reflux. J Vasc Surg. 2001 Nov; 34(5):774-8.
5
Labropoulos N, Mansour MA, Kang SS, et al. New insights into perforator vein incompetence.
Eur J Vasc Endovasc Surg. 1999 Sep; 18(3):228-34.
6
Delis KT, Husmann M, Kalodiki E, et al. In situ hemodynamics of perforating veins in chronic
venous insufficiency. J Vasc Surg. 2001 Apr; 33(4):773-82.
7
Meyer T, Cavallaro A, Lang W. Duplex ultrasonography in the diagnosis of incompetent Cockett
veins. Eur J Ultrasound. 2000 Jun; 11(3):175-80.