Objectives. To present a detailed description of the gastrocnemius venous network.Design. Anatomical study in cadavers.Material and methods. Forty lower limbs from 20 adult male cadavers were studied. All gastrocnemius veins were dissected from the gastrocnemius muscle heads proximally toward their drainage site.Results. Eighty heads of 40 gastrocnemius muscles showed 438 gastrocnemius veins. the number of veins per muscle head varied between 2 and 12. There were 221 gastrocnemius trunks distributed as 95 main gastrocnemius trunks, 81 axial and 45 collateral ones. Front the 95 main gastrocnemius trunks, 83 (87%) drained into the popliteal vein. Direct observation of the gastrocnemius venous network allowed its to classify the anatomical distribution as four distinct types.Conclusions. the majority of main gastrocnemius venous trunks drain into the popliteal vein. There is wide variability in the number of gastrocnemius veins. We propose a classification of four distinct types of anatontical pattern.Universidade Federal de São Paulo, Dept Surg, BR-05409010 São Paulo, BrazilUniversidade Federal de São Paulo, Dept Surg, BR-05409010 São Paulo, BrazilWeb of Scienc

Aragão, José Aderval

Miranda Junior, Fausto

Pitta, Guilherme Benjamin Brandão

Poli de Figueiredo, Luiz Francisco

Reis, F. P.

European Journal of Vascular and Endovascular Surgery

Aragão, José Aderval [UNIFESP]

Pitta, Guilherme Benjamin Brandão [UNIFESP]

Miranda Junior, Fausto [UNIFESP]

Poli de Figueiredo, Luiz Francisco [UNIFESP]

Repositório Institucional UNIFESP

*Correspondof Surgery, FApt. 203, CEPE-mail address1078–5884/00Anatomical Study of the Gastrocnemius Venous Networkand Proposal for a Classification of the VeinsJ.A. Araga˜o,1 F.P. Reis,1 G.B.B. Pitta,2 F. Miranda Jr2 and L.F. Poli de Figueiredo2*Departments of 1Anatomy, Tiradentes University, Sergipe, and 2Surgery, Federal University of Sa˜o Paulo, Sa˜oPaulo, BrazilObjectives. To present a detailed description of the gastrocnemius venous network.Design. Anatomical study in cadavers.Material and methods. Forty lower limbs from 20 adult male cadavers were studied. All gastrocnemius veins weredissected from the gastrocnemius muscle heads proximally toward their drainage site.Results. Eighty heads of 40 gastrocnemius muscles showed 438 gastrocnemius veins. The number of veins per muscle headvaried between 2 and 12. There were 221 gastrocnemius trunks distributed as 95 main gastrocnemius trunks, 81 axial and45 collateral ones. From the 95 main gastrocnemius trunks, 83 (87%) drained into the popliteal vein. Direct observation ofthe gastrocnemius venous network allowed us to classify the anatomical distribution as four distinct types.Conclusions. The majority of main gastrocnemius venous trunks drain into the popliteal vein. There is wide variability inthe number of gastrocnemius veins. We propose a classification of four distinct types of anatomical pattern.Keywords: Calf veins; Deep venous thrombosis; Gastrocnemius veins; Gastrocnemius muscle; Venous anatomy.IntroductionGastrocnemius veins may be the starting point of someepisodes of deep vein thrombosis and incompetence ofthese veins may lead to chronic venous insufficiency.However, the anatomical arrangement of these veinshas been largely ignored by both classical anatomicaltextbooks and contemporary vascular literature.1–8 Acomplete description of the gastrocnemius venousnetwork is important to provide support for non-invasive investigations such as duplex scanning whereit is desirable to have knowledge of the normalpatterns of these vessels. No anatomical or radiologi-cal study has been published which describes in detailthe distribution, number and drainage of the gastro-cnemius veins. Our objective was to characterise theanatomical distribution of the gastrocnemius veins.We hope to provide a better understanding of thepathophysiology of deep venous thrombosis and anuseful guide for clinicians performing duplex ultra-sound examination as well as surgeons operating oning author. Luiz F. Poli de Figueiredo, MD, Departmentederal University of Sa˜o Paulo, Rua Oscar Freire, 154605409-010 Sa˜o Paulo, SP, Brazil.: lpoli@uol.com.br0439+ 04 $35.00/0 q 2005 Elsevier Ltd. All rights reserpatients with recurrent varicose veins or chronicvenous insufficiency.9–13Material and MethodsOur study was approved by the Ethics Committee ofthe Federal University of Sa˜o Paulo. It was performedin 40 lower limbs from 20 adult male cadavers, with anestimated age between 40 and 60 years old, fixed andmaintained in 10% formaldehyde solution. Thesecadavers showed no macroscopic evidence of diseaseof the lower extremity such as fractures, ulcers,ischaemic lesions, oedema or varicose veins.Circumferential lines were drawn 10 cm above thepatella and 10 cm below the tibial tuberosity. Then aposterior longitudinal line was drawn in the midlinebetween the circumferential lines. Incisions weremadeover those lines and the skin flaps were made laterallyand medially. Dissection was performed in layers,preserving the small saphenous vein. The poplitealfossa was carefully dissected, identifying the neuraland vascular elements, the ischiatic nerve and itsdivision into tibial and peroneal nerves. Ischiaticnerve branches were dissected and the heads of thegastrocnemius muscle were identified. All gastrocne-mius veins were dissected from the gastrocnemiusEur J Vasc Endovasc Surg 31, 439–442 (2006)doi:10.1016/j.ejvs.2005.10.022, available online at http://www.sciencedirect.com onved.J. A. Araga˜o et al.440muscle heads toward their drainage site. The maingastrocnemius venous trunkswere opened longitudin-ally to allow assessment of the presence and number ofvalves. We consideredmeasurement of the diameter ofthese veins but consider that due to the likely post-mortem changes in the veins including those attribu-table to preservation of the cadavers in formalinsolution, such data would have no direct correspon-dence with those made in life. We have, therefore,omitted mention of vein dimensions in this article.Fig. 1. Diagram showing the distribution of gastrocnemiusvenous network types 1, 2, 3 and 4. A, popliteal vein; B, maingastrocnemius venous trunk; C, axial gastrocnemius venoustrunk; D, gastrocnemius veins; E, soleal veins; F, smallsaphenous vein; G, collateral gastrocnemius venous trunk.ResultsEighty heads of 40 gastrocnemius muscles showed 438gastrocnemius veins. The number of veins per musclehead varied between 2 and 12, with amode of 4 and 5, amean of 4.6. There were 221 gastrocnemius trunksdistributed as 95 main gastrocnemius trunks (finaldrainage from the muscle), 81 axial and 45 collateralones. The length of the trunks varied between 0.5 and5.5 cm, with a mean length of 2.3, SD 1.24 cm and amode of 1.7. From the 95main gastrocnemius trunks, 83(87%) drained into the popliteal vein and the remaining12 (13%) drained into the posterior tibial vein, peronealvein and tibio-peroneal truncal vein. Gastrocnemiusveins draining into the small saphenous vein wasobserved in one leg, as shown in Fig. 2, type 4.The direct observation of the gastrocnemius venousnetwork allowed us to describe a characteristicanatomical distribution, which were classified in fourdistinct types as follows (Figs. 1 and 2):Type 1 Characterised by veins emerging from thelateral and medial heads of gastrocnemiusmuscle, converging to an axial venous trunk,which continued proximally toward the maingastrocnemius trunk.Type 2 Characterised by veins emerging from thelateral and medial heads of gastrocnemiusmuscle but draining into collateral trunks,converging to an axial venous trunk and thentoward the main gastrocnemius trunk.Type 3 Characterised by veins emerging from thelateral and medial heads of gastrocnemiusmuscle, converging directly toward the maingastrocnemius trunk.Type 4 Characterised by veins emerging from thelateral and medial heads of gastrocnemiusmuscle with no conversion to any of thegastrocnemius trunks. The most commontypes were 1 and 2, as shown in Table 1.We observed 65 valves in the main gastrocnemiustrunks, 48 of them located in the proximal segment, 11Eur J Vasc Endovasc Surg Vol 31, April 2006in the intermediate and six at the distal segment.Valves were detected in all muscle heads in venousnetwork types 1, 2 and 3. Since, type 4 implies thatthere was no main gastrocnemius trunk, no valveswere detected. The majority of main gastrocnemiustrunks contained only one valve.In type 1 networks, there were 44 main gastro-cnemius venous trunks, 22 in the medial and 22 in thelateral muscle head, with 35 valves; in 14 trunks (32%)no valve was detected. In type 2, there were 37 maintrunks, 21 in the medial and 16 in the lateral musclehead, with 37 valves; in 14 trunks (38%) there was novalve. In type 3, there were 14 main gastrocnemiustrunks, eight in the medial and six in the lateral musclehead,with sevenvalves; in seven trunks (50%), novalvewas detected.DiscussionOur study shows that number of the gastrocnemiusveins varies from 2 to 12 per muscle head. Ourfindings contrast with many reports in which theFig. 2. Representative anatomic dissection of gastrocnemius of gastrocnemius venous network types 1, 2, 3 and 4. AG,gastrocnemius artery; CLG, lateral gastrocnemius muscle head; CMG, medial gastrocnemius muscle head; NFC, commonfibular nerve; NT, tibial nerve; TA, axial trunk; TGP, main gastrocnemius trunk; VG, gastrocnemius vein; VP, popliteal vein;VS, soleal vein; VSP, small saphenous vein; TC, collateral trunk; MBF, biceps femoris muscle; MP, plantar muscle; RMT, tibialnerve muscular branches.Gastrocnemius Venous Network 441smallest number of trunks was one and the maximumwas six.2,3,5,14 In accordance with common sense themain gastrocnemius venous trunk drains into thepopliteal vein.2,4,7,8,15–18 There was reduplication ofthis trunk in 17 muscle heads, and absence in two. Themajority of the main gastrocnemius trunks showedone valve. Thirty-seven percent of the main gastro-cnemius trunks contained no valve.We believe that our main contribution is thedescription of gastrocnemius venous network types.We are not aware of a previous detailed descriptionsuch as we have presented here. We did not provide avery detailed description of their intramuscular pathand arrangement, but did focus on the differentpatterns of the termination of the gastrocnemiusveins, probably the most accessible to ultrasoundimaging and the region most frequently dissectedsurgically. The usefulness of our description remainsto be demonstrated. It is almost impossible to describethese veins patterns by venography. Duplex scanningfrequently detects thrombi in ‘muscular veins’, andrarely distinguishes between soleal and gastrocnemiusveins. The present classification and the schematicpresentation of network types may assist vascularEur J Vasc Endovasc Surg Vol 31, April 2006Table 1. Distribution of gastrocnemius veins acording to theproposed classificationTypes Leg Muscle head Number ofnetworksType 1Right Medial 11Lateral 13Left Medial 11Lateral 9SubtotalZ44Type 2Right Medial 12Lateral 8Left Medial 9Lateral 8SubtotalZ37Type 3Right Medial 5Lateral 4Left Medial 3Lateral 2SubtotalZ14Type 4Right Medial 0Lateral 0Left Medial 1Lateral 1SubtotalZ2TotalZ97J. A. Araga˜o et al.442surgeons and radiologists better to interpret theirfindings. It is more difficult to establish a role for ourfindings in physiological and pathophyisologicalstudies. The subjects of our study were muscles fromapparently normal cadavers rather than from patientswith chronic venous disease. Anatomical studies lackthe ability to evaluate venous haemodynamics sodirect conclusions about implications for blood flowcannot be made from our work. What we present hereis a ‘static’ anatomical view that may be the basis forfuture ‘dynamic’ studies using ultrasound imagingand perhaps newer imaging techniques. Questionsraised by ultrasound investigations could be clarifiedby future anatomical studies addressing the gastro-cnemius venous network.We conclude that the majority of main gastrocne-mius venous trunks drain into the popliteal vein.There is wide variability in the number of gastro-cnemius veins. We propose a classification of fourdistinct types of anatomical pattern.Eur J Vasc Endovasc Surg Vol 31, April 2006References1 Hollinshead WH. General survey of the lower limb. In:Hollinshead WH, ed. Anatomy of surgeons. 2nd ed New York:Harper e Row, 1968:625–629.2 Williams AF. The formation of the popliteal vein. Surg GynecolObstet 1953;97:769–772.3 Cockett FB. The pathology and treatment of venous ulcers of theleg. Br J Surg 1955;43:260–278.4 Salvidea CJ, Iuliani N, Landa AWP. Importante componentede la patologia venosa: venas gemelares internas, estu´diosanatoˆmicos y flebogra´ficos. Implicaˆncias y resultados quirurgi-cos. Rev Argent Flebologia 1984;6:278–289.5 Verberch AW. Sistema venoso soleo-gemelar: su rol em lainsuficieˆncia venosa de miembros [tese]. Co´rdoba, UniversidadNacional de Co´rdoba, 1997.6 Kosinski C. Observations on the superficial venous system of thelower extremity. J Anat 1926;60:131–142.7 Vandendriessche M. Le rapport entre l’insuffisance des veinesjumelles et les varices [Association between gastrocnemius veininsufficiency and varicose veins]. Phle´bologie 1989;42:171–184.8 Hobbs JT. The enigma of the gastrocnemius vein. Phlebology 1988;3:19–30.9 Gillot CI. Anatomie chirurgicale des perforantes de la jambe[Surgical anatomy of perforating veins of the leg]. Phle´bologie1987;40:563–574.10 Urigo F, Pischedda A, Mocci M, Carpanese L, Canalis GC.Incompetence of the m. gemellus veins in varicose veins: itsincidence and phlebographic study. Radiol Med (Torino) 1992;84:48–53.11 Juhan C, Barthe´le´my P, Alimi Y, Di Mauro P. Re´cidives apre`schirurgie des veines jumelles [Recurrence following surgery ofthe gastrocnemius veins]. J Mal Vasc 1997;22:326–329.12 Kobak M, Lev M. Anatomy of the deep venous system of thepopliteal fossa and lower leg. Arch Surg 1954;68:530–537.13 Blanchemaison PH, Gorny PH, Muntlak H, Griton PH,CloarecM. Angioscopie et traitement chirurgical des varices duterritoire de la veine saphe`ne externe [Angioscopy and thesurgical treatment of varices in the area of the external saphenousvein]. Phle´bologie 1990;43:543–550.14 Dodd H. Varicosity of the external and pseudo-varicosity of theshort (external) saphenous vein. Br J Surg 1959;46:520–530.15 Dodd H. The varicose tributaries of the popliteal vein. Br J Surg1965;52:350–354.16 Coulier B. Hyperechogenicity of medial gastrocnemial veinsduring ultrasound scanning of the calf in sitting patients: anormal variant. Eur Radiol 2002;12:1843–1848.17 Gillet JL, Perrin M, Hiltbrand B, Bayon JM, Gobin JP,Calvignac JL et al. Apport de l’e´cho-Doppler pre´ et post-ope´ratoire dans la chirurgie veineuse superficielle de la fossepoplite´e [Pre- and postoperative contribution of Dopplerultrasonography in surperficial venous surgery of the poplitealfossa]. J Mal Vasc 1997;22:330–335.18 Sherman RS. Varicose veins: further findings based on anatomicand surgical dissections. Ann Surg 1949;130:218–232.Accepted 23 October 2005

Anatomical study of the gastrocnemius venous network and proposal for a classification of the veins

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Anatomical study of the gastrocnemius venous network and proposal for a classification of the veins

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