Spiegazione della nuova terminologia anatomica delle vene degli arti inferiori

CAGGIATI, Alberto

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A. Caggiati

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Acta Chirurgica Belgica

The Nomenclature of the Veins of the Lower Limbs, Based on their Planar Anatomy and Fascial Relationships

Archivio della ricerca- Università di Roma La Sapienza

Acta chir belg, 2004, 104, 000-000All past editions of the official Terminologia Anatomica(TA) were extremely concise regarding with the veins ofthe lower limb (1), especially if the great number of ves-sels described in the clinical literature is considered. Forexample, the list of perforating veins and that of saphe-nous collaterals were inadequate and some importantdeep veins were not mentioned.This is why, time after time, many clinicians introdu-ced new names to indicate “new” veins, resulting in aterminological chaos (more than one name for the samevein and/or the same name for more than one vein). A revision and extension of venous terminology wasneeded in order to facilitate effective exchange of infor-mation and to avoid inappropriate treatment of venousdiseases (2). An “ad hoc” International InterdisciplinaryCommittee (International Union of Phlebology andInternational Federation of Anatomical Association) ela-borated a revision of the venous nomenclature (3) whichhas been already accepted by the Federative Interna-tional Committee on Anatomical Terminology (FICAT)and will be included in the next edition of the official“Terminologia Anatomica”.In this article, main terminological changes andextensions are reported, taking into account the impro-vements in anatomical knowledge furnished by moderntechniques of “virtual” dissection (Duplex, spiral CT,MR). Three planes of veinsThe veins of the lower limbs are traditionally designatedaccording with their relationships with the Deep Fascia(DF). This separates the limb in two venous planes : theepifascial plane, with the superficial veins, and the sub-fascial one, with the deep veins. A third group includesthose veins which cross the DF (Perforating Veins, PV). This traditional classification considers the subcuta-neous tissue an amorphous layer of fat. On the contrary,the subcutaneous tissue is supported by a connectiveskeleton which strands, in correspondence of the saphe-nous veins (SVs), interlace to form a continuous mem-brane. This membrane is officially called “saphenousfascia” (SF) (3, 4, 5).The SF overlies the SVs to join the underlying DF atthe sides of the vessels. The two fasciae (SF+DF)delimit a narrow fatty space which is officially named“saphenous compartment” (SC) (4, 5) because it con-tains, besides SVs, only related nerves and arteries. The roots of SVs (medial marginal vein, superficialvenous arch of the foot and lateral marginal vein), andthe thigh extension of the Small Saphenous Vein areenclosed in a similar space. As a consequence, the SCextends uninterrupted from the groin down to the dorsalfoot and, on the posterior face of the limbs, from thelateral malleolus to the gluteal fold. All other superficial veins (saphenous tributaries,accessories and collaterals) course out of the SC, in amore superficial plane of the subcutaneous tissue, closeto the dermis.According with their fascial relationships, the veinsof the lower limbs are to be divided in three groups(table 1), one for each of the three planes delimited bythe DF and SF : Subfascial Veins (Deep Vv.),Interfascial Veins (SVs), Epifascial Veins (SuperficialVv.). The Nomenclature of the Veins of the Lower Limbs, Based on their PlanarAnatomy and Fascial RelationshipsA. CaggiatiDepartment of Anatomy, University “La Sapienza”, Rome Italy.Table 1Old classification New classificationSUPERFICIAL VEINSEPIFASCIAL VEINSsaphenous fasciaINTERFASCIAL VEINSmuscular fascia muscular fasciaDEEP VEINS DEEP VEINSDeep VeinsWith regard to the deep veins, the Committee proposed :1. to avoid the misleading term “Superficial FemoralVein”, because it is not a superficial vein. TheFemoral Vein origins from the popliteal vein andcontinues into the Common Femoral Vein afterhaving received the Deep Femoral Vein.2. To avoid the misleading term “Perforating Veins” toindicate the roots of the Deep Femoral Vein. Thesehave been designated Deep Femoral Communi-cating Veins. The term “Perforating” is to be usedexclusively for those veins which connect superficialwith deep veins by piercing the DF. 2 A. Caggiati3. To designate the Sural veins (6) as : the Soleal Veins,the Medial Gastrocnemius Veins, the LateralGastrocnemius Veins, and, finally, theIntergemellar Vein.4. To introduce the term Sciatic Vein to indicate thevein accompanying the sciatic nerve and which con-tinues into the inferior gluteal vein.2. Interfascial veins :With regard to the interfascial veins, the Committeerecommended that :1) The Saphenous Veins must be indicated only withthe term “Great” and “Small” in order to respecttheir official name (Vena Saphena Magna and Parva)and to avoid confusions between acronyms (respec-tively, GSV and SSV). 2) The cranial prolongation of the SSV along the poste-rior thigh must be indicated with the term Upward(or Thigh) Extension of the SSV (1).3. Epifascial (superficial) veinsThe epifascial venous plane is composed by a net ofinterconnecting veins which are extremely variable innumber, size, path and connection. However, an ordercan be found in this variability. In fact, if most of epif-ascial veins are short, thin, unnamed and unnameable, afew of them are quite constant and show distinct anato-mical markers. These are designated in longitudinal andoblique ones.Longitudinal epifascial veins are parallel to the SVsand richly connected with them. For these reasons, theyare designated as “Accessories” of the relative Saphenaand discriminated on the basis of their topography. The Accessories of the GSV which course in a moreanterior position are called Anterior Accessory of theGSV (2).The Accessories of the GSV which course in a moreposterior position are called Posterior Accessory of theGSV (3).Finally, those running along the same path but moresuperficially are called Superficial Accessory of theGSV. Besides SVs Accessories, the Lateral Venous Plexus(also called vein of Albanese) is to be considered in thegroup of longitudinal epifascial veins. Due to their course, oblique epifascial veins play thehemodynamic role of communicating main longitudinalveins (SVs or their accessories). The flow in them isdirected cranially toward the GSV.The oblique veins of the leg are calledIntersaphenous Veins.—————(1) The term “Vein of Giacomini” is misleading and must be sub-stituted with “Giacomini’s anastomosis. It is an anastomosis betweenthe SSV and the GSV. The “Giacomini’s anastomosis” courses alongthe Thigh Extension of the SSV (that is an interfascial vein) and thePosterior Thigh Circumflex Vein (an epifascial vein).(2) The upper portion of the AAGSV courses, like the GSV, undera fascia similar to the SF. The AAGSV can be discriminated from theGSV because it courses just above the femoral vessels.(3) The PAGSV of the leg corresponds to the well known “PosteriorArch Vein”.Fig. 1Schematic drawing of the fascial and venous arrangement ofthe lower limbs. D : Dermis ; EV : Epifascial Veins ; SF :Saphenous Fascia ; SC : Saphenous Compartment ; DF : DeepFascia ; DV : Deep Veins.Fig. 2Extension of the Compartment of the GSV (on the left) and ofthe SSV (on the right). Note that the two compartments areconnected on the dorsum of the foot (along the marginal veinsand the superficial venous arch).The Nomenclature of the Veins of the Lower Limbs 3In the thigh, oblique veins are designated “CircumflexVeins” due to their path. In the anterior thigh, the obliqueveins which connect the Lateral Venous Plexus with theGSV are called Anterior Thigh Circumflex Vein(s)(ATCV). In the posterior thigh, the Posterior ThighCircumflex Vein(s) (PTCV) originate from the SSV,from the Lateral Plexus or from reticular veins of theposterior thigh, to drain into the GSV or its PosteriorAccessory. Perforating veinsThe term Perforating Vein (PV) or Perforator is the onlyacceptable to indicate the veins crossing the DF to con-nect superficial with deep vein. PV are numerous andvery variable in arrangement, connection, size and dis-tribution (7). PV were designated according with theirtopography and were grouped as in table 2 and in Figure5. Despite the apparent complexity, groups and namesare consistent with their relevant anatomy.Fig. 3A) The approximate path of the Posterior Accessories of theGSV. B) The approximate path of the Anterior Accessories ofthe GSV. C) The Thigh extension of the SSV. D) The approxi-mate path of the lateral plexus. E and F) At the leg, intersap-henous veins. At the thigh, the Posterior Thigh CircumflexVeins. G and H) The Lateral Venous Plexus may be drained bythe Posterior or Anterior Thigh Circumflex Veins.Fig. 4The path of oblique veins, which connect main longitudinalveins. SAGSV, AAGSV and PAGSV : Superficial, Anteriorand Posterior Accessory Great Saphenous Veins. SC :Saphenous Compartment. * : Oblique communicating veins.Table 2Perforating veinsMain groups Sub-groups Ref. FOOT PERFORATORSDORSAL PV OR INTERCAPITULAR VEINS 1MEDIAL PV 2LATERAL PV 3PLANTAR PV 4ANKLE PERFORATORSMEDIAL PV 5ANTERIOR PV 6LATERAL PV 7LEG PERFORATORSMEDIAL PV– PARATIBIAL PV– POSTERIOR TIBIAL PV89ANTERIOR PV 10LATERAL PV 11POSTERIOR PV– MEDIAL GASTROCNEMIUS PV– LATERAL GASTROCNEMIUS PV– INTERGEMELLAR PV– PARA-ACHILLEAN PV12131415KNEE PERFORATORSMEDIAL PV 16SUPRAPATELLAR PV 17LATERAL PV 18INFRAPATELLAR PV 19POPLITEAL FOSSA PV 20THIGH PERFORATORSMEDIAL THIGH PV– PV OF THE FEMORAL CANAL– INGUINAL PV2122ANTERIOR THIGH PV 23LATERAL THIGH PV 24POSTERIOR THIGH PV– POSTERO-MEDIAL– SCIATIC PV– POSTEROLATERAL252627PUDENDAL PV 28GLUTEAL PERFORATORSSUPERIOR GLUTEAL PV 29MID GLUTEAL PV 30LOWER GLUTEAL PV 314 A. CaggiatiEponyms and synonymsEponyms cannot be included in the OfficialTerminology. However, eponym or synonym can beused in the clinical practice only if clearly correspondedto an official names. For this reason, the Committeeindicated the correspondence between more usedeponyms or synonyms with the official names of thatveins.ConclusionsAnatomy of the venous system forms the basis of clini-cal phlebology and is crucial to the correct evaluationand appropriate treatment of venous disorders.Deficiency in the nomenclature of the veins of the lowerlimbs, however, became obvious as knowledge accumu-lated about their physiology and pathophysiology.The official names of some veins have been changedand previously unnamed veins have received names rele-vant to their anatomy and clinical significance accordingto the guidelines of the FICAT. Some of the terminolo-gy recommendations are innovative, but they have beenadopted in most of the recent phlebological papers andmeeting.References1. Federative International Committee for Anatomical Terminology.Terminologia Anatomica. George Thieme Verlag, Stuttgart, 1998.2. BUNDENS W. P., BERGAN J. J., HALASZ N. A., MURRAY J., DREHOBL M.The superficial femoral vein : a potentially lethal misnomer. JAMA,1995, 274 : 1296-1298. 3. CAGGIATI A., BERGAN J. J., GLOVICZKI P., JANTET G., WENDELL-SMITH C. P., PARTSCH H. Nomenclature of the veins of the lowerlimbs : an international interdisciplinary consensus statement. JVasc Surg, 2002, 36 : 416-22.4. CAGGIATI A. Fascial relationships of the long saphenous vein.Circulation, 1999, 100 : 2547-2549.5. CAGGIATI A. Fascial relationships of the short saphenous vein. JVasc Surg, 2001, 34 : 241-246.6. VAN DER STRICHT J., STAELENS J. Veines musculaires du mollet.Phlébologie, 1994, 47 : 135-143.7. MAY R., PARTSCH H., STAUBESAND J. Perforating Veins. Urban andSchwarzenberg, München, 1980.A. Caggiati, M.D., Ph.D.Department of Anatomy,University “La Sapienza”,Via Borelli 50,00153, Rome Italy,E-mail : alberto.caggiati@uniroma1.it.Table 3Posterior Arch Vein (Leonardo‘s Vein) Leg portion of the PAGSVGiacomini’s anastomosis Thigh SSV + PTCVCockett PV Posterior tibial PVBoyd PV Paratibial PVDodd PV PV of the femoral(Hunterian) canalBassi PV ParaAchillean PVMay PV Intergemellar PVHach PV Posterolateral thigh PVGillot PV Medial Gastrocnemius PVFig. 5The location of the main groups of PV. For legends, seeTable 2.

The nomenclature of the veins of the lower limbs, based on their planar anatomy and fascial relationships

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The nomenclature of the veins of the lower limbs, based on their planar anatomy and fascial relationships

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Archivio della ricerca- Università di Roma La Sapienza