Detailed Anatomy of Varicose Veins

1. Definition

2. Normal Venous Anatomy of the Lower Limb (The Essential Background)

2.1 Superficial Venous System

Great Saphenous Vein (GSV)

• The longest vein in the body
• Originates from the medial end of the dorsal venous arch of the foot
• Passes anterior to the medial malleolus
• Ascends along the medial aspect of the calf and thigh
• Drains into the common femoral vein at the saphenofemoral junction (SFJ) in the groin, passing through the saphenous opening (fossa ovalis) in the deep fascia
• Contains 4-25 valves (commonly >6), with at least one valve within a few centimeters of the SFJ
• The SFJ typically has at least four named tributaries: superficial epigastric vein, superficial circumflex iliac vein, superficial external pudendal veins, and the accessory saphenous vein
• The saphenous nerve runs within the GSV compartment below the knee and is at risk during surgery
• Complete duplication of the GSV in the thigh occurs in ~8% of cases, with partial duplication in a further 25% - Mulholland & Greenfield's Surgery 7e, p. 5215

Small Saphenous Vein (SSV)

• Originates from the dorsolateral aspect of the foot
• Passes posterior to the lateral malleolus
• Ascends along the posterolateral calf
• Drains into the popliteal vein at the saphenopopliteal junction (SPJ), usually at the popliteal crease
• Contains an average of 7-10 valves (range 4-13)
• The sural nerve lies in close proximity within the SSV compartment and is at risk during surgery
• The SSV drains into the popliteal vein in fewer than two-thirds of cases - it can travel well above the knee before diving to meet the deep system (the Giacomini vein is a thigh extension of the SSV)
• Mulholland & Greenfield's Surgery 7e, p. 5215

THIEME Atlas of Anatomy - Superficial veins, anterior and posterior views. Note the saphenous opening, accessory saphenous vein, and the posterior arch vein (a main tributary of the GSV in the calf).

2.2 Deep Venous System

• Tibial and peroneal veins contain 7-19 valves each
• Popliteal vein has 1-2 valves; femoral vein has ~3 valves
• ~70% of common femoral veins have a valve within 1 cm of the inguinal ligament
• Common iliac veins are generally valveless
• The soleal sinuses act as the primary blood reservoir and pump during calf muscle contraction - Harrison's 22E, p. 2223; Mulholland & Greenfield's, p. 5215

2.3 Perforating (Communicating) Veins

• THIEME Atlas of Anatomy - General Anatomy & Musculoskeletal System, p. 551
• Gray's Anatomy for Students, p. [varicose veins section]

Pfenninger & Fowler's Procedures for Primary Care. Named perforating veins of the lower limb - the sites of clinically important valvular incompetence.

Perforator vein anatomy with Dodd, Boyd and Cockett veins clearly labeled.

3. Venous Valves - The Anatomical Key

• Valves are composed of a fine connective tissue skeleton covered by endothelium
• They are bicuspid (two cusps), delicate yet extremely strong
• They direct blood flow: superficial → deep and caudad → cephalad (against gravity)
• With exception of the foot veins (where flow can be reversed during muscle relaxation)
• The common iliac vein is generally valveless; only 10% of internal iliac and 25% of external iliac veins have valves

(A) Normal valve function vs. varicose vein with incompetent valve causing reflux and wall dilation. (B) Cross-section showing relationship between deep vein, perforating vein and superficial vein - both competent and incompetent states. (University of Michigan Vascular Surgery)

Normal vein (left) showing competent valve and normal unidirectional flow vs. varicose vein (right) showing deformed valve, dilated vein, skin bulging and thin vein wall.

4. The Calf Muscle Pump - Functional Anatomy

1. Systolic phase (muscle contraction): The soleal sinuses and deep calf veins are compressed within their fascial envelope, generating pressures up to 300 cmH₂O. Blood is forced proximally through competent valves into the valveless veins of the abdomen. Perforator valves close to prevent escape into the superficial system.
2. Diastolic phase (muscle relaxation): Calf compartment pressure falls. Blood flows from the superficial veins through competent perforators into the deep system (superficial system acts like an "atrium"; deep veins like a "ventricle").
3. Standing still: Foot vein pressure = hydrostatic column from foot to right heart ≈ 70-80 cmH₂O. - Pfenninger & Fowler's Procedures for Primary Care, p. 636

5. Sites of Valvular Incompetence in Varicose Veins

1. Saphenofemoral junction (SFJ) - the saphena varix; GSV meets femoral vein in the groin
2. Midthigh Hunterian/Dodd perforators - between GSV and femoral vein
3. Calf Cockett perforators - 5, 10, and 15 cm above the medial malleolus
4. Saphenopopliteal junction (SPJ) - SSV meets popliteal vein in the popliteal fossa

• Medial thigh and calf varicosities → incompetent GSV/SFJ
• Posterolateral calf varicosities → incompetent SSV/SPJ
• Anterolateral thigh/calf varicosities → isolated anterior accessory GSV incompetence
• Bailey and Love's Short Practice of Surgery 28th Edition, p. 1051

6. Classification by Anatomical System

• Deep venous insufficiency or post-thrombotic limb (DVT sequelae)
• Incompetent perforating veins causing outward "blow-out" pressure
• Congenital conditions (e.g., Klippel-Trenaunay syndrome)
• Arteriovenous fistulas
• Harrison's 22E; Robbins Pathologic Basis of Disease

7. Clinical Anatomy - Distribution Patterns

(a) Left leg GSV-distribution varicosities, marked for intervention. (b) Right leg SSV-distribution varicosities with superficial phlebitis. (c) Anterior accessory GSV incompetence with gaiter-area skin changes. - Bailey & Love's 28th Edition

8. Surgical Anatomy - Key Danger Points

9. Key Anatomical Summary

LOWER LIMB VENOUS ANATOMY RELEVANT TO VARICOSE VEINS

IVC
 |
Common iliac vein (no valves)
 |
External iliac vein
 |
Common femoral vein ←—[SFJ]—— Great Saphenous Vein (GSV)
 |                                    |
 |                              medial thigh ← Hunterian/Dodd
 |                              perforators   perforating veins
 |                                    |
Femoral vein ←——————————————————— GSV calf
 |                                    |
 |                              Cockett perforators
 |                               (5, 10, 15 cm above
 |                                medial malleolus)
 |
Popliteal vein ←—[SPJ]———— Small Saphenous Vein (SSV)
 |                                    |
 |                              posterolateral calf
 |
Tibial/peroneal veins (deep)