1. N EED TO K NOW L EG VENOUS A NATOMY Competency 1- Demonstrate appropriate examination technique http://1.bp.blogspot.com/_FYzmMSSuvWc/TEHO- q8vipI/AAAAAAAAFeg/SplD_bhoS60/s1600/nic_k20_999.jpg

2. I NTRODUCTION In order to competently complete a DVT leg examination it is important that the Sonographer understands the normal anatomy of the venous system as well as the common variations involved. The venous system is divided into the superficial and deep system. The superficial includes the Great Saphenous vein and Short saphenous vein and the deep involves the; common femoral,femoral,profunda, popliteal, gastrocnemius, soleal, anterior tibial, posterior tibial and peroneal veins (Rumack, Wilson, Charboneau, & Levine, 2011). The deep veins are located beneath the muscle fascia and their role is to drain the muscles of the lower extremity (Meissner, 2005).

3. The following slides demonstrate step by step location and normal lower leg venous anatomy There are some variations involved in the venous anatomy, the most common involves the duplicating veins particularly the femoral and popliteal (Thrush & Hartshorne, 2010).

4. L EFT C OMMON F EMORAL V EIN The common femoral vein continues from the external iliac vessel in the inguinal region. It then bifurcates into the femoral and profunda vein (Rumack, Wilson, Charboneau, & Levine, 2011).

5. L EFT S APHENOFEMORAL J UNCTION The saphenofemoral junction involves the common femoral vein and great saphenous vein and lies immediately below the beginning of the common femoral vein.

6. L EFT C OMMON F EMORAL V EIN The above image demonstrates the common femoral vein just before its bifurcation

7. L EFT PROFUNDA VEIN (D EEP FEMORAL V EIN ) The profunda vein can only be assessed at its proximal portion as it dives deep within the muscle. It is positioned just superior to the bifurcation (Rumack, Wilson, Charboneau, & Levine, 2011).

8. L EFT F EMORAL V EIN The femoral vein continues from the common femoral vein. It lies medial to the quadriceps muscles and extends from the proximal femur to distal joining the popliteal vein (Rumack, Wilson, Charboneau, & Levine, 2011).

9. L EFT P ROXIMAL F EMORAL VEIN

10. L EFT M ID F EMORAL V EIN

11. L EFT D ISTAL F EMORAL V EIN As the femoral vein continues it travels distally through the adductor canal. This canal provides an intermuscular passage for the femoral vessels (Moore, Agur, & Dalley, 2010).

12. L EFT G REAT S APHENOUS V EIN The great saphenous vein begins medially at the proximal portion of the common femoral vein and continues to the foot located within the superficial subcutaneous tissue (Rumack, Wilson, Charboneau, & Levine, 2011).

13. M ID GREAT SAPHENOUS VEIN

14. L EFT P OPLITEAL V EIN The popliteal vein extends from the distal femoral vein in the posterior aspect of the knee and lies anterior to the popliteal artery. The first branch is the anterior tibial veins (Rumack, Wilson, Charboneau, & Levine, 2011).

15. L EFT T IBIOPERONEAL TRUNK V EINS The tibioperoneal trunk bifurcates into the paired peroneal and posterior tibial veins. (Rumack, Wilson, Charboneau, & Levine, 2011)

16. L EFT S HORT S APHENOUS V EIN The short saphenous vein or (small) can insert into the popliteal vein in a number of locations. It travels down the mid posterior calf within the subcutaneous tissue extending to the ankle (Rumack, Wilson, Charboneau, & Levine, 2011).

17. M ID S HORT S APHENOUS V EIN

18. L EFT L ATERAL G ASTROCNEMIUS V EINS The Gastrocnemius veins are located within the medial and lateral gastrocnemius muscles. The veins drain into the popliteal vein. The lateral gastrocnemius veins usually appear smaller than the medial (Arger, 2004).

19. L EFT M EDIAL G ASTROCNEMIUS V EINS

20. L EFT S OLEAL V EINS The soleal veins and sinuses drain the veins of the soleal muscle directly into the posterior tibial and peroneal veins. The are not accompanied with arteries and vary in size (Arger, 2004).

21. L EFT P OSTERIOR TIBIAL AND P ERONEAL V EINS DISTAL The paired peroneal veins travel with the artery and sit medial to the fibula. The paired posterior tibial veins also follow the artery and are situated posterior to the tibia (Arger, 2004).

22. L EFT P OSTERIOR TIBIAL AND P ERONEAL P ROXIMAL V EINS

23. L EFT POPLITEAL FOSSA The popliteal fossa is a diamond shaped space located at the posterior aspect of the knee. A common pathology seen within this region is a Bakers cyst which appears between the gastrocnemius muscle and semimembranous (Moore, Agur, & Dalley, 2010).

24. C ONCLUSION Through an understanding of the venous anatomy the Sonographer will be able to competently detect abnormal pathology, such as Deep vein thrombosis. They will be able to describe its location, extent and position in relation to other vessels.

25. B IBLIOGRAPHY Arger, P. (2004). The Complete Guide to Vascular Ultrasound. Philadelphia: Lippincott Williams & Wilkins. Meissner, M. (2005). Lower Extremity Venous Anatomy. Seminars in Interventional Radiology, 14- 156. Moore, Agur, & Dalley. (2010). Essential Clinical Anatomy 4th ed. Lippincott, Williams & Wilkins. Rumack, C., Wilson, S., Charboneau, J., & Levine, D. (2011). Diagnostic Ultrasound 4th edn. Philadelphia: Elsevier Mosby. Thrush, A., & Hartshorne, T. (2010). Vascular Ultrasound- How, Why and When. London: Churchill Livingstone.