Venous & Lymphatic Drainage of Lower Limb

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 VENOUS  DRAINAGE  OF  LOWER  LIMB 

  • All veins of lower limb are provided with valves to direct the venous blood towards the heart against gravity.
  • Lower limb presents 3 distinguishable sets of veins..
Superficial Veins
Deep Veins
Perforating Veins

SUPERFICIAL  VEINS :-

  • They lie in the superficial fascia.. consist of..
    1. Great / Long  Saphenous  Vein
    2. Small / Short  Saphenous  Vein

GREAT / LONG  SAPHENOUS  VEIN :-

  • It is longest vein of the body.
  • Contains 10 - 20 valves, having a fixed terminal valve at Sapheno-femoral junction.
  • It begins at the medial end of dorsal venous arch of the foot where the medial marginal vein joins the arch.

Dorsal Venous Arch-

  • It lies on the dorsum of foot against the bases of metatarsals with convexity distally.
  • It receives  4 dorsal metatarsal veins, each of which is formed by the union of 2 dorsal digital veins.

Course -

It passes upwards lying 2.5cm in front of medial malleolus


Runs backwards & crosses the medial surface of tibia obliquely


Reaches behind the medial border of tibia near the knee and occupies the postero-medial aspect of knee joint


 

Ascends along the medial side of the thigh & passes through the spahenous opening

It ends by draining into the Femoral vein after piercing the cribriform fascia & femoral sheath at saphenous opening.

Structures Accompanying -

  • In the Thigh- Medial femoral cutaneous nerve
  • At the Knee- Saphenous artery (branch of Descending genicular artery)
  • In the Leg & Foot- Saphenous nerve

Tributaries -

Just below the Knee-

  • Posterior arch vein
  • Anterior leg vein
  • Communicating veins to small saphenous vein

In the Thigh-

  • Antero-lateral vein
  • Postero-medial vein (also called as Accessory saphenous vein)

Just before piercing the Cribriform fascia-

  • Superficial epigastric vein (occasionally connected to lateral thoracic vein via Thoraco-epigastric vein)
  • Superficial circumflex iliac vein
  • Superficial external pudendal vein

After piercing the Cribriform fascia-

  • Deep external pudendal vein

SMALL / SHORT  SAPHENOUS  VEIN :-

  • It contains 7 - 13 valves.
  • It begins at the lateral end of dorsal venous arch of the foot where the lateral marginal vein joins the arch.

Course -

It passes upwards lying below & behind the lateral malleolus


Ascends along the lateral margin of tendo-calcaneus


Runs along the mid line on the back of leg


Pierces the deep fascia between the two heads of Gastrocnemius & undergoes a sub-fascial course on the roof of popliteal fossa


It ends by draining in to the Popliteal vein at the middle of popliteal fossa

Variations in Termination -

  • May drain into the great saphenous vein in the leg or upper part of thigh
  • May bifurcate & drain into great saphenous vein & popliteal vein

Structures Accompanying -

  • In the Leg- Sural nerve
  • At the Popliteal fossa- Posterior femoral cutaneous nerve



DEEP  VEINS :-

  • They are surrounded by muscles & accompany the arteries.
  • Eg:-  Femoral vein, Popliteal vein, Tibial vein, Common peroneal vein.
  • Below the knee most of the deep veins are arranged as Venae comitantes.
  • Deep veins in the soleus muscle are arranged in the form of Venous sinuses.

Factors helping Venous Return -

In Upright position-

  • Contraction of calf muscles (calf pump) (peripheral heart)
  • Pulsations of arteries
  • Valves in the veins

In Recumbent position-

  • Contraction of heart & diaphragm during inspiration.

PERFORATING  VEINS :-

  • They pierce the deep fascia & communicate the superficial veins with deep veins.
  • They are valved at each end & permit only the unidirectional blood flow from superficial to deep veins.
  • There are Direct & Indirect perforators.
  • Great & Small saphenous veins are considered as large sized direct perforators.
  • Direct perforators are constant in number with fixed positions.

Positions of Direct Perforators -

  1. Mid-hunter perforator- Connects the great saphenous vein with femoral vein in the adductor canal.
  2. Knee perforator- Connects the great saphenous vein with posterior tibial vein below the knee.
  3. Medial ankle perforators- Usually 3 in number, connect the posterior arch vein with posterior tibial vein on the medial side of ankle.
  4. Lateral ankle perforators- connects the small saphenous vein with peroneal vein.

APPLIED  ASPECTS :-

Varicose Veins -

Definition- Abnormally dilated & tortuous superficial veins.

Cause- Incompetence of venous valves, resulting in passage of high pressure blood from deep to superficial veins.

Tourniquet test-

  • It is done to recognize the sites of incompetent valves.
  • On a lying down position patient’s affected lower limb is elevated to empty the varicose veins.
  • A rubber tube (tourniquet) is tied at the thigh & patient is allowed to stand with a gentle exercise.
  • If the varicose veins fill within 30 sec, valves of perforators are incompetent.
  • When the tourniquet is removed, if the varicose veins fill at once from above, sapheno-femoral valve is incompetent.

Treatment-

  • Stripping operation for incompetent perforator valves-  Great saphenous vein is avulsed by turning inside out after disconnecting it at its termination & at ankle or knee.
  • Trendelenburg’s operation for incompetent sapheno-femoral valve-  Great saphenous vein is detached at its termination & all its tributaries are ligated individually.

Deep Vein Thrombosis (DVT) -

Cause- 

  • Venous stasis- due to prolonged hospital stay or muscular inactivity, leading to..
  • Thrombosis- thrombus formation at the site of venous stasis.
  • Thrombophlebitis- inflammation may develop around the vein.
Complications- 
  • Pulmonary Thromboembolism- thrombus may dislodge to form embolus which migrates to the lungs & obstructs the airways.
  • Varicose Ulcer- may develop over the area of venous stasis.

Venesection / Phlebotomy -

  • Surgical exposure of a vein for intravenous access when peripheral veins are collapsed in hypovolemic shock, infants & obese patients.
  • Great saphenous vein is preferred because of its constant position in front of the medial malleolus.   
  • Care to be taken not to include saphenous nerve while ligating the vein.

Aortico-coronary by-pass Operation -

  • In coronary artery by-pass grafting (CABG) operation, great saphenous vein is used for vascular grafting between the aorta & coronary artery distal to the obstruction.
  • Because of the presence of valves the vein is grafted with its valves directed towards the coronary artery.




LYMPHATIC  DRAINAGE  OF  LOWER  LIMB

  • The lymph from lower limb is drained into inguinal lymph nodes, which are arranged into 2 groups - Superficial and deep.

SUPERFICIAL  INGUINAL  LYMPH  NODES

  • These are situated in the subcutaneous fat.
  • Consist of upper & lower groups.

Upper Group :–

  • Contains 5 – 6 nodes.
  • Forms a chain below the inguinal ligament.
  • It has lateral & medial nodes.

Lateral nodes -

  • They receive afferent lymphatics from-
  • Gluteal region & adjoining anterior abdominal wall below the umbilicus.

Medial nodes -

  • They receive afferents lymphatics from-
  • Subcutaneous tissue of anterior abdominal wall below the umbilicus.
  • In male, penis including prepuce & scrotum.
  • In female, vulva & vagina blow the hymen.
  • Perineum & lower part of anal canal below the pectinate line.
  • Cornuae of uterus.

Lower Group :–

  • They are 4 or 5 in number.
  • Accompany the lateral side of termination of great saphenous vein.
  • They receive afferents from all superficial lymph vessels of lower limb except the vessels following small saphenous vein.
Efferent vessels from all superficial inguinal lymph nodes form 20 or more in number.
  • They drain into external iliac nodes.
  • Some traverse the femoral canal and intercepted by deep inguinal lymph nodes.

DEEP  INGUINAL  LYMPH  NODES

  • These vary from 1 – 2 in number.
  • They lie on the medial side of femoral vein within the femoral canal (gland of Cloquet).
They receive afferent vessels from-
  • Deep lymph vessels which accompany the femoral vessels
  • Glans penis or glans clitoridis
  • Superficial inguinal nodes
Efferent vessels from deep inguinal nodes drain into external iliac nodes.

APPLIED  ANATOMY

  • The upper group of superficial inguinal nodes may be enlarged due to spread of infection or malignant growth extending from lymphatic territory drained by these nodes.
  • The lower group of superficial nodes are enlarged in diseases affecting the lower limb except the area drained by those lymph vessels following small saphenous vein.
  • Syphilitic lesion of prepuce involves the medial members of upper group of superficial nodes, whereas lesion of glans penis produces enlargement of deep inguinal lymph nodes of Cloquet.





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