Duplicated popliteal and superficial femoral veins: incidence and potential significance

Embolization of a duplicated femoral vein for treatment of lower extremity deep venous insufficiency: A case report

BACKGROUND

Lower extremity deep venous insufficiency (DVI) occurs secondary to structural or functional abnormalities of deep venous valves in the affected extremities. The effectiveness of surgical treatment for improvement of the hemodynamic status in these patients remains controversial in clinical practice.

METHOD

In this case report, we describe a patient who presented with severe right lower extremity edema and liposclerosis and underwent venography, which suggested a variation in the number of femoral veins. The valve within the duplicated femoral vein was significantly incompetent; however, the valve of the main trunk of the femoral vein showed normal function. We performed embolization of the duplicated femoral vein.

RESULTS

The patient tolerated the procedure well without recurrent symptoms.

CONCLUSIONS

Individualized assessment based on venography findings is useful to establish the therapeutic approach in patients with DVI.

Extensive but minimally symptomatic deep vein thrombosis in duplicated femoral veins

Duplicated femoral veins predispose to venous thrombosis, but patients may present with minimal/no symptoms. The required length of treatment is unclear, but periodic ultrasound surveillance may play a role in the absence of definitive treatment options.

Point-of-Care Ultrasonography in Internal Medicine: Limitations and Pitfalls for Novice Users

Point-of-care ultrasound (POCUS) is increasingly being adopted in the field of internal medicine, leading to the development of POCUS curricula in undergraduate and postgraduate medical education programs. Prominent internal medicine societies and organizations worldwide recognize the expanding utilization of POCUS by internal medicine physicians, emphasizing the need for practitioners to be aware of both its benefits and limitations. Despite the growing enthusiasm for POCUS, clinicians, particularly those with limited clinical experience, must be cautious regarding its inherent limitations and the potential impact on their clinical practice. This review aims to outline the limitations and potential drawbacks of POCUS for medical students, residents, and internists who wish to stay abreast of the escalating use of POCUS in internal medicine and have a desire, or have already commenced, to incorporate POCUS into their practice. Additionally, it provides recommendations for enhancing POCUS proficiency to mitigate these limitations.

Variations in the Clinical Anatomy of the Femoral and Popliteal Vessels

Objective:

The aim of this study was to assess the topography of the femoral and popliteal vessels focusing mainly on the venous variants, in patients with chronic venous disease (CVD).

Materials and Methods:

Duplex ultrasonography (DUS) was performed on 200 patients with varicose veins (VVs) and 253 patients with postthrombotic syndrome (PTS). In addition, an anatomical dissection was performed on 30 amputated lower extremities, without signs of CVD.

Results:

Duplication of the femoral vein (FV) was found in 14% of patients with VVs. Multiple FV trunks were identified in 42% of patients with PTS. One patient had a developmental anomaly with a hypoplastic FV and dilated deep FV. Two trunks of the popliteal vein (PV) below the knee level were detected in 83.3% of cases during anatomical dissection, in 87.5% of cases in patients with VVs, and in 90.1% of cases in PTS subjects during DUS. In 98.2% of cases, popliteal artery (PA) had a typical bifurcation. One patient was presented with a duplication of PA above the level of the knee. In 1.8% of cases, the PA was divided into an anterior tibial and peroneal artery.

Conclusion:

This study found variant anatomy in the FV and PV, which is frequent, with major changes occurring in patients with PTS. Variant anatomy of the PA was also found and is considered uncommon, occurring in less than 2% of cases.

Prevalence of femoral vein duplication: systematic review and metaanalysis

Background: Duplication of the femoral vein is an important anatomical variation of the venous anatomy which has been shown to have an impact on the diagnosis of deep venous thrombosis by compression ultrasonography. The presence of duplication may result in false negative findings while evaluating for deep venous thrombosis, with serious consequences such as pulmonary embolism and death. This metaanalysis aims to determine the pooled prevalence of duplicated femoral veins. Methods: A systematic search was conducted through the major databases PubMed, Hinari, Embase and Medline to identify studies eligible for inclusion. Appropriate data were extracted and pooled into a random-effects metaanalysis using MetaXL software. The primary and secondary outcomes of the study included the pooled prevalence of duplicated femoral veins and the prevalence of bilaterally duplicated femoral veins, respectively. Results: A total of 11 studies (n = 3,682 limbs) were included. The overall pooled prevalence of duplicated femoral veins was 19.7% (95% CI 11–30). There was a significant difference in prevalence between cadaveric studies (2%, 95% CI 1–4) and imaging studies (25%, 95% CI 17–34). Conclusion: Duplication of the femoral vein is a common variation in the lower limbs. Routine watch-out should be practiced especially when performing lower limb Doppler studies in cases of deep venous thrombosis in order to avoid misdiagnosis and improve diagnostic accuracy.

Ultrasound Use in Diagnosis and Management of Venous Leg Ulcer

Leg ulcers caused by venous diseases are effectively assessed by Doppler ultrasonography. The examination provides clear anatomical and physiological information for the diagnosis, treatment planning, and real-time guiding during the surgical treatment. Diagnostic Doppler ultrasonography assesses deep, superficial, and perforator veins, starting from patency assessment by direct visualization and simply compression test. The internal flow can be assessed by pulse wave analysis, which is used for rule out downstream flow obstruction and valvular incompetence. The venous valve function of deep, superficial, and perforator systems can be evaluated by measuring the time of the retrograde flow after flow augmentation performing in the upright position. At the end of the study, the venous map will be obtained and this map will guide clinicians to target treatment where the culprit is. The ultrasound technology has made a big shift in the treatment in the venous disease. In recent years, after the evolution and wide availability of ultrasound, newer treatment modalities have emerged for venous treatment. These include endovenous thermal ablation, endovenous adhesive closure, and ultrasound-guided foam sclerotherapy. Patients no longer require general anesthesia or hospitalization. Therefore utilization of duplex ultrasound has also surged and played an essential role in both diagnosis and therapy in venous ulcer. This article has dedicated to reviewing basic anatomy, the technique in diagnosis, and treatment.

Surgical Technique for Deep Venous Reflux Suppression in Femoral Vein Duplication

BACKGROUND

Deep venous surgery is a challenging field with limited indications. Femoral vein duplication (FVD) is a frequent anatomical variant (55% prevalence). The aim was to describe a simple technique for managing deep venous reflux in FVD, when just one of the two segments exhibits deep venous reflux.

METHODS

The technique consists of closing the refluxing femoral branch with a titanium clip. In this way abolition of reflux along the duplicated vessel is achieved, together with the restoration of femoral vein drainage.

RESULTS

The technique is feasible and associated with improvement in limb haemodynamics.

CONCLUSIONS

Thanks to the high prevalence of FVD, the proposed technique provides an opportunity to treat a larger number of cases affected by primary or post-thrombotic deep venous reflux.

Unilateral fenestration of the internal jugular vein: a case report

The internal jugular vein (IJV) is a significant landmark that is encountered during dissection of the cervical lymph nodes in oncological surgery, central venous catheter insertion and interventional radiological procedures. The variations in the patterns of its course, and knowledge of these variations, are important. During the neck dissection of an approximately 75-year-old male cadaver, unilateral fenestration of the IJV, the medial branch of which received the submental and linguofacial veins, was found--a case that hitherto has not been reported. An embryological evaluation and the clinical implications of the anomaly are described. Clinicians and surgeons performing neck vascular or reconstructive surgery should be made aware of this variation of the IJV in the hope of preventing inadvertent injury.

Diagnostic ultrasonography for peripheral vascular emergencies

Over the past decade, emergency and critical care physicians have been empowered with the ability to use bedside ultrasonography to assist in the evaluation and management of a variety of emergent conditions. Today a single health care provider at the bedside with Duplex ultrasound technology can evaluate peripheral vascular calamities that once required significant time and a variety of health care personnel for the diagnosis. This article highlights peripheral thromboembolic disease, aneurysm, pseudoaneurysm, and arterial occlusion in the acute care setting.

The deep venous system of the lower extremity: new nomenclature

The correct and precise nomenclature of the veins of the lower extremity is a necessary tool for communication. Three important changes have been done over the last 13 years. Terminologia Anatomica, the latest version of the Latin anatomical nomenclature, was published in 1998, extended in the area of the lower extremity veins with two consensus documents, in 2001, during the 14th World Congress of the International Union of Phlebology and in 2004 during the 21st World Congress of the International Union of Angiology. This article is a free continuation of two previous articles, reviewing the detailed anatomy and correct nomenclature of the superficial veins of the lower extremities and veins of pelvis. Now, it is concentrated on the deep venous system, in which 15 new terms have been added in both Latin and English languages.

Three-dimensional evaluation of the anatomic variations of the femoral vein and popliteal vein in relation to the accompanying artery by using CT venography

OBJECTIVE

We wanted to describe the three-dimensional (3D) anatomic variations of the femoral vein (FV) and popliteal vein (PV) in relation to the accompanying artery using CT venography.

MATERIALS AND METHODS

We performed a retrospective review of 445 bilateral (890 limbs) lower limb CT venograms. After the 3D relationship between the FV and PV and accompanying artery was analyzed, the presence or absence of variation was determined and the observed variations were classified. In each patient, the extent and location of the variations and the location of the adductor hiatus were recorded to investigate the regional frequency of the variations.

RESULTS

THERE WERE FOUR DISTINCT CATEGORIES OF VARIATIONS: agenesis (3 limbs, 0.3%), multiplication (isolated in the FV: 190 limbs, 21%; isolated in the PV: 14 limbs, 2%; and in both the FV and PV: 51 limbs, 6%), anatomical course variation (75 limbs, 8%) and high union of the tibial veins (737 limbs, 83%). The course variations included medial malposition (60 limbs, 7%), anterior rotation (11 limbs, 1%) and posterior rotation (4 limbs, 0.4%). Mapping the individual variations revealed regional differences in the pattern and frequency of the variations.

CONCLUSION

CT venography helps to confirm a high incidence of variations in the lower limb venous anatomy and it also revealed various positional venous anomalies in relation to the respective artery.

Femoral vein duplication: incidence and potential significance

Objective

The purpose of this study was to determine the prevalence of femoral vein duplication and the incidence of bilateral anomalies in a normal cohort of patients presenting with varicose veins.

Methods

Two hundred and forty patients underwent bilateral lower limb deep venous ultrasound examination with particular attention to the femoropopliteal segment.

Results

The incidence of femoral vein duplication was 41%. Of the 140 people with femoral vein duplications, 60 (42%) were bilateral and 80 (57%) were unilateral.

Conclusion

Femoral vein duplication is a common anatomical variant of the lower limb deep venous system. Ultrasound in skilled and experienced hands with the latest ultrasound units can readily demonstrate this venous anomaly on a consistent basis.

A duplex scan-based morphologic study of the femoral vein: Incidence and patterns of duplication

The presence of femoral vein (FV) duplicity has potential influence in the misdiagnosis of deep vein thrombosis. Also, FVs are suitable vascular substitutes, especially in the substitution of infected prosthetic grafts. The objective of this study was to describe the prevalence, anatomic patterns and characteristics of FV duplicity in adult individuals by duplex scan examination. A total of 174 adult individuals were submitted to duplex-scan examinations of both lower limbs. Individuals with duplex signs of present or previous DVT or with poor quality duplex images were excluded from the investigation. The remaining group consisted of 157 individuals (94 females), with a total of 314 limbs studied. Along with the conventional duplex investigation sequence, the FV was scanned both in transversal and longitudinal views. The number, extension and diameter of FVs were documented. It was found that 173 limbs (55.1%) had duplicated FV. Duplicity in the whole femoral extension was noted in 82 (26.1%) limbs, and out of these only 28 (8.9% of the overall number) had accessory veins with a diameter approximate to (at least 75%) the main FV. Partial (distal or proximal) duplications were seen in 89 (28.3%) limbs. A third FV was present in 28 limbs. As a possible vascular substitute, 99.0% of the main FVs and 25.4% of the accessory veins presented diameters superior to 6 mm, a suitable value for iliac substitution. In conclusion, FV duplicity is frequent, and occurred in 55% of all limbs studied. However, complete extension duplicated veins with similar diameters was an uncommon condition, noticed in fewer than 10% of limbs.

Variations in lower limb venous anatomy: implications for US diagnosis of deep vein thrombosis

PURPOSE

To retrospectively review bilateral venograms free of thrombus to evaluate the frequency and types of variations seen in venous anatomy.

MATERIALS AND METHODS

A retrospective review of 404 bilateral (808 limbs) lower limb venograms obtained from medical patients participating in a thromboprophylaxis clinical trial and found to be free of thrombus was performed. Venograms were evaluated according to predetermined criteria for the presence of duplication of vessels and inter- and intraindividual variations in venous anatomy. Variations were assessed with analysis of variance and chi2 tests.

RESULTS

Two vessels were seen in the popliteal fossa on 337 (42%) of 808 venograms, and 41 (5%) were true duplicated popliteal veins. There were 253 (31%) duplicated superficial femoral veins (SFVs), with 12 (1.5%) being complex duplicated systems. Of 265 duplicated SFVs, 138 (52%) began in the midthigh region and 80 (30%), in the adductor canal region. The duplicated vessel was medial to the main SFV in 122 (46%), lateral in 131 (49%), and both (ie, triplications) in 12 (4.5%). The length of the duplicated SFV ranged from 1 to 35 cm; 6-15 cm was the most common length in 162 (62%) SFVs. There was no significant association between the incidence of anatomic variations and age or sex (P >.1). The presence of multiple vessels in one leg was strongly correlated with the probability of occurrence in the other leg (P <.001).

CONCLUSION

Variations in lower limb venous anatomy are common and have important implications for the US diagnosis of deep vein thrombosis.

Planning endovascular vein valve implantation: significance of vein size variability

OBJECTIVE

Endovascular placement of prosthetic valves is currently in clinical trials as treatment for lower extremity venous hypertension caused by valvular insufficiency. Femoropopliteal vein sizing is a critical factor in treatment planning. A wide diameter range could influence selection of an endoprosthesis. Quantitative data describing intrasubject vein diameter variation are scant. We measured vein diameters with ultrasound imaging to assess minimum-maximum diameter range under forced conditions of venoconstriction and venodilatation.

METHODS

Diameter of the common femoral vein (CFV), proximal femoral vein (PFV), mid-femoral vein (MFV), and distal femoral vein (DFV) in the thigh and the popliteal vein (PV) was measured in the morning under conditions of minimal venodilation and in the afternoon under conditions of stressed venodilatation that included activities of daily living and a 5-minute treadmill walk. Measurements were obtained twice on two different days in both extremities in 20 subjects with CEAP clinical classification C(0) (n = 10), C(3) (n = 7), C(4) (n = 1), or C(5) (n = 2).

RESULTS

Average vein diameter increased, from 11.2 +/- 2.5 (SD) mm to 14.5 +/- 2.3 mm at the CFV, from 6.9 +/- 1.8 mm to 9.4 +/- 1.9 mm at the PFV, from 6.9 +/- 1.6 mm to 9.0 +/- 1.8 mm at the MFV, from 7.3 +/- 1.7 mm to 9.1 +/- 1.5 mm at the DFV, and from 8.4 +/- 1.4 mm to 9.7 +/- 1.8 mm at the PV (P <.001 for all differences). Maximum diameter change was 8.2 mm at the CFV, 7.0 mm at the PFV, 6.6 mm at the MFV, 6.0 mm at the DFV, and 5.1 mm at the PV. Dilatation of 4 mm or greater occurred in 43% of CFV, 15% of PFV, 11% of MFV, 3% of DFV, and 1% of PV. Minimum vein diameter was found at PFV in 41%, MFV in 34%, and DFV in 23% of morning measurements and at PFV in 21%, MFV in 38%, DFV in 28%, and PV in 16% of afternoon measurements.

CONCLUSIONS

Femoropopliteal veins demonstrated a wide range of diameters, and significant diameter changes were detected in all vein segments. Variations in vein diameter must be evaluated in candidates for endovascular venous valve prostheses. Such devices must adapt to a wide range in vein diameter.