Venous Physiology
and Hemodynamics
of Lower Limbs
Riju Ramachandran Menon
Contents
Introduction ............................................................
Normal Venous Drainage of Lower Limbs ..........
The Veins of Lower Limb .........................................
Venous Valves ...........................................................
Muscle Pumps ...........................................................
Correlation with Ambulatory Venous
Pressure Studies .....................................................
Abnormal Hemodynamics in Chronic
Venous Disorders....................................................
Reflux in Superficial Veins........................................
Reflux/Obstruction of the Deep Veins ......................
Incompetence of Perforators .....................................
Summary.................................................................
References ...............................................................
R.R. Menon
General Surgery, Amrita Institute of Medical
Sciences, Amrita Lane, Kochi, Kerala 682041, India
e-mail: rijurmenon@gmail.com
S. Vaidyanathan et al., Chronic Venous Disorders of the Lower Limbs: A Surgical Approach,
DOI 10.1007/978-81-322-1991-0_3, © Springer India 2015
3
Introduction
17
The venous system of the lower limbs is an
17
18 organized and functional unit. Returning blood to
18 the heart is its primary function. Several factors are
18 involved in the control of this system. These include
gravity, the reservoir capacity, venous tone, sympa-
20 thetic control of smooth muscles, and many other
mechanisms. Most of our misunderstanding of
20 venous diseases stems from the inability to appre-
21 ciate the delicate anatomy and physiology. Details
21 of anatomy were considered in Chap. 2.
22
This chapter focuses on the physiology of the
23 lower limb venous system. In this section, we
23 plan to discuss the following:
• Physiology of normal venous drainage
• Altered hemodynamics in venous disorders
A simple and effective way to comprehend
venous physiology would be to consider the flow
and pressure patterns in health and disease. In
the clinical setting, this information is obtained
by the ambulatory venous pressure (AVP)
studies.
Normal Venous Drainage
of Lower Limbs
The peripheral venous system functions as a res-
ervoir to store blood and as a conduit to return
blood to the heart. In a person in the erect pos-
ture, blood entering the lower-extremity venous
system must travel against gravity and against
17
18 3 Venous Physiology and Hemodynamics of Lower Limbs
fluctuating thoracoabdominal pressures to return
to the central circulation. Proper functioning of
the system depends on the coordinated function-
ing of several parts.
There are three components of the venous sys-
tem. These are the veins of the lower limb, the
valves in the veins, and the muscle pumps.
The Veins of Lower Limb
The veins of the lower extremity are arranged
into the superficial, deep, and perforating
systems [1]. Blood flow in these veins is always
unidirectional and cephalad. Gravity and hydro-
static pressure oppose venous return in the
upright position. A system of valves, an efficient
peripheral pump mechanism, and a negative
intrathoracic pressure overcome the effects of
gravity [2, 3].
The superficial venous system comprising the
GSV and SSV and the interconnecting network
of veins function as conduits to return blood to
the deep venous system [2]. The predominant
flow from the saphenous system is through the
perforator into the deep veins. This arrangement
is especially dominant during activity. Blood sel-
dom travels up along the entire length of the
superficial veins except when the deep veins are
blocked. Eighty percent of the blood from the
lower limb is conveyed to the heart through the
deep venous system.
The deep venous system is located below
the muscular fascia and serves as collecting
veins and the outflow from the extremity.
Venous sinuses of the gastrocnemius and
soleus muscles are blood-filled spaces with a
capacitance function and serve as chambers of
the peripheral heart. The venous sinuses drain
to the deep veins. The deep veins are sur-
rounded by powerful muscle and the deep fas-
cia of the leg.
The perforating veins connect the deep and the
superficial system. Their primary function is as
drainage conduits from superficial to the deep
system.
Venous Valves
• The superficial, deep, and most perforating
veins contain bicuspid valves formed from
folds of endothelium, supported by a thin
layer of connective tissue. Valves are most
numerous in the distal leg and decrease in
number in the upper part of the limb [4].
Valves subserve two functions:
• They promote unidirectional cephalad flow
toward the heart.
• They break the hydrostatic column of blood
into segments.
Normally, at rest, the valves remain open. The
valves close during muscular activity. This is a
passive event and is initiated by a higher pressure
in the supravalvular segment produced by pos-
ture and muscle activity. There is a transient
phase of retrograde flow lasting for less than
0.5 s. This retrograde flow must be of sufficient
velocity to coapt the cusps completely [5]
(Fig. 3.1).
In the upright posture, a reflux lasting less
than 0.5 s is physiological; if the duration exceeds
0.5 s, it is defined as pathological reflux. The
importance of incompetence of a single valve or
several valves in genesis of clinical effects is not
definitely known [2].
Muscle Pumps
The calf muscle pump is the most powerful force
that facilitates venous return from the lower
limbs. The thigh and foot muscle pumps also
function to some extent toward this purpose.
Contraction of the calf muscle pump increases
the pressure within the fascial compartments and
forces blood up along the deep venous system
(systole of the muscle pump). The competent
valves prevent reflux distally within the deep
venous system or through the perforators into the
superficial veins (Fig. 3.2).
When the calf muscles relax, the pressure in
the fascial compartment drops. During this phase,
blood from the superficial veins and the sinuses
Normal Venous Drainage of Lower Limbs
Fig. 3.1 Mechanism of valve closure
19
SFJ
GSV
80 % flow 20 % flow
Formoral vein
Fig. 3.2 Normal venous drainage of lower limb
fills the deep system through the perforating
veins (diastole of the muscle pump). The deep
fascia of the leg supports the muscle pump con-
siderably. The net effect of a series of contrac-
tions of the calf muscle pump would be to
promote a streamlined, unidirectional, and ceph-
alad flow toward the heart. This effectively
reduces the pressure and volume in the superfi-
cial venous system during ambulation [3, 6].
The thigh muscle pump is not as powerful as
the calf muscle pump in spite of the fact that
these muscles are bulkier. Two reasons are attrib-
uted for its less powerful action – rapid refill and
less compressible intermuscular location of the
deep veins in the thigh [2]. The ejection fraction
of the calf muscle pump is around 65 %, in com-
parison with only 15 % for the thigh pump [6].
The foot and lower leg biomechanics also play
a major role in venous return. When the sole of
20
the foot makes contact with the ground, the
lateral plantar veins are emptied and blood is
forced into the posterior tibial veins. This marks
the first but essential step of venous return from
the lower limbs. The calf muscle pump then
sequentially takes over from the foot muscle
pump [7]. When the foot muscle pump contracts,
50 % of the perforators of the foot permit flow
from the deep to the superficial veins [2]. The
role of the foot muscle pump could be crucial in
the genesis of chronic venous disorders. It has
been identified that static foot disorders may be
associated with impaired venous return from the
lower limbs [7].
In an average individual walking 100 steps a min-
ute, the combined stroke volume of the calf muscle
pumps of both sides is estimated as 6.0 l/min2.
Correlation with Ambulatory
Venous Pressure Studies
In the clinical setting, the function of the calf
muscle pump is best demonstrated by recording
the ambulatory venous pressure (AVP) in the foot
veins. AVP studies are primarily aimed at record-
ing the drop in venous pressure in the superficial
veins of the foot following a series of calf muscle
contractions such as standing on toes [8].
A foot vein is cannulated and connected to a
pressure transducer and a three-channel recorder
or a manometer system through a three-way
stopcock and a saline reservoir. The pressure in
the foot vein with the patient standing upright
and at rest is first recorded – resting pressure
(RP). This will be roughly equivalent to the
weight of the column of blood from the right
heart to the point of measurement and varies
according to the height of the individual. On an
average, it is around 100 mm of Hg. The subject
is asked to perform a series of standing on toe
movements with the cannula in situ. This will
produce a powerful contraction of the calf mus-
cle. The pressure after a series of 10–15 contrac-
tions drops down by 50–60 % and thereafter
remains steady irrespective of the extent of
activity. The lowest pressure recorded after the
3 Venous Physiology and Hemodynamics of Lower Limbs
Normal venous pattern
A
Pressure in mmHg
100 C
B
40
without PSO
Time in sec 25
Fig. 3.3 AVP normal venous pattern. Note the prominent
drop in PEP. (A) Resting pressure at start of exercise. (B)
Maximum pressure fall with exercise. (BC) Recovery
time
series of muscle contractions is designated as
the postexercise pressure (PEP). On cessation of
the exercise, when the subject is at rest, the pres-
sure slowly returns to the original resting value.
The time taken for the PEP to return to the RP is
designated as the recovery time (RT). In normal
subjects, this is about 20–30 s. This AVP pattern
is known as the normal venous pattern (Fig. 3.3).
In patients with venous disorders, the drop in
PEP is very negligible. Also, the recovery time is
much faster (0–5 s). Thus the AVP pattern, nor-
mal and abnormal, can give an insight into the
functioning of the calf muscle pump in health and
disease.
Abnormal Hemodynamics
in Chronic Venous Disorders
As we have seen in the previous section, the
activity of the calf muscle pump reduces the pres-
sure and volume of blood in the superficial
venous system. This remarkable ability of the
muscle pump is diminished in patients with
venous disorders of the lower limbs, resulting in
a persistently elevated PEP. In clinical parlance,
this is referred to as ambulatory venous hyperten-
sion. Side by side, the RT is short from rapid
reflux refilling. The pathological situations
Abnormal Hemodynamics in Chronic Venous Disorders
leading onto development of ambulatory venous
hypertension include the following:
• Presence of reflux in the saphenous systems
• Reflux/obstruction in deep veins
• Incompetence of medial calf perforators
In clinical practice, these pathologies exist in
combination. But for clarity, they will be consid-
ered in isolation.
Reflux in Superficial Veins
An incompetent superficial system permits blood
to reflux. If the perforators are normal, the calf
muscle pump can cope up with the extra load and
reduce the exercise pressure. If there is a large-
volume SF/SP junction reflux, the extra load is
carried into the deep veins through the next reen-
try perforator. This establishes a vicious cycle
often referred to as private circulation [9]. To
accommodate the extra load, two secondary
events develop; the volume overload can stretch
the deep veins and the perforators can get dilated
and become secondarily incompetent. These
changes are reversible. Elimination of reflux in
the saphenous system can revert both changes.
The cause of valve failure in the saphenous
system is not very clear. Till now, primary struc-
tural changes in the valve cusp resulting in reflux
from above downward were considered to be the
sequence of events. This is the traditional descend-
ing valvular incompetence theory of Friedrich
Trendelenburg. Recently it has been suggested
that valvular incompetence is secondary to vein
wall dilatation. Venous dilatation can develop
below the valves. Reflux in saphenous system can
proceed in an ascending fashion. This is the
ascending valvular incompetence theory [10].
Correlation with AVP Studies
AVP studies in this group of patients demonstrated
elevated PEP and rapid RT. However, it was
observed that this high pressure returned to near
normal values when the test was repeated after
applying a tourniquet in the thigh below the SFJ to
occlude the superficial veins (proximal saphenous
occlusion – PSO). The RT also normalized after
21
A C
C1
B
Pressure in mmHg
B1
A,B,C-without PSO
A,B1,C1-with PSO
Time in sec
Fig. 3.4 AVP superficial venous pattern. PSO normalizes
the AVP pattern. (A) Resting pressure at start of exercise.
(B) Maximum pressure fall with exercise. (BC) Recovery
time
PSO [8]. This pattern of AVP is known as “super-
ficial venous pattern.” These findings indicate that
in this subset of patients ambulatory venous hyper-
tension could be easily controlled by correction of
reflux in the saphenous system (Fig. 3.4).
Reflux/Obstruction of the Deep Veins
Reflux in the deep veins, axial or segmental, is a com-
mon finding in patients with primary chronic venous
insufficiency. In patients with post-thrombotic syn-
drome, there could be reflux, obstruction, or both.
Reflux in deep veins resulting from valvular
incompetence from any cause can produce sig-
nificant alterations of venous return. The normal,
streamlined, unidirectional, and cephalad blood
flow in deep veins is converted into a turbulent,
bidirectional, up-and-down movement, the “yo-
yo” effect [10] (Fig. 3.5).
There is stagnation and distention of the deep
veins which in turn make the perforators and
superficial systems secondarily incompetent –
“safety valves.” Skin changes and ulcerations are
very common in such a situation. The effects are
more pronounced in the presence of chronic
obstruction in the deep veins or when obstruction
and reflux coexist as in patients with post-
thrombotic syndrome.
22
Incompetent SFJ
Varicose GSV
Fig. 3.5 Yo-yo effect. Effect of reflux in deep veins. “Safety
valve” – incompetent perforator and superficial vein
Correlation with AVP
The PEP remains elevated in this group of patients
with reflux/obstruction in deep veins. PSO using
above knee tourniquet does not lower the high
exercise pressure, unlike in the previous group.
This pattern is known as “deep venous pattern”
(Fig. 3.6). Such patients may need extensive pro-
cedures such as valve reconstruction in the deep
veins. When there is an obstruction in the deep
veins, the PEP may even rise above the RP. These
patients typically experience the symptom of
venous claudication. Relieving the obstruction
in the deep veins by endovenous stenting of an
occluded iliac segment can offer considerable
improvement in such patients.
Incompetence of Perforators
The impact of incompetent perforators in venous
hemodynamics is very complex. The effect depends
on the status of the other systems. As long as the
calf muscle pump is functioning normally, the extra
load resulting from reflux from the perforators does
3 Venous Physiology and Hemodynamics of Lower Limbs
Deep venous pattern
C
A
Pressure in mmHg
B C1
B1
Without PSO
with PSO
Time in sec
Fig. 3.6 Deep venous pattern. PSO had no effect on PEP.
(A) Resting pressure. (B) Maximum pressure fall with
exercise. (BC) Recovery time
not create any strain. This is because the volume of
blood ejected from these vessels is not very signifi-
cant. Such a situation is observed when perforator
incompetence coexists with saphenous reflux. This
is the consequence of the private circulation
described earlier. As already mentioned, elimina-
tion of reflux in the saphenous system reverts the
dilated perforators to normal size.
Incompetent perforators affect lower
limb venous physiology only when they are
hemodynamically significant. Objective findings
of such pathological perforators are outward
flow duration more than 500 ms and size equal to
or more than 3.5 mm [11]. Such perforators are
commonly associated with a pathological deep
venous system. Negus named them “Leaking
Bellows.” They produce large-volume, high-
pressure leak of blood from deep to superficial
veins during calf muscle contraction – the ankle
blowout syndrome [12]. The calf muscle pump
cannot cope up with such a situation of high
venous pressure. Skin changes and ulceration are
very common in such a setting.
Correlation with AVP
When saphenous reflux is the dominant factor
along with perforator incompetence, the high PEP
drops down with PSO. But the drop in PEP may
not be as marked as in a patient with isolated saphe-
nous reflux [8]. In this group of patients, elimina-
tion of the saphenous reflux would normalize the
venous dynamics significantly. In combined deep
and perforator incompetence with or without