3d. The Veins of the Lower Extremity, Abdomen, and Pelvis

The veins of the lower extremity are subdivided, like those of the upper, into two sets, superficial and deep; the superficial veins are placed beneath the integument between the two layers of superficial fascia; the deep veins accompany the arteries. Both sets of veins are provided with valves, which are more numerous in the deep than in the superficial set. Valves are also more numerous in the veins of the lower than in those of the upper limb. 1 The Superficial Veins of the Lower Extremity The superficial veins of the lower extremity are the great and small saphenous veins and their tributaries. 2 On the dorsum of the foot the dorsal digital veins receive, in the clefts between the toes, the intercapitular veins from the plantar cutaneous venous arch and join to form short common digital veins which unite across the distal ends of the metatarsal bones in a dorsal venous arch. Proximal to this arch is an irregular venous net-work which receives tributaries from the deep veins and is joined at the sides of the foot by a medial and a lateral marginal vein, formed mainly by the union of branches from the superficial parts of the sole of the foot. 3 On the sole of the foot the superficial veins form a plantar cutaneous venous arch which extends across the roots of the toes and opens at the sides of the foot into the medial and lateral marginal veins. Proximal to this arch is a plantar cutaneous venous net-work which is especially dense in the fat beneath the heel; this net-work communicates with the cutaneous venous arch and with the deep veins, but is chiefly drained into the medial and lateral marginal veins. 4 The great saphenous vein (v. saphena magna; internal or long saphenous vein) (Fig. 581), the longest vein in the body, begins in the medial marginal vein of the dorsum of the foot and ends in the femoral vein about 3 cm. below the inguinal ligament. It ascends in front of the tibial malleolus and along the medial side of the leg in relation with the saphenous nerve. It runs upward behind the medial condyles of the tibia and femur and along the medial side of the thigh and, passing through the fossa ovalis, ends in the femoral vein. 5 Tributaries.—At the ankle it receives branches from the sole of the foot through the medial marginal vein; in the leg it anastomoses freely with the small saphenous vein, communicates with the anterior and posterior tibial veins and receives many cutaneous veins; in the thigh it communicates with the femoral vein and receives numerous tributaries; those from the medial and posterior parts of the thigh frequently unite to form a large accessory saphenous vein which joins the main vein at a variable level. Near the fossa ovalis (Fig. 580) it is joined by the superficial epigastric, superficial iliac circumflex, and superficial external pudendal veins. A vein, named the thoracoepigastric, runs along the lateral aspect of the trunk between the superficial epigastric vein below and the lateral thoracic vein above and establishes an important communication between the femoral and axillary veins. 6

FIG. 580– The great saphenous vein and its tributaries at the fossa ovalis. (See enlarged image) The valves in the great saphenous vein vary from ten to twenty in number; they are more numerous in the leg than in the thigh. 7 The small saphenous vein (v. saphena parva; external or short saphenous vein) (Fig. 582) begins behind the lateral malleolus as a continuation of the lateral marginal vein; it first ascends along the lateral margin of the tendocalcaneus, and then crosses it to reach the middle of the back of the leg. Running directly upward, it perforates the deep fascia in the lower part of the popliteal fossa, and ends in the popliteal vein, between the heads of the Gastrocnemius. It communicates with the deep veins on the dorsum of the foot, and receives numerous large tributaries from the back of the leg. Before it pierces the deep fascia, it gives off a branch which runs upward and forward to join the great saphenous vein. The small saphenous vein possesses from nine to twelve valves, one of which is always found near its termination in the popliteal vein. In the lower third of the leg the small saphenous vein is in close relation with the sural nerve, in the upper two-thirds with the medial sural cutaneous nerve. 8 The Deep Veins of the Lower Extremity The deep veins of the lower extremity accompany the arteries and their branches; they possess numerous valves. 9

FIG. 581– The great saphenous vein and its tributaries. (See enlarged image)

FIG. 582– The small saphenous vein. (See enlarged image) The plantar digital veins (vv. digitales plantares) arise from plexuses on the plantar surfaces of the digits, and, after sending intercapitular veins to join the dorsal digital veins, unite to form four metatarsal veins; these run backward in the metatarsal spaces, communicate, by means of perforating veins, with the veins on the dorsum of the foot, and unite to form the deep plantar venous arch which lies alongside the plantar arterial arch. From the deep plantar venous arch the medial and lateral plantar veins run backward close to the corresponding arteries and, after communicating with the great and small saphenous veins, unite behind the medial malleolus to form the posterior tibial veins. 10

The posterior tibial veins (vv. tibiales posteriores) accompany the posterior tibial artery, and are joined by the peroneal veins. 11 The anterior tibial veins (vv. tibiales anteriores) are the upward continuation of the venæ comitantes of the dorsalis pedis artery. They leave the front of the leg by passing between the tibia and fibula, over the interosseous membrane, and unite with the posterior tibial, to form the popliteal vein. 12 The Popliteal Vein (v. poplitea) (Fig. 583) is formed by the junction of the anterior and posterior tibial veins at the lower border of the Popliteus; it ascends through the popliteal fossa to the aperture in the Adductor magnus, where it becomes the femoral vein. In the lower part of its course it is placed medial to the artery; between the heads of the Gastrocnemius it is superficial to that vessel; but above the knee-joint, it is close to its lateral side. It receives tributaries corresponding to the branches of the popliteal artery, and it also receives the small saphenous vein. The valves in the popliteal vein are usually four in number. 13 The femoral vein (v. femoralis) accompanies the femoral artery through the upper two-thirds of the thigh. In the lower part of its course it lies lateral to the artery; higher up, it is behind it; and at the inguinal ligament, it lies on its medial side, and on the same plane. It receives numerous muscular tributaries, and about 4 cm. below the inguinal ligament is joined by the v. profunda femoris; near its termination it is joined by the great saphenous vein. The valves in the femoral vein are three in number. 14 The Deep Femoral Vein (v. profunda femoris) receives tributaries corresponding to the perforating branches of the profunda artery, and through these establishes communications with the popliteal vein below and the inferior gluteal vein above. It also receives the medial and lateral femoral circumflex veins. 15

FIG. 583– The popliteal vein. (See enlarged image) The Veins of the Abdomen and Pelvis (Figs. 585, 586, 587) The external iliac vein (v. iliaca externa), the upward continuation of the femoral vein, begins behind the inguinal ligament, and, passing upward along the brim of the lesser pelvis, ends opposite the sacroiliac articulation, by uniting with the hypogastric vein to form the common iliac vein. On the right side, it lies at first medial to the artery: but, as it passes upward, gradually inclines behind it. On the left side, it lies altogether on the medial side of the artery. It frequently contains one, sometimes two, valves. 16 Tributaries.—The external iliac vein receives the inferior epigastric, deep iliac circumflex, and pubic veins. 17 The Inferior Epigastric Vein (v. epigastrica inferior; deep epigastric vein) is formed by the union of the venæ comitantes of the inferior epigastric artery, which communicate above with the superior epigastric vein; it joins the external iliac about 1.25 cm. above the inguinal ligament. 18 The Deep Iliac Circumflex Vein (v. circumflexa ilium profunda) is formed by the union of the venæ comitantes of the deep iliac circumflex artery, and joins the external iliac vein about 2 cm. above the inguinal ligament. 19 The Pubic Vein communicates with the obturator vein in the obturator foramen, and ascends on the back of the pubis to the external iliac vein. 20 The hypogastric vein (v. hypogastrica; internal iliac vein) begins near the upper part of the greater sciatic foramen, passes upward behind and slightly medial to the hypogastric artery and, at the brim of the pelvis, joins with the external iliac to form the common iliac vein. 21

FIG. 584– The femoral vein and its tributaries. (Poirier and Charpy.) (See enlarged image) Tributaries.—With the exception of the fetal umbilical vein which passes upward and backward from the umbilicus to the liver, and the iliolumbar vein which usually joins the common iliac vein, the tributaries of the hypogastric vein correspond with the branches of the hypogastric artery. It receives (a) the gluteal, internal pudendal, and obturator veins, which have their origins outside the pelvis; (b) the lateral sacral veins, which lie in front of the sacrum; and (c) the middle hemorrhoidal, vesical, uterine, and vaginal veins, which originate in venous plexuses connected with the pelvic viscera. 22 1. The Superior Gluteal Veins (vv. glutaeæ superiores; gluteal veins) are venæ comitantes of the superior gluteal artery; they receive tributaries from the buttock corresponding with the branches of the artery, and enter the pelvis through the greater sciatic foramen, above the Piriformis, and frequently unite before ending in the hypogastric vein. 23

FIG. 585– The veins of the right half of the male pelvis. (Spalteholz). (See enlarged image) 2. The Inferior Gluteal Veins (vv. glutaeæ inferiores; sciatic veins), or venæ comitantes of the inferior gluteal artery, begin on the upper part of the back of the thigh, where they anastomose with the medial femoral circumflex and first perforating veins. They enter the pelvis through the lower part of the greater sciatic foramen and join to form a single stem which opens into the lower part of the hypogastric vein. 24 3. The Internal Pudendal Veins (internal pudic veins) are the venæ comitantes of the internal pudendal artery. They begin in the deep veins of the penis which issue from the corpus cavernosum penis, accompany the internal pudendal artery, and unite to form a single vessel, which ends in the hypogastric vein. They receive the veins from the urethral bulb, and the perineal and inferior hemorrhoidal veins. The deep dorsal vein of the penis communicates with the internal pudendal veins, but ends mainly in the pudendal plexus. 25

FIG. 586– The iliac veins. (Poirier and Charpy.) (See enlarged image)

FIG. 587– Scheme of the anastomosis of the veins of the rectum. (Poirier and Charpy.) (See enlarged image) 4. The Obturator Vein (v. obturatoria) begins in the upper portion of the adductor region of the thigh and enters the pelvis through the upper part of the obturator foramen. It runs backward and upward on the lateral wall of the pelvis below the obturator artery, and then passes between the ureter and the hypogastric artery, to end in the hypogastric vein. 26 5. The Lateral Sacral Veins (vv. sacrales laterales) accompany the lateral sacral arteries on the anterior surface of the sacrum and end in the hypogastric vein. 27 6. The Middle Hemorrhoidal Vein (v. hæmorrhoidalis media) takes origin in the hemorrhoidal plexus and receives tributaries from the bladder, prostate, and seminal vesicle; it runs lateralward on the pelvic surface of the Levator ani to end in the hypogastric vein. 28 The hemorrhoidal plexus (plexus hæmorrhoidalis) surrounds the rectum, and communicates in front with the vesical plexus in the male, and the uterovaginal plexus in the female. It consists of two parts, an internal in the submucosa, and an external outside the muscular coat. The internal plexus presents a series of dilated pouches which are arranged in a circle around the tube, immediately above the anal orifice, and are connected by transverse branches. 29 The lower part of the external plexus is drained by the inferior hemorrhoidal veins into the internal pudendal vein; the middle part by the middle hemorrhoidal vein which joins the hypogastric vein; and the upper part by the superior hemorrhoidal vein which forms the commencement of the inferior mesenteric vein, a tributary of the portal vein. A free communication between the portal and systemic venous systems is established through the hemorrhoidal plexus. 30 The veins of the hemorrhoidal plexus are contained in very loose, connective tissue, so that they get less support from surrounding structures than most other veins, and are less capable of resisting increased blood-pressure. 31 The pudendal plexus (plexus pudendalis; vesicoprostatic plexus) lies behind the arcuate public ligament and the lower part of the symphysis pubis, and in front of the bladder and prostate. Its chief tributary is the deep dorsal vein of the penis, but it also receives branches from the front of the bladder and prostate. It communicates with the vesical plexus and with the internal pudendal vein and drains into the vesical and hypogastric veins. The prostatic veins form a well-marked prostatic plexus which lies partly in the fascial sheath of the prostate and partly between the sheath and the prostatic capsule. It communicates with the pudendal and vesical plexuses. 32 The vesical plexus (plexus vesicalis) envelops the lower part of the bladder and the base of the prostate and communicates with the pudendal and prostatic plexuses. It is drained, by means of several vesical veins, into the hypogastric veins. 33 The Dorsal Veins of the Penis (vv. dorsales penis) are two in number, a superficial and a deep. The superficial vein drains the prepuce and skin of the penis, and, running backward in the subcutaneous tissue, inclines to the right or left, and opens into the corresponding superficial external pudendal vein, a tributary of the great saphenous vein. The deep vein lies beneath the deep fascia of the penis; it receives the blood from the glans penis and corpora cavernosa penis and courses backward in the middle line between the dorsal arteries; near the root of the penis it passes between the two parts of the suspensory ligament and then through an aperture between the arcuate pubic ligament and the transverse ligament of the pelvis, and divides into two branches, which enter the pudendal plexus. The deep vein also communicates below the symphysis pubis with the internal pudendal vein. 34 The uterine plexuses lie along the sides and superior angles of the uterus between the two layers of the broad ligament, and communicate with the ovarian and vaginal plexuses. They are drained by a pair of uterine veins on either side: these arise from the lower part of the plexuses, opposite the external orifice of the uterus, and open into the corresponding hypogastric vein. 35 The vaginal plexuses are placed at the sides of the vagina; they communicate with the uterine, vesical, and hemorrhoidal plexuses, and are drained by the vaginal veins, one on either side, into the hypogastric veins. 36

FIG. 588– The penis in transverse section, showing the bloodvessels. (Testut.) (See enlarged image) The common iliac veins (vv. iliacæ communes) are formed by the union of the external iliac and hypogastric veins, in front of the sacroiliac articulation; passing obliquely upward toward the right side, they end upon the fifth lumbar vertebra, by uniting with each other at an acute angle to form the inferior vena cava. The right common iliac is shorter than the left, nearly vertical in its direction, and ascends behind and then lateral to its corresponding artery. The left common iliac, longer than the right and more oblique in its course, is at first situated on the medial side of the corresponding artery, and then behind the right common iliac. Each common iliac receives the iliolumbar, and sometimes the lateral sacral veins. The left receives, in addition, the middle sacral vein. No valves are found in these veins. 37 The Middle Sacral Veins (vv. sacrales mediales) accompany the corresponding artery along the front of the sacrum, and join to form a single vein, which ends in the left common iliac vein; sometimes in the angle of junction of the two iliac veins. 38

FIG. 589– Vessels of the uterus and its appendages, rear view. (Testut.) (See enlarged image) Peculiarities.—The left common iliac vein, instead of joining with the right in its usual position, occasionally ascends on the left side of the aorta as high as the kidney, where, after receiving the left renal vein, it crosses over the aorta, and then joins with the right vein to form the vena cava. In these cases, the two common iliacs are connected by a small communicating branch at the spot where they are usually united. 39 The inferior vena cava (v. cava inferior) (Fig. 577), returns to the heart the blood from the parts below the diaphragm. It is formed by the junction of the two common iliac veins, on the right side of the fifth lumbar vertebra. It ascends along the front of the vertebral column, on the right side of the aorta, and, having reached the liver, is continued in a groove on its posterior surface. It then perforates the diaphragm between the median and right portions of its central tendon; it subsequently inclines forward and medialward for about 2.5 cm., and, piercing the fibrous pericardium, passes behind the serous pericardium to open into the lower and back part of the right atrium. In front of its atrial orifice is a semilunar valve, termed the valve of the inferior vena cava: this is rudimentary in the adult, but is of large size and exercises an important function in the fetus (see page 540). 40 Relations.—The abdominal portion of the inferior vena cava is in relation in front, from below upward, with the right common iliac artery, the mesentery, the right internal spermatic artery, the inferior part of the duodenum, the pancreas, the common bile duct, the portal vein, and the posterior surface of the liver; the last partly overlaps and occasionally completely surrounds it; behind, with the vertebral column, the right Psoas major, the right crus of the diaphragm, the right inferior phrenic, suprarenal, renal and lumbar arteries, right sympathetic trunk and right celiac ganglion, and the medial part of the right suprarenal gland; on the right side, with the right kidney and ureter; on the left side, with the aorta, right crus of the diaphragm, and the caudate lobe of the liver. 41 The thoracic portion is only about 2.5 cm. in length, and is situated partly inside and partly outside the pericardial sac. The extrapericardial part is separated from the right pleura and lung by a fibrous band, named the right phrenicopericardiac ligament. This ligament, often feebly marked, is attached below to the margin of the vena-caval opening in the diaphragm, and above to the pericardium in front of and behind the root of the right lung. The intrapericardiac part is very short, and is covered antero-laterally by the serous layer of the pericardium. 42 Peculiarities.—In Position.—This vessel is sometimes placed on the left side of the aorta, as high as the left renal vein, and, after receiving this vein, crosses over to its usual position on the right side; or it may be placed altogether on the left side of the aorta, and in such a case the abdominal and thoracic viscera, together with the great vessels, are all transposed. 43 Point of Termination.—Occasionally the inferior vena cava joins the azygos vein, which is then of large size. In such cases, the superior vena cava receives the whole of the blood from the body before transmitting it to the right atrium, except the blood from the hepatic veins, which passes directly into the right atrium. 44 Tributaries.—The inferior vena cava receives the following veins: 45

Lumbar.		Renal.		Inferior Phrenic.
Right Spermatic or Ovarian.		Suprarenal.		Hepatic.

The Lumbar Veins (vv. lumbales) four in number on each side, collect the blood by dorsal tributaries from the muscles and integument of the loins, and by abdominal tributaries from the walls of the abdomen, where they communicate with the epigastric veins. At the vertebral column, they receive veins from the vertebral plexuses, and then pass forward, around the sides of the bodies of the vertebræ, beneath the Psoas major, and end in the back part of the inferior cava. The left lumbar veins are longer than the right, and pass behind the aorta. The lumbar veins are connected together by a longitudinal vein which passes in front of the transverse processes of the lumbar vertebræ, and is called the ascending lumbar; it forms the most frequent origin of the corresponding azygos or hemiazygos vein, and serves to connect the common iliac, iliolumbar, and azygos or hemiazygos veins of its own side of the body. 46 The Spermatic Veins (vv. spermaticæ) (Fig. 590) emerge from the back of the testis, and receive tributaries from the epididymis; they unite and form a convoluted plexus, called the pampiniform plexus, which constitutes the greater mass of the spermatic cord; the vessels composing this plexus are very numerous, and ascend along the cord, in front of the ductus deferens. Below the subcutaneous inguinal ring they unite to form three or four veins, which pass along the inguinal canal, and, entering the abdomen through the abdominal inguinal ring, coalesce to form two veins, which ascend on the Psoas major, behind the peritoneum, lying one on either side of the internal spermatic artery. These unite to form a single vein, which opens on the right side into the inferior vena cava, at an acute angle; on the left side into the left renal vein, at a right angle. The spermatic veins are provided with valves. 107 The left spermatic vein passes behind the iliac colon, and is thus exposed to pressure from the contents of that part of the bowel. 47 The Ovarian Veins (vv. ovaricæ) correspond with the spermatic in the male; they form a plexus in the broad ligament near the ovary and uterine tube, and communicate with the uterine plexus. They end in the same way as the spermatic veins in the male. Valves are occasionally found in these veins. Like the uterine veins, they become much enlarged during pregnancy. 48

FIG. 590– Spermatic veins. (Testut.) (See enlarged image) The Renal Veins (vv. renales) are of large size, and placed in front of the renal arteries. The left is longer than the right, and passes in front of the aorta, just below the origin of the superior mesenteric artery. It receives the left spermatic and left inferior phrenic veins, and, generally, the left suprarenal vein. It opens into the inferior vena cava at a slightly higher level than the right. 49 The Suprarenal Veins (vv. suprarenales) are two in number: the right ends in the inferior vena cava; the left, in the left renal or left inferior phrenic vein. 50 The Inferior Phrenic Veins (vv. phrenicæ inferiores) follow the course of the inferior phrenic arteris; the right ends in the inferior vena cava; the left is often represented by two branches, one of which ends in the left renal or suprarenal vein, while the other passes in front of the esophageal hiatus in the diaphragm and opens into the inferior vena cava. 51 The Hepatic Veins (vv. hepaticæ) commence in the substance of the liver, in the terminations of the portal vein and hepatic artery, and are arranged in two groups, upper and lower. The upper group usually consists of three large veins, which converge toward the posterior surface of the liver, and open into the inferior vena cava, while that vessel is situated in the groove on the back part of the liver. The veins of the lower group vary in number, and are of small size; they come from the right and caudate lobes. The hepatic veins run singly, and are in direct contact with the hepatic tissue. They are destitute of valves. 52

FIG. 591– The portal vein and its tributaries. (See enlarged image)

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