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Purpose: To evaluate congenital anastomotic channels between femoropopliteal veins and deep femoral veins with the use of computed tomographic (CT) venography., Materials and Methods: CT venography of 488 limbs in 244 patients (105 men; mean age, 61 y; age range, 18-96 y) performed between January 2016 and December 2016 was retrospectively evaluated. The presence or absence of anastomotic channels (> 3 mm in diameter) connecting a femoropopliteal vein to a deep femoral vein was determined, and the observed channels were classified based on their location and course., Results: Two types of anastomotic channels were observed in 32 patients (13%): a persistent sciatic vein (PSV) in 24 limbs of 15 patients (6%) and a retrofemoral channel (RFC) in 22 limbs of 19 patients (8%). A PSV anastomosed with the popliteal vein in the popliteal fossa, coursed posterior to the adductor magnus muscle, and drained into the deep femoral vein. An RFC anastomosed with the femoral vein at the level of the adductor hiatus, coursed posterior to the femoral shaft, and drained into the deep femoral vein. PSVs and RFCs were of similar size or larger than adjacent femoropopliteal veins in 50% (12 of 24) and 22% of limbs (4 of 22), respectively., Conclusions: Anastomotic channels connecting a femoropopliteal vein to a deep femoral vein are not a rare variation and may have an important role in collateral venous drainage of the lower extremities., (Copyright © 2019 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Contemporary texts frequently present the venous system of the lower limb as a prime example of bilateral symmetry. However, overt bilateral asymmetry may be noted. This study was designed to examine and to quantify the level of symmetry in the lower extremity veins., Methods: This prospective cohort study evaluated major anatomic differences between right and left lower extremity veins in adult patients. Two hundred patients presenting with signs and symptoms of chronic venous disease (CVD; class 2-6) and venous reflux on duplex ultrasound were examined. A second group of 25 healthy volunteers without reflux or obstruction were used as controls. Those with conditions that could potentially alter vasculature, including vascular malformation, lower extremity trauma, and previously documented surgery for venous disease or bypass operations, were excluded. Only overt changes in the main superficial veins (great saphenous and small saphenous veins) and deep veins (femoral, popliteal, peroneal, and tibial veins) of the lower extremities were examined for symmetry. The level of small saphenous vein termination and thigh extension veins were also included. Location and extent of hypoplasia or aplasia and venous duplication or triplication were noted for all venous segments., Results: Of the 100 patients (200 limbs) with CVD class 2-3 (age, 49 years; range, 21-78 years), the extent of asymmetry in the superficial system, deep system, and combined was 84%, 86%, and 100%, respectively. Similarly, of the 100 patients (200 limbs) with CVD class 4-6 (age, 56 years; range, 28-84 years), the level of asymmetry in the superficial system, deep system, and combined was 83%, 84%, and 100%, respectively. Fifty (100 limbs) healthy volunteers (age, 46 years; range, 18-74 years) also presented similarly elevated levels of asymmetry compared with both cohorts of differing CVD class severity (superficial, 78%; deep, 84%; both, 100%). The most common reason for asymmetry in the great saphenous vein was hypoplasia or aplasia, whereas duplication was rare. In the small saphenous vein, the level of termination, thigh extension, and hypoplasia were the more frequent reasons. In the deep veins, duplication of the femoral and popliteal veins at different locations and extents was the most common finding for asymmetry. These findings remained consistent for all subgroups of patients and healthy controls., Conclusions: A complete lack of symmetry is consistently seen in CVD patients and healthy subjects. Asymmetry in the veins of the lower extremities appears to be the norm. This is true despite examination of only overt changes and exclusion of multiple veins from the comparison., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Phacomatosis pigmentovascularis (PPV) is a rare genodermatosis characterized by the co-existence of an extensive vascular and a pigmentary nevus with or without extracutaneous manifestations. We report two such rare cases. The first is a 3-year-old boy exhibiting a rare association of cutis marmorata telangiectatica congenita with aberrant dermal melanocytosis along with hypospadias and melanosis oculi (traditionally classified as PPV type Vb or phacomatosis cesiomarmorata - Happle's classification). The other patient is a 5-year-old boy with Sturge-Weber syndrome, Klippel-Trenaunay syndrome, aplasia of iliac, femoral, and popliteal veins and congenital heart disease, associated with aberrant dermal melanocytosis and melanosis oculi (also classified as PPV type IIb or phacomatosis cesioflammea). These sporadic cases display a unique constellation of additional, previously unreported systemic associations, which will further expand the clinical spectrum of phacomatosis pigmentovascularis.

Objective: Bilateral large variant veins were encountered in the lower extremity. It was aimed to identify the structural characteristics of this rare case and then, regarding the structural features, to overview its formation process and denomination., Material and Method: During the routine dissection of a 93-year-old male cadaver, bilateral large variant veins were found at the thigh. Valves of the veins were examined and evaluated together with the vascular wall histology., Results: The variant vein was loosely attached to the sciatic nerve by fibrous tissue and had anastomoses with the popliteal vein in the popliteal fossa on each side. The popliteal veins were hypoplastic on both sides. The right variant vein was passing through the fibers of the adductor magnus muscle 56.2 mm above the adductor hiatus, which corresponds to the third perforating branch of deep femoral vein. The left one was turning to the front over the adductor magnus muscle, at the lower border of quadratus femoris muscle. The left variant vein was corresponding to the descending branch of the medial circumflex femoral vein. Both variant veins had one incomplete and three well-developed valves., Conclusion: In accordance with the findings, the variant vein was concluded to be an embryonic remnant, rather than an acquired one subsequent to any obstruction of the femoral vein. Regarding their connection with the popliteal vein but not with the internal iliac vein, both variant veins were denominated as "lower type persistent sciatic vein". Such a variation would be important with respect to the risk of complication during popliteal sciatic nerve blockade.

Regional capillary malformation of a lower extremity is associated with the overgrowth of bone or soft tissue in several disorders, most commonly Klippel-Trenaunay syndrome and Parkes Weber syndrome. We have observed a subset of patients with a capillary malformation of the leg, minor growth disturbance, and prominent veins. The objective of the current study is to describe a series of patients with regional capillary malformation of the lower extremity in association with phlebectasia. This is a retrospective series of 17 patients diagnosed with capillary-venous malformation of the lower extremity. We excluded patients with clinical or radiographic evidence of lymphatic or arteriovenous malformation. Age, presentation, associated features, radiographic findings, and management were documented. In most patients the capillary malformation covered a large area without sharply demarcated borders. Four patients had one or more discrete, well-defined capillary stains involving less than 5% of the total surface area of the affected lower limb. Prominent veins were most common in the popliteal fossa and on the knee and dorsal foot. Approximately two-thirds of patients had a leg length discrepancy, with the affected leg being longer (n = 6) or shorter (n = 4); in many the affected leg was also slightly larger (n = 8) or smaller (n = 4) in girth. Radiographic imaging showed dilatation of superficial (n = 16), muscular (n = 9), and deep veins (n = 6). We characterize a subset of patients with regional capillary-venous malformation of the lower extremity with prominent veins and minor hypotrophy/hypertrophy that differs from Klippel-Trenaunay syndrome (capillary-lymphatic-venous malformation) but belongs at the minor end of the spectrum of vascular disorders with overgrowth., (© 2013 Wiley Periodicals, Inc.)

The plantaris muscle (PM) is a vestigial muscle in human. The PM arises as a small muscular belly from the lateral condyle of the femur and then its long tendon inserts into the calcaneum or blends with the tendocalcaneus. There are many reports to describe the variations in the origin, nature of muscle, course of the tendon, and insertion of PM. However, here we report a case of a rare and unreported variation of PM with one common origin and two muscle bellies with peculiar relations with the neurovascular bundle in the popliteal fossa. Although its anatomical functions are insignificant, its tendon is useful as a graft in various reconstructive surgeries and variation in this muscle and its relation to nearby neurovascular bundle may be of clinical interest. Therefore, the present variation is worth considering in predicting uncommon neurovascular entrapment in the leg and may also be useful in various surgical procedures in the region of the knee joint.

Background: To retrospectively review the bilateral venous system within the popliteal fossa to evaluate the types of variations and their frequency seen in venous anatomy., Materials and Methods: During routine dissection of formalin-fixed cadavers, a retrospective review of 32 bilateral (64 limbs) lower limbs obtained from adult donors was performed. Deep veins present in the popliteal fossa were evaluated according to predetermined criteria for the presence of duplication of vessels and interindividual variations in venous anatomy., Results: More than one deep venous vessel was seen in the popliteal fossa in 20 (31.3%) of 64 limbs. In 12 (18.7%) cases there was a high (just below the level of the adductor hiatus) origin of the popliteal vein: from 2 tributaries in 10 (15.6%) and 3 tributaries in 2 (3.1%). In 5 (7.8%) cases true duplicated popliteal veins were observed. There were also 3 (4.7%) cases, including one bilateral, of persistent sciatic vein., Conclusions: Variations in popliteal fossa venous anatomy are common and have important implications for the diagnosis of deep vein thrombosis.

Isolated popliteal venous entrapment is unusual and often caused by variation or aberrant origins of the gastrocnemius muscle, thickened perivenous fascia or an abnormal vascular bundle. We report a unique case of a fit and well 35-year-old man with popliteal venous entrapment after presenting to the vascular unit with symptomatic varicose veins. The cause of the entrapment was found to be an aberrant medial sural artery on operative exploration. The artery was ligated, releasing the entrapped vein. The patient made an uneventful recovery with resolution of symptoms of venous insufficiency without evidence of muscle ischaemia.

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.

Background: Klippel-Trénaunay syndrome (KTS) is a capillary-lymphatic-venous malformation associated with soft tissue and skeletal hypertrophy of one or more limbs. Deep venous system (DVS) anomalies are reported to be present in 8% to 18% of patients with KTS; approximately 25% of patients with KTS have hand or foot malformations., Objective: We sought to assess whether the presence of hand or foot malformations in KTS is a predictor of DVS anomalies., Methods: Retrospective data were collected from 51 consecutive patients with KTS seen in a university hospital between January 2000 and February 2008. Patients with possible Proteus syndrome were not included. The presence and patency of the DVS was studied using conventional venography, multidetector computed tomography, or fast 3-dimensional magnetic resonance imaging venography., Results: Seventeen hand or foot malformations were present in 9 patients, consisting of: toe macrodactyly in 5 patients (two bilateral and one with plantar expansion); toe microdactyly in one patient; finger macrodactyly in one patient; finger macrodactyly and ectrodactyly in one patient; syndactyly in 4 patients; and clinodactyly with camptodactyly of the hand of one patient with lower limb KTS. Eleven patients had DVS anomalies (one with aplasia of entire DVS; one with duplication of the superficial femoral vein; 7 with hypoplasia of femoral vein; and 7 with aplasia of the popliteal vein). All patients with hand or foot malformations also had DVS anomalies (P < .001)., Limitations: Small sample size was a limitation., Conclusion: The presence of hand or foot malformations in KTS may predict the presence of DVS anomalies.

The profunda femoris artery is normally accompanied by a profunda femoris vein (deep femoral vein), which begins at the adductor magnus with various tributaries and drains into the femoral vein at the femoral triangle. Very rarely, the profunda femoris vein establishes communication with the popliteal vein. We present an anomalous profunda femoris vein in a 62-year-old male cadaver whose vein was located in the popliteal fossa as a direct communicating channel between the popliteal vein and the femoral vein.

Since up to 20% of patients undergoing lower extremity revascularization do not have an adequate venous conduit, some authors have explored the use of prosthetic grafts with adjunctive techniques for lower extremity revascularization. However, the long-term graft patency of those procedures has not been well documented. The purpose of this study was to examine the long-term patency of polytetrafluoroethylene (PTFE) bypass with adjunctive arteriovenous fistula and venous interposition (AVF/VI) for infrapopliteal revascularization. Over a 10-year period, 246 lower extremity reconstructions were performed in 176 (71.5% men) patients with critical ischemia in whom a totally autogenous vein bypass was not feasible. Seventy-six limbs had undergone 1 or more failed ipsilateral infrainguinal bypasses. Indications for surgery were chronic critical limb-threatening ischemia (86%) (rest pain, ischemic ulcer, or gangrene) or acute ischemia (14%). Ages ranged from 46 to 91 years (mean 74 +/-0.6 [SD] years). Risk factors such as diabetes, hypertension, coronary artery disease, end-stage renal disease, and use of tobacco were present in 49%, 49%, 52%, 8%, and 67% of the patients, respectively. During the follow-up, 112 cases (45%) required reinterventions. Twenty-seven patients (15%) required bypass revision twice. During the follow up, 56 limbs (23%) were amputated (above-the-knee amputation 25 (10%); below-the-knee amputation 31 (13%). To date, 150 (85%) patients of a total of 176 are deceased. The primary graft patency rates were as follows: at 1 year, 51%; at 2 years, 41%; 3 years, 35%; and 5 years, 24%. Limb salvage rates were as follows: 1 year, 79%; 2 years, 76%; 3 years 76%; and 5 years, 74%. Patient survival rates were as follows: 1 year, 69%; 2 years, 60%; 3 years, 54%; and 5 years, 40%. Amputation-free patient survival rates were as follows: 1 year, 66%; 2 years, 57%, 3 years, 51%, and 5 years, 30%. This technique appears to offer reasonable patency and limb salvage rates in patients in whom autogenous bypass grafts are not feasible.

Popliteal vascular entrapment syndrome can result in calf claudication, aneurysm formation, distal arterial emboli, or popliteal vessel thrombosis. The most commonly reported causes of this syndrome have been anomalies of the medial head of the gastrocnemius muscle as it relates to the course of the popliteal artery. We report two cases of rare anomalous slips of the lateral head of the gastrocnemius muscle causing popliteal vascular entrapment syndrome.

A 19 year old male patient is described with a large popliteal venous aneurysm causing pulmonary embolism and intermittent claudication. It was resected and replaced with a saphenous vein graft.

Primary popliteal venous aneurysms are very rare vascular abnormalities, with 50 cases reported in the English literature. Thromboembolic complications are common in popliteal venous aneurysms. Since medical treatment has been proved inadequate, surgical repair is recommended with a minimum time delay. However, it involves some risk because of the complex anatomy of the popliteal space. We report on a case of popliteal venous aneurysm, in which the tibial nerve was involved in the aneurysmal wall and was injured by surgical repair.

Background: Duplication of the popliteal and superficial femoral veins (PV, SFV) is a normal variant previously reported in up to 25% of limbs. Little clinical significance, however, has been attributed to this apparently common anomaly. The present study was designed to determine the incidence of duplications in individuals presenting for venous incompetence studies, and whether their presence could, in theory, act as a predisposing factor to deep venous thrombosis (DVT) formation., Methods: Duplex ultrasound examinations were performed in which venous duplications were actively searched for and recorded. The diameters of both limbs of any duplicated system and the single vessel immediately distal to it were recorded. Using these measurements, the changes in total cross-sectional area (CSA) associated with these anomalies were calculated. In addition, with the knowledge that the volume flow rate must remain constant, the velocity changes associated with such systems were calculated., Results: A total of 248 limbs from 177 patients was scanned. Duplications were found in 39 (15.7%) of these limbs. Of these, 30 limbs (77%) involved only the SFV, seven (18%) involved both the SFV and PV, and two (5%) involved only the PV. Short-segment SFV duplications were used to calculate the percentage change in total CSA and therefore blood flow velocities. Of the 13 (33%) suitable for such calculations, and calculating for each individual duplicated system, a mean increase in the vessel's total CSA of 42%, which corresponded to a theoretical decrease in blood flow velocity of 36%, was found., Conclusion: The present study confirms the significantly high incidence of duplications of the PV and SFV and raises the possibility of the potential for DVT formation secondary to changes in flow velocities.

Postoperative iliac and popliteal arteriovenous fistulas are extremely rare. This article describes the percutaneous endovascular treatment of iatrogenically induced arteriovenous fistula in two patients with simultaneous use of intravascular ultrasound. In a 61-year-old woman, a fistula between popliteal artery and vein, inadvertently created during implantation of a prosthetic knee joint, was treated with a novel polytetrafluorethylene (PTFE) stent graft. A 48-year-old man underwent endovascular treatment of a large fistula between the right common iliac artery and the left common iliac vein, inadvertently induced during surgery on an intervertebral disc. Congestive heart failure induced by the arteriovenous communication was reduced rapidly. Our results indicate that percutaneous treatment in conjunction with intravascular ultrasound is a useful therapeutic option for vascular lesions. It is less invasive than open vascular reconstruction and has a comparably high success rate.

Klippel's syndrome is due to a malformation of the deep veins. From 1944 to 1978 we have operated on 614 cases. In 51 % of these cases the malformation concerned the popliteal vein, in 16 % it concerned the superficial femoral vein, and in 25 % both veins were affected. We had only 3 % of iliac malformations and 1 % of inferior vena caval malformation. In the popliteal vein, ageneses and atresias were of equal incidence, but compressions by fibrous bands were much more frequent. In the femoral vein, compressions were most frequent, followed by atresias. Ageneses were very rare. In the iliac vein, atresias were twice as common as ageneses, whereas with the inferior vena cava we only found ageneses. The obstruction to the deep veins can be sectioned but one must also free the supplying vessels.

The authors present the case of a patient with phlebothrombosis of the left lower limb, not diagnosed with traditional ultrasonographic methods (Doppler c w) but recognized by the echo Doppler (duplex scanner) method. The diagnosis was made difficult by the presence of a congenital double left popliteal vein, with hypoechogenic thrombosis of only one of the two twin veins. The authors stress the diagnostic importance of the duplex scanner method in the study of the phlebobstructive pathologies of the lower limbs.

We have operated upon 588 patients with Klippel and Trenaunay syndrome. The underlying factor is a congenital malformation of the deep veins: agenesis, atresia or compression by fibrovascular bands of the popliteal, femoral or iliac veins. Of these 588 patients, 6 children between 15 months and 4 years of age had severe rectal bleeding and hematuria. One of these children died from massive bleeding of the rectum with septicemia. Another boy was saved by rectal resection and the last one by subtotal cystectomy. The important venogram shows an absence of the anterior venous pathway (superficial femoral vein) compensated by the abnormal development of 2 venous groups, the vein of the sciatic nerve and large veins along the external aspect of the inferior limb. These 2 venous groups penetrate into the pelvis by the sciatic and gluteal notches and terminate in the internal iliac vein which becomes enormous and has a very high flow. This overflow hinders drainage of the venous collateral from the rectum, the bladder and the vagina. The retro adductor vein, prolongated by the deep femoral vein, represents an anastomosis between the sciatic nerve vein and the common femoral vein. The surgeon must try to widen this pathway.

112 patients with varicose small sephenous vein were operated upon. The operation was preceded by a careful clinical investigation, including phlebography. The observed changes were correlated with operative findings. It is shown that varicosity may be conditioned by an obstruction of blood outflow in the popliteal vein or small saphenous vein ostium. A relationship between some structural variants of the small saphenous vein and hemodynamic disturbances was noted.

Two cases of recurrent pulmonary emboli secondary to thrombosis in anomalies of the deep veins of the lower limb are presented. In both cases the source of emboli was not evident clinically, and it was only after venography that the venous anomalies were discovered, both being confined to one limb and amenable to surgical intervention. Such anomalies have not previously been reported as sources of venous thromboembolism in adults. The importance of venography in establishing the source of pulmonary emboli, especially when recurrent, is stressed.

A report of spontaneously thrombosing arteriovenous fistulas in the popliteal and crural region jeopardizing the peripheral circulation is presented. A favourable effect was achieved with a femoral-posterior tibial bypass utilising a great saphenous graft.

The authors report a case of femoropopliteal venous bypass graft entrapped between the inner femoral condylar epiphysis and the medial head of the gastrocnemius muscle, the graft being inadvertently placed medially to this tendinous structure. What makes the case exceptional is that the indication for the venous bypass graft was a femoropopliteal thrombosis, secondary to an initially overlooked popliteal artery entrapment syndrome. In the discussion, the authors made an extensive review of the literature on this rare abnormal relationship between the popliteal artery and the medial head of the gastrocnemius (embryology, anatomical variations, clinical features, diagnostic measures and treatment).

Problems concerning the surgical treatment of patients with congenital hypoplasia of the deep veins of the lower limb are analyzed. Among 218 patients with angiodysplasia of the lower limbs 108 were found to have a venous form of the lesion, in 90 of whom hypoplasia of the deep venous system was diagnosed from clinico-angiographic findings. Corrective operations developed by the authors (excision of the venous conglomerate or hemangiomas together with the changed subcutaneous fat of the dorsal surface of the foot in combination with replantation of a perforated skin graft and extensive operation of the Linton type) made it possible to achieve regression of the symptoms of severe chronic venous insufficiency of the lower limb in 85% of cases.