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and Hemodynamics 3
of Lower Limbs
Contents Introduction
Introduction ............................................................ 17
The venous system of the lower limbs is an
Normal Venous Drainage of Lower Limbs .......... 17
The Veins of Lower Limb ......................................... 18 organized and functional unit. Returning blood to
Venous Valves ........................................................... 18 the heart is its primary function. Several factors are
Muscle Pumps ........................................................... 18 involved in the control of this system. These include
Correlation with Ambulatory Venous gravity, the reservoir capacity, venous tone, sympa-
Pressure Studies ..................................................... 20 thetic control of smooth muscles, and many other
Abnormal Hemodynamics in Chronic mechanisms. Most of our misunderstanding of
Venous Disorders.................................................... 20 venous diseases stems from the inability to appre-
Reflux in Superficial Veins........................................ 21 ciate the delicate anatomy and physiology. Details
Reflux/Obstruction of the Deep Veins ...................... 21 of anatomy were considered in Chap. 2.
Incompetence of Perforators ..................................... 22
This chapter focuses on the physiology of the
Summary................................................................. 23 lower limb venous system. In this section, we
References ............................................................... 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.
S. Vaidyanathan et al., Chronic Venous Disorders of the Lower Limbs: A Surgical Approach, 17
DOI 10.1007/978-81-322-1991-0_3, © Springer India 2015
18 3 Venous Physiology and Hemodynamics of Lower Limbs
SFJ
GSV
80 % flow 20 % flow
Formoral vein
Pressure in mmHg
the first but essential step of venous return from 100 C
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
B
from the deep to the superficial veins [2]. The 40
role of the foot muscle pump could be crucial in without PSO
the genesis of chronic venous disorders. It has
been identified that static foot disorders may be
Time in sec 25
associated with impaired venous return from the
lower limbs [7]. Fig. 3.3 AVP normal venous pattern. Note the prominent
In an average individual walking 100 steps a min- drop in PEP. (A) Resting pressure at start of exercise. (B)
ute, the combined stroke volume of the calf muscle Maximum pressure fall with exercise. (BC) Recovery
pumps of both sides is estimated as 6.0 l/min2. time
Pressure in mmHg
• Reflux/obstruction in deep veins
• Incompetence of medial calf perforators
In clinical practice, these pathologies exist in
B1
combination. But for clarity, they will be consid-
ered in isolation. A,B,C-without PSO
A,B1,C1-with PSO
Pressure in mmHg
B C1
B1
Without PSO
with PSO
Varicose GSV
Time in sec