Venous outflow of the leg: anatomy and physiologic mechanism of the plantar venous plexus

Imaging Features of Plantar Vein Thrombosis: An Easily Overlooked Condition in the Differential Diagnosis of Foot Pain

Plantar vein thrombosis is a venous disorder affecting deep plantar veins that can manifest with non-specific localized pain, plantar foot pain, swelling, and sensation of fullness. Plantar veins are not routinely assessed during sonographic scans for deep venous thrombosis, which makes plantar venous thrombosis a commonly missed diagnosis. This paper provides a comprehensive review of the venous anatomy of the foot and imaging findings of plantar venous thrombosis as well as discusses the current literature on the topic and its differential diagnoses.

Two stages of salvaging an extensively necrotic foot with chronic limb-threatening ischemia by arterialization of great saphenous vein and free latissimus dorsi musculocutaneous flap transfer for wound coverage with the arterialized vein as the recipient vessel: A case report

Patients with chronic limb-threatening ischemia (CLTI) without other options for adequate arterial revascularization could undergo deep (or distal) venous arterialization for limb salvage. Additionally, patients with extensive foot wound with CLTI sometimes require free flap transfer for limb salvage. We herein report a case of successful reconstructive limb-salvage surgery for an extensively necrotic foot with CLTI, using a two-stage operation involving venous arterialization using foot-perforating veins and subsequent free flap transfer (with preservation of the arterialized vein). The patient was a 59-year-old man with CLTI. The patient's right foot had dry necrotic tissue after Lisfranc joint amputation. Only one straight-line to the posterior tibial artery was achieved after endovascular therapies (four times). At the first stage of surgery, an arterial-venous shunt bypass from the superficial femoral artery to the distal great saphenous vein (GSV) (near the foot-perforating vein) was created. Arterial blood supply reached the necrotic area via the foot venous circulation system. At the second stage of surgery, free latissimus dorsi musculocutaneous flap (8 × 27 cm) transfer with preservation of the arterialized vein was performed. The pedicle artery was anastomosed to the bypass graft (end-to-side). The pedicle vein was anastomosed to the proximal stump of the GSV (end-to-end). The flap and residual foot survived completely, at a one-year follow-up postoperatively. An indocyanine green bypass-through angiography revealed the angiosome through the venous arterialization bypass graft, which included the flap; entire forefoot; and partial regions of the midfoot and heel. This two-stage operation might be considered a useful option for limb-salvage and complete wound-healing in patients with severe non-healing wound with CLTI. The two methods could compensate and overcome the problems of either method: incomplete wound-healing after venous arterialization, and the absence of a recipient artery for free flap transfer.

Varicose Veins and Chronic Venous Disease

Chronic venous disease is a worldwide problem associated with significant morbidity and is expected to increase in prevalence as the current population ages. This is a comprehensive review of the anatomy, pathophysiology, genomics, clinical classification, and treatment modalities of chronic venous disease.

Four new cases of isolated foot vein thrombosis: Is the first metatarsal interspace perforator responsible?

Isolated foot vein thrombosis is an infrequently reported condition, the cause of which is still questioned. Four new cases are detailed, covering different physio-pathological situations ranging from plantar vein to Lejars' sole thrombosis. They are compared to the literature. The common vein altered in most of the cases is the first metatarsal interspace perforator, which is hypothesized as the area of the onset of many cases of foot vein thrombosis. Diagnostic workup could reveal neoplasia, inflammatory diseases, or coagulation abnormality. There is no consensus regarding plantar vein thrombosis treatment, and conservative therapy, non-steroidal anti-inflammatory drugs and anticoagulant therapy have been reported.

The effects of shoe type on lower limb venous status during gait or exercise: A systematic review

This systematic review evaluated the literature pertaining to the effect of shoes on lower limb venous status in asymptomatic populations during gait or exercise. The review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed-NCBI, EBSCO Host, Cochrane Library and Science Direct databases were searched (March 2019) for words around two concepts: shoes and venous parameters. The inclusion criteria were as follows: (1) the manuscript had to be published in an English-language peer-reviewed journal and the study had to be observational or experimental and (2) the study had to suggest the analysis of many types of shoes or orthotics on venous parameters before, during and/or after exercise. Out of 366 articles, 60 duplications were identified, 306 articles were analyzed, and 13 articles met the eligibility criteria after screening and were included. This review including approximately 211 participants. The methodological rigor of these studies was evaluated with the modified Downs and Black quality index. Nine studies investigated the effect of shoes on blood flow parameters, two on venous pressure and two on lower limb circumferences with exercise. Evidence was found that unstable shoes or shoes with similar technology, sandals, athletic or soft shoes, and customized foot orthotics elicited more improvement in venous variables than high-heeled shoes, firm shoes, ankle joint immobilization and barefoot condition. These venous changes are probably related to the efficiency of muscle pumps in the lower limbs, which in turn seem to be dependent on shoe features associated with changes in the kinetics, kinematics and muscle activity variables in lower limbs during gait and exercise.

New Discoveries in Anatomy and New Terminology of Leg Veins: Clinical Implications

Advances in diagnosis and in endovascular and surgical treatments of both acute and chronic venous diseases have focused attention on several, previously clinically less important, details of venous anatomy. The time has come to standardize venous nomenclature so that general practitioners and specialists in the United States and abroad speak the same language. There is a need to adopt a universal terminology for the saphenous veins, to avoid the myriad of eponyms of perforators and, most importantly, to omit once and for all, the term “superficial” femoral vein when talking about a deep vein of the thigh. New anatomic names, such as the saphenous fascia and saphenous subcompartment, have to gain better recognition. To achieve the desired consensus on venous nomenclature, an international meeting was held in Rome, Italy, in 2001, under the auspices of the International Union of Phlebology. In this review on venous anatomy, we describe the most important previously published clinical recommendations from this conference, and suggest modifications based on their clinical experience using the new terminology.

Early Mobilization after Free-flap Transfer to the Lower Extremities: Preferential Use of Flow-through Anastomosis

BACKGROUND

Prolonged bed rest and elevation have traditionally been considered necessary after free-flap transfer to the lower extremities. In this retrospective study, we tried to mobilize patients early after free-flap transfer to the lower extremity by means of flow-through anastomosis for both arteries and veins.

METHODS

This study included 13 consecutive patients who underwent immediate free-flap transfer after wide resection of soft-tissue tumors of the lower extremity from March 2012 through July 2013. The defects were above the knee in 5 patients and below the knee in 8 patients. In all patients, flow-through anastomosis was used for both arteries and veins. The patients were mobilized starting on the first postoperative day, and their activities of daily life were gradually expanded, depending on the wound conditions. Postoperative complications and the progression of their activities of daily life were investigated retrospectively.

RESULTS

No anastomotic failure or take back occurred. Partial flap necrosis occurred in 1 patient because of a poor perforator but was unrelated to early mobilization. All patients could move to wheelchairs on the first postoperative day. Within 1 week, 12 of 13 patients could start dangling and 10 of 13 patients could start ambulating.

CONCLUSIONS

This study demonstrates that early mobilization after free-flap transfer to the lower extremity is made possible by flow-through anastomosis for both arteries and veins. Flow-through flaps have stable circulation from the acute phase and can tolerate early dangling and ambulation.

Foot sling for the treatment of diurnal leg oedema: effect due to foot muscle pump stimulation?

Hintergrund und Design: Prospektive Pilot-fallserie zur Beurteilung der Effektivität, Verträglichkeit und Einfachheit der Anwendung einer neuartigen Fußschlinge (Stimfeet) zur Behandlung von habituellen Beinödemen.

Patienten und Methoden: Eingeschlossen wurden acht Patientinnen mit nachweisbarer prätibialer Dellenbildung bei habituellen Beinödemen. Hämodynamisch relevante Refluxe oder Obstruktionen der Beinvenen wurden duplexsonographisch ausgeschlossen. Die Patientinnen erhielten eine einwöchige ganztägige Behandlung mit medizinischen Kompressionsstrümpfen (MKS) bis zum Knie (18–23 mmHg) und nach zweitägiger Pause mit Stimfeet (maximal vier Stunden ohne Unterbrechung) oder umgekehrt. Vor und nach jeder Behandlungswoche erfolgten jeweils zwei wasserplethysmographische Volumenmessungen pro Bein. Mittels standardisierter Fragebögen wurden die Effektivität, Verträglichkeit und Einfachheit der Anwendung evaluiert. In einem Patiententagebuch wurden die Nebenwirkungen dokumentiert.

Ergebnisse: MKS führten zu einer größeren Volumenreduktion (mittleres Δ rechts: 39,00 g, links: 24,44 g) verglichen mit Stimfeet (mittleres Δ rechts: 5,06 g, links: 2,81 g). Die Ergebnisse unterschieden sich jedoch nicht signifikant (t-test: rechts: p=0,55, links: p=0,63). In Bezug auf weniger Einschränkung (n=5), Komfort (n=6), Reduktion der Symptome (n=5), Verbesserung der Lebensqualität (n=5), Verbesserung der Arbeitsbedingungen (n=5) und den Erwartungen entsprechend (n=5) bevorzugten mehr Patientinnen den MKS. Die Einfachheit der Anwendung wurde gleich bewertet. Die am häufigsten dokumentierten Nebenwirkungen von Stimfeet waren Druck- und Schürfstellen (n=6) und Verrutschen/Notwendigkeit der Fixierung (n=5).

Schlussfolgerung: MKS waren der neuartigen Fußschlinge in der Behandlung habitueller Beinödeme überlegen. Bei einer Minderheit der Patientinnen führte die neuartige Fußschlinge jedoch zur Besserung der Beschwerden und Ödemreduktion. Die Wirksamkeit wird möglicherweise durch eine Stimulation der Fußmuskelpumpe bedingt. Methoden zur Aktivierung der Fußmuskelpumpe stellen eine neue Therapieoption für die Behandlung von Beinödemen dar.

Spontaneous plantar vein thrombosis: state of the art

We aim here to highlight the importance of diagnosing and treating promptly the rarely thought of diagnosis of plantar vein thrombosis. We hereby report two cases with no known thrombotic risk factors. Less than 20 cases are reported in the literature. Detection of this unusual site of involvement of the deep venous system can be easily made by ultrasound examination if searched for. Plantar vein thrombosis is a rarely evoked pathology. Knowledge of its occurrence could further improve its diagnosis especially that it could reveal an unknown neoplasia or coagulation abnormality.

PLANTAR THROMBOPHLEBITIS: MAGNETIC RESONANCE IMAGING FINDINGS

Objective: Demonstrate the magnetic resonance imaging (MRI) findings in plantar thrombophlebitis. Methods: Retrospective review of twenty patients with pain in the plantar region of the foot, in which the MRI findings indicated plantar thrombophlebitis. Results: A total of fourteen men and six women, mean age 46.7 years were evaluated. Eight of these patients also underwent Doppler ultrasonography, which confirmed the thrombophlebitis. The magnetic resonance images were evaluated in consensus by two radiologists with experience in musculoskeletal radiology (more than 10 years each), showing perivascular edema in all twenty patients (100%) and muscle edema in nineteen of the twenty patients (95%). All twenty patients had intraluminal intermediate signal intensity on T2-weighted (100%) and venous ectasia was present in seventeen of the twenty cases (85%). Collateral veins were visualized in one of the twenty patients (5%). All fourteen cases (100%), in which intravenous contrast was administered, showed perivenular tissues enhancement and intraluminal filling defect. Venous ectasia, loss of compressibility and no flow on Doppler ultrasound were also observed in all eight cases examined by the method. Conclusion: MRI is a sensitive in the evaluation of plant thrombophlebitis in patients with plantar foot pain.

Venous emptying from the foot: influences of weight bearing, toe curls, electrical stimulation, passive compression, and posture

This study investigated the hemodynamic properties of the plantar venous plexus (PVP), a peripheral venous pump in the human foot, with Doppler ultrasound. We investigated how different ways of introducing mechanical changes vary in effectiveness of displacing blood volume from the PVP. The contribution of the PVP was analyzed during both natural and device-elicited compressions. Natural compressions consisted of weight bearing on the foot and toe curl exercises. Device-elicited compressions consisted of intermittent pneumatic compression (IPC) of the foot and electrically elicited foot muscle contractions. Ten healthy participants had their posterior tibial, peroneal, anterior tibial, and popliteal vein blood flow monitored while performing these natural and device-elicited compressions of the PVP supine and in an upright position. Results indicated that 1) natural compression of the PVP, weight bearing and toe curls, expelled a significantly larger volume of blood than device-elicited PVP compression, IPC and electrical stimulation; 2) there was no difference between the venous volume elicited by weight bearing and by toe curls; 3) expelled venous volume recorded at the popliteal vein under all test conditions was significantly greater than that recorded from the posterior tibial and peroneal veins; 4) there was no significant difference between the volume in the posterior tibial and peroneal veins; 5) ejected venous volume recorded in the upright position was significantly higher than that recorded in the supine position. Our study shows that weight bearing and toe curls make similar contributions to venous emptying of the foot.

The impact of intermittent pneumatic compression devices on deep venous flow velocity in patients with congestive heart failure

BACKGROUND

Intermittent pneumatic compression (IPC) has been used to prevent deep venous thrombosis (DVT), but the effects of IPC on the hemodynamics of popliteal and soleal veins, especially in patients with congestive heart failure (CHF) have not been evaluated. The aim of this study was to evaluate the effects of IPC on the flow velocity of deep veins in the lower extremities and to compare the efficacy of two different types of IPC in deep venous flow enhancement in patients with CHF.

METHODS

Flow velocities of popliteal and soleal veins were recorded in 19 patients with CHF and in 19 control subjects using a high-resolution linear probe. Peak and mean flow velocities were measured (1) at rest, (2) with sequential foot and calf IPC (SFC-IPC) which consists of an electrically driven air compressor and four air chambers, and (3) with impulse foot IPC (IF-IPC) which consists of a pneumatic impulse generator operated at an applied pressure of 130 mmHg.

RESULTS

In the resting condition, popliteal venous flow velocity in the CHF group was attenuated (12.8+/-4.7 cm/s vs. 21.1+/-13.5 cm/s; p<0.05). Both SFC-IPC and IF-IPC increased venous velocity, but the increase with IF-IPC in CHF patients was lower than that in control subjects. In the soleal veins, after applying SFC-IPC, the peak and mean velocity in CHF increased to the same extent as in the control group. IF-IPC increased soleal venous velocity in control subjects, but there was no increase in CHF patients.

CONCLUSION

Two-dimensional Doppler scanning revealed a significant increase in the mean and peak velocities in the soleal and popliteal veins with SFC-IPC but not with IF-IPC in patients with CHF. These results indicate that SFC-IPC could have favorable effects in preventing DVT in patients with CHF.

Plantar Vein Thrombosis—Evaluation by Ultrasound and Clinical Outcome

Objective: This study was designed to describe the characteristics and clinical outcome of patients diagnosed with plantar vein thrombosis. Methods: Patients presenting with sudden pain and/or swelling of the foot were evaluated by duplex scanning of the affected leg. All the main foot veins were imaged with high resolution multi-linear array transducers. The location and extent of thrombosis was recorded in detail. All patients were scheduled for clinical and ultrasound follow-up within a week from the diagnosis and at various intervals thereafter. Results: Acute thrombosis was found in the plantar veins in 11 patients of whom 7 were females. Pain was presented in all patients, swelling in 8 and the left foot was involved in 7. From the risk factors evaluated, the most common were recent surgery 4, use of contraceptive pills 3, followed by malignancy, airplane travel, HIV-AIDS infection, and past history of DVT in one each. Plantar veins were exclusively affected in 8, with lower segment of the posterior tibial veins in 2 and the great saphenous vein in 1. In the follow up, there was evidence of thrombosis extension in 3 patients. At six months partial recanalization was found in 9 and complete in 2. Conclusions: Pain and swelling of the foot can be caused by plantar vein thrombosis. Complete or partial recanalization occurs in these patients by 6 months. Thrombi in the plantar veins can progress more proximally with the possibility of postthrombotic events.

The venous pump of the first metatarsophalangeal joint: clinical implications

BACKGROUND

Although the anatomy and physiology of the venous circulation of the ankle and midfoot are well documented, the physiologic importance of forefoot mobility has not been reported in the literature. The question of this study was whether the first metatarsophalangeal (MTP) joint may operate, like the ankle, as a "pump" to encourage venous return.

METHODS

Forty-nine cadaver foot specimens were examined using dissection, plastination, vessel infiltration, and maceration, and radiographic (including venography, MRI, and magnetic resonance angiography) techniques. The anatomy and physiology were described and compared to the ankle joint. Forty patients had biphasic Doppler flow studies.

RESULTS

The major finding was the medial drainage of the plantar venous sinus, which is fibrotically bound to the joint capsule. Functional venous valves were evident distally and within fibrous vascular lumens. Mobilization of the first MTP joint led to compression and emptying of the veins. Passive mobilization of the first MTP joint led to an average flow increase of 55% +/- 7 (p < 0.0001), while active movement led to an average increase of 78% +/- 7 (p < 0.0001).

CONCLUSIONS

Our described connection between the joint capsule and veins indicates a "toe-ankle pump" with a significant increase of venous blood flow during motion of the MTP joint. Possible clinical applications for an external MTP pump include anti-edema or thromboprophylactic therapy, especially in patients with foot or ankle injuries. A new toe-pump has been designed based on these results.

Venous ulcers

Chronic venous ulceration is a common and important medical problem, which causes significant morbidity. Venous ulcers are expensive to treat, have substantial economic effects in terms of days of work lost, and adversely impact patient's quality of life. History and clinical findings are helpful in making the diagnosis of venous ulceration, but additional diagnostic testing is helpful in confirming the diagnosis and excluding arterial disease. The objectives of venous ulcer management include healing of the ulcer, prevention of recurrence, and improvement of edema. Compression is the cornerstone of venous ulcer therapy. Adjunctive modalities such as biologic skin substitutes, dressings, debridement, surgical intervention, and drugs may also facilitate the healing process.

Blood flow velocity of the femoral vein with foot exercise compared to pneumatic foot compression

STUDY OBJECTIVE

To compare the effects of foot exercise with an intermittent pneumatic foot compression (IPC) device on blood flow velocity of the femoral veins.

DESIGN

Prospective, controlled study.

SETTING

General intensive care unit of a university hospital.

PATIENTS

20 patients on bed rest in the intensive care unit.

INTERVENTIONS

Patients were divided into 2 groups: group A, foot exercise (n = 10); and group B, IPC device (n = 10). The foot exercise was done once by a nurse for 5 minutes with the dorsiflexion of the ankle (15 times per minute) in group A patients. The IPC device (A-V Impulse System, compression setting: 130 mm Hg for 3 seconds followed by a resting period of 60 seconds) was used for 2 hours in group B.

MEASUREMENTS

Peak blood flow velocity of the femoral vein was measured using the ultrasound unit with a 7.5-MHz linear array probe (ALOKA SSD-5500) at 0, 5, 15, 30, 60, and 120 minutes.

MAIN RESULTS

Peak blood flow velocities in both groups increased significantly vs the control values during the study. At 5 minutes, group A showed a significant increase in the peak blood flow velocity compared with group B.

CONCLUSIONS

Foot exercise by a nurse for 5 minutes was equally or more effective compared with the IPC device in increasing peak blood flow velocity of the femoral vein. The effect of the 5-minute foot exercise lasted for 2 hours.

Short-stretch compression bandages and the foot pump: their relationship to restricted mobility

Practitioners are generally advised not to use short-stretch bandages on patients who are immobile. But this appears to reflect confusion about calf muscle function, which research indicates still occurs during periods of limited mobility.

Nonpharmacologic thromboembolic prophylaxis in total knee arthroplasty

Deep venous thrombosis is the most common complication in patients having elective total knee replacement. Pneumatic compression devices play an important role in the prophylaxis of deep venous thrombosis and effectively decrease the risk of distal deep venous thrombosis. The combination therapy with pharmacologic agents has the benefit of decreasing the rate of proximal deep venous thrombosis and therefore is recommended. In the absence of clinical data, recent in vivo flow studies suggest that calf or combined foot and calf compression are superior to foot compression alone. Epidural anesthesia in comparison with general anesthesia decreases the incidence of thromboembolic disease after total knee arthroplasty. Although hypotensive anesthesia and intraoperative heparin have been proven to substantially lower the incidence of deep venous thrombosis after total hip arthroplasty, the current literature does not support its application during the implantation of a total knee replacement. Pneumatic compression devices are an important part of deep venous thrombosis prophylaxis especially in the early postoperative period considering that pharmacologic anticoagulation is contraindicated in the first 12 hours after spinal anesthesia and in the presence of an epidural line.

Thrombosis risk in the trauma patient. Prevention and treatment

Hypercoagulability is frequently seen in the trauma patients. Debate continues over the best method of prophylaxis, diagnosis, and treatment for the trauma patient. From experience with orthopedic and general surgery patients, much has been learned about prophylaxis and diagnosis, and as treatment protocols have been taken from internal medicine literature. Universal guidelines relating specifically to the trauma patient have not, however, been established. Overall, most of the literature suggests using LMWH for the prophylaxis of trauma patients. When LMWH is contraindicated, SCD should be used, with AVFP as a second choice. Surveillance screening for DVT remains controversial, but surveillance before transfer to extended care facilities has proven beneficial. Finally, when DVT is diagnosed, treatment should be initiated as soon as possible and should be continued until the DVT has resolved. Long-term anticoagulation therapy or use of caval filters may be necessary to prevent the morbidity of PE or thrombophlebitic syndrome.

Hemodynamic evaluation of foot venous compression devices

PURPOSE

Venous compression devices effectively prevent deep venous thrombosis. Recently, because traumatic injury of the limb often precludes application of calf devices, newer methods have been developed that are only applied to the foot. This study was designed to evaluate the venous hemodynamic effects produced by four different compressive devices compared with calf-only intermittent pneumatic compression (IPC).

METHODS

Twenty-seven healthy volunteers had application of each device followed by duplex scanning determination of the venous hemodynamics at the popliteal vein (PV) and the common femoral vein (CFV). Endpoints included (1) resting (peak) systolic velocity (RSV); (2) maximum venous velocity (MVV) during device activation; (3) acceleration, the slope of the line from RSV to MVV; and (4) return time (RT) from MVV back to RSV. The devices evaluated included two commercially available mechanical foot devices, (1) foot compressive device (FCD1), and (2) FCD2; (3) an experimental mechanical foot device (FCD3); (4) an experimental pneumatic foot device (FCD4); and (5) a calf-only IPC device (IPC).

RESULTS

The RSV was higher in the CFV than the PV. The initial RSV was not statistically significant between the five experimental groups (p = 0.37) at either the PV or CFV, although the RSV was higher in the CFV than in the calf (CFV, 24.3 +/- 6.7 cm/sec; PV, 12.5 +/- 3.7 cm/sec; p < 0.0001). MVV was significantly higher with FCD2 and the IPC (p = 0.0002) at the PV level, but this difference decreased at the CFV. Acceleration was greatest with the two available foot devices, FCD1 and FCD2, compared with the other three devices (p < 0.0001) at both levels. On the other hand, the RT was significantly longer only with the IPC; RT was four to 10 times slower at the PV and three to five times slower at the CFV compared with the other four devices.

CONCLUSIONS

The two commercially available foot devices, FCD1 and FCD2, and the IPC produced significant alterations in venous hemodynamics. Changes produced at the PV level by both foot and calf devices were seen proximally at the CFV, although the changes were usually less. The mechanical devices produced rapid acceleration of venous flow to an elevated MVV, whereas the IPC produced an elevated peak with a sustained period of flow above baseline (RT). Further clinical comparison should be completed before widespread adaptation of these devices as an equivalent to existing IPC devices.