Blood Vessels of Lower Limb.pptx

The main artery of the lower limb is the femoral artery. It is a continuation of the external iliac artery (terminal branch of the abdominal aorta). The external iliac becomes the femoral artery when it crosses under the inguinal ligament and enters the femoral triangle.

In the femoral triangle, the profunda femoris artery arises from the posterolateral aspect of the femoral artery. It travels posteriorly and distally, giving off three main branches:

Perforating branches – Consists of three or four arteries that perforate the adductor magnus, contributing to the supply of the muscles in the medial and posterior thigh.
Lateral femoral circumflex artery – Wraps round the anterior, lateral side of the femur, supplying some of the muscles on the lateral aspect of the thigh.
Medial femoral circumflex artery – Wraps round the posterior side of the femur, supplying its neck and head. In a fracture of the femoral neck this artery can easily be damaged, and avascular necrosis of the femur head can occur.

1. Blood Vessels of Lower L imb Dr Mathew Joseph MBBS, MD(AIIMS), BCC(Palliative Medicine) Assistant Professor Department of Anatomy Amala Institute of Medical Sciences, Thrissur

2. Arteries of Lower Limb The main artery of the lower limb is the Fem oral artery . It is a continuation of the Ex ternal i liac artery (terminal branch of the abdominal aorta). The external iliac becomes the femoral artery when it crosses under the inguinal ligament and enters the femoral triangle .

3. Arteries of Lower Limb - Thigh In the femoral triangle, the profunda femoris artery arises from the posterolateral aspect of the femoral artery. Perforating branches – Consists of three or four arteries that perforate the adductor magnus, contributing to the supply of the muscles in the medial and posterior thigh. Lateral femoral circumflex artery – Wraps round the anterior, lateral side of the femur, supplying some of the muscles on the lateral aspect of the thigh. Medial femoral circumflex artery – Wraps round the posterior side of the femur, supplying its neck and head. In a fracture of the femoral neck this artery can easily be damaged, and avascular necrosis of the femur head can occur.

4. Arteries of Lower Limb -Thigh

5. Arteries of Lower Limb After exiting the femoral triangle, the femoral artery continues down the anterior aspect of the thigh, through a tunnel known as the adductor canal . During its descent, the artery supplies the anterior thigh muscles. The adductor canal ends at an opening in the adductor magnus, called the adductor hiatus . The femoral artery moves through this opening, and enters the posterior compartment of the thigh, proximal to the knee. The femoral artery is now known as the popliteal artery

6. Arteries of Lower Limb - Knee, Leg The popliteal artery descends down the posterior thigh, giving rise to genicular branches that supply the knee joint. It moves through the popliteal fossa, exiting between the gastrocnemius and popliteus muscles. At the lower border of the popliteus, the popliteal artery terminates by dividing into the anterior tibial artery and the tibioperoneal trunk . T he tibioperoneal trunk bifurcates into the posterior tibial and fibular arteries .

7. Arteries of Lower Limb - Leg Posterior tibial artery – continues inferiorly, along the surface of the deep posterior leg muscles (such as tibialis posterior). It enters the sole of the foot via the tarsal tunnel, accompanying the tibial nerve. Fibular (peroneal) artery – descends posteriorly to the fibula, within the posterior compartment of the leg. It gives rise to perforating branches, which penetrate the intermuscular septum to supply muscles in the lateral compartment of the leg. The other division of the popliteal artery, the anterior tibial artery, passes anteriorly between the tibia and fibula, through a gap in the interosseous membrane. It then moves inferiorly down the leg. It runs down the entire length of the leg, and into the foot, where it becomes the dorsalis pedis artery

8. Medial and Lateral malleolar arteries

9. Lower Limb Venous Drainage Superficial veins : Great Saphenous Vein and Short Saphenous Vein Deep veins: Tibial, Peroneal, Popliteal, Femoral veins Perforators:

10. Blood flow deep veins in the sole superficial veins in the dorsum But In leg and thigh from superficial to deep veins.

11. Factors helping venous return Negative intra-thoracic pressure. Transmitted pulsations from adjacent arteries. Valves maintain uni-directional flow. Valves in perforating veins prevent reflux into low pressure superficial veins. Calf Pump—Peripheral Heart. Vis-a –tergo produced by contraction of heart. Suction action of diaphragm during inspiration.

12. Dorsal venous arch of Foot It lies in the subcutaneous tissue over the heads of metatarsals with convexity directed distally. It is formed by union of 4 dorsal metatarsal veins.

13. Each dorsal metatarsal vein recieves blood in the clefts from dorsal digital veins. and proximal and distal perforating veins conveying blood from plantar surface of sole.

14. Begins from the medial side of dorsal venous arch. Supplemented by medial marginal vein Ascends 2.5 cm anterior to medial malleolus. Passes posterior to medial border of patella. Great saphenous Vein

15. Ascends along medial thigh. Penetrates deep fascia of femoral triangle: Pierces the Cribriform fascia. Saphenous opening. Drains into femoral vein.

16. superficial circumflex iliac v. superficial epigastric v. superficial ext. pudendal v. posteromedial vein anterior leg vein posterior arch vein anterolateral vein GREAT SAPHENOUS VEIN Tributaries of Great Saphenous vein dorsal venous arch Thoraco-epigastric vein Deep external pudendal v. medial marginal vein

17. saphenous opening superficial circumflex iliac superficial epigastric superficial external pudendal posteromedial vein adductor c. perforator great saphenous vein anterolateral vein anterior leg vein posterior arch vein medial perforators dorsal venous arch Tributaries of Great Saphenous vein medial marginal vein

18. Short/ Lesser saphenous Vein: Drains lateral side of dorsal venous arch. Passes posterior to lateral malleolus. Accompanies sural nerve. Ascends along midline of calf. Empties into popliteal vein in popliteal fossa.

19. Short/ Lesser saphenous Vein: Variable termination It may join GSV in upper third of thigh either directly or through accesory saphenous vein. May bifurcate : join GSV and other in popliteal vein. May end in GSV in leg or deep vein of leg

20. Deep veins Present within the deep fascia surrounded by powerful muscles. Blood flow in greater pressure and volume. Accounts for 80 -90% venous return.

21. Deep veins Accompany arteries Below the knee- venae comitantes. Above the knee- single major vein

22. Deep veins of lower limb Femoral vein Popliteal vein POPLITEAL ANTERIOR TIBIAL MEDIAL MALL E O L US POSTERIOR TIBIAL PE R ON E AL FEMORAL

23. PERFORATORS Communicate superficial veins to deep veins Have role in varicose veins. All veins in lower limb have valves

24. Fairly constant in position: 1 lateral ankle perforators 3 Medial ankle perforators a)Postero inferior to medial malleolus 10 cm above med.malleolus 15 cm above med.malleolus Gastrocnemius perforators of Boyd around knee Mid thigh perforators of Dodd Hunter’s perforator in thigh

25. Valves in Great Saphenous Vein 10-20 valves 1 valve just before GSV pierces Cribriform fascia valve at Sapheno-femoral junction In 80% of people, a valve is present in external iliac vein which protects Sapheno-femoral junction.

26. Dilated,tortuous and elongated veins with reversal of blood flow mainly due to valvular incompetence Includes varicose veins in legs Hemorrhoids Varicocele Oesophageal varices Varicose veins

27. Risk factors Age Gender Height left>right Heredity Pregnancy Obesity and overweight Elevate intra abdominal pressure Deep vein thrombophlebitis Posture Incompetency of valves

28. Saphena varix A saphena varix is a dilatation at the top of the Great saphenous vein due to valvular incompetence. The varix is: soft and compressible disappears immediately on lying down exhibits an expansile cough impulse

29. Trendelenburg test Used to assess the competence of SFJ Patient lies flat. Elevate the leg and gently empty the veins Palpate the SFJ and ask the patient to stand whilst maintaining pressure.

30. Rapid filling after thumb released→ SFJ is incompetent Filling from below upwards without releasing thumb →presence of distal incompetent perforators

31. Patient in the supine position The lower limb raised above the level of heart Tourniquet is then applied around the saphenofemoral junction to compress the superficial veins (but not too tight as to occlude the deeper veins) Then the patient asked to stand Normally, the superficial vein will fill from below within 30-35 seconds If the superficial veins fill more rapidly with the tourniquet in place there is valvular incompetence below the level of the tourniquet in the "deep veins or perforators.

32. If there has been no rapid filling even after 20 seconds the tourniquet is released. If rapid filling from above then it indicates that the deep and perforating veins are competent & superficial veins are incompetent

33. The test is reported in 2 parts Standing up of the patient with tourniquet on based on rapid filling + or – deep veins/perforators incompetent When Tourniquet is removed based upon rapid filling + or - superficial vein incompetent The test can be repeated with the tourniquet at different levels to further pinpoint the level of valvular incompetence

34. Perthes Test Empty the vein as above, place a tourniquet around the thigh, stand the patient up. Ask them to rapidly stand up and down on their toes filling of the veins indicated deep venous incompetence. This is a painful and rarely used test.

35. V A R ICOSE U L C E R

36. T r en d elen b u r g ’ s Operation

37. VENOUS CUT DOWN Cutaneous supply of skin immediately in front of the medial malleolus is from branches of saphenous nerve These branches are blocked with LA A transverse incision is made through the skin and subcutaneous tissue across the long axis of the vein just anterio- superior to the medial malleolus.

38. Femoral Vein C a th e t eri z a tion

39. Coronary artery bypass