Video of venous valve in action Ultrasoundparticularly duplex ultrasoundis a common way that veins can be seen. Veins of clinical significance[ edit ] The Batson Venous plexus, or simply Batson's Plexus, runs through the inner vertebral column connecting the thoracic and pelvic veins. These veins get their notoriety from the fact that they are valveless, which is believed to be the reason for metastasis of certain cancers. The great saphenous vein is the most important superficial vein of the lower limb.
This pain worsened through the subsequent weeks and she developed fevers, chills, and night sweats, and she came to the emergency department. There, she was found to have left thigh and leg swelling.
Duplex revealed a left iliofemoral DVT starting from the iliocaval tributary and extending to her left femoral vein figure above. A CT scan revealed a pulmonary embolism to the left lung below.
No precipitating factors were present. Vascular surgery was consulted. Plan was for catheter directed thrombolysis. The thrombus was crossed, and ballooning showed there was chronicity to the occlusion in the pelvis evidenced by waisting of the balloon on inflation. A multihole infusion catheter was placed across the thrombus from the thigh to the inferior vena cava and recombinant tissue plasminogen activator was infused overnight.
Clinically, there was no change overnight and when the patient was restudied next morning, there was still an occlusion starting at the common femoral vein. At this point, I had a choice as to what to do next. First, I could stop, and have the patient start anticoagulation and return several months later -often, the common femoral vein returns to drain into pelvic collaterals.
As I had discussed in an earlier post, venous interventions are no different from arterial ones in that inflow, draining vein, and outflow have to be considered.
In the case of the veins, I like to think of it as connecting major confluences, and for a leg, the common femoral venous confluence is paramount. Intervening from the popliteal vein to the vena cava is inferior to being able to connect draining veins at the common femoral confluence to the vena cava.
So getting the common femoral vein to patency is critical, and can sometimes be achieved with anticoagulation and time. The second option is to break out a thrombectomy catheter and try to remove the thrombus by various machinations, ie.
I felt that given the three week time course of the thrombus, the best we could get was some clearance of thrombus, leaving behind a complex network of chronic thrombus and fibrinous scar with the overnight lysis.
The fourth option, mechanical aspiration sheath thrombectomy MASTis a technique developed by Dan Clair, our former chair. As a concept, it is very simple. The sheath is then removed and the contents emptied.
For this case, an 18 F sheath was introduced into the femoral vein in mid thigh. The blood is ejected into a basin and a cell saver in non-malignant cases is used to salvage the whole blood.
This reopened the common femoral vein. This was for me a very important step as without achieving this, I would have had to stent into the femoral vein, excluding many smaller veins draining into the common femoral vein, and effectively basing my revascularization off the popliteal vein confluence, an inferior inflow source for venous revascularization.
CFV post MAST With the common femoral vein open, placing stents from the vena cava to the common femoral vein was straightforward and described elsewhere reference.
This is disconcerting, but size does matter. Second, IVUS is critical in confirming that everything is open. Third, the 14mm nitinol stent placed into the common femoral vein will stay open, unlike a stent placed into the artery across the inguinal ligament.
It likely has to do with the deeper position of the vein in relation to the artery which protects the vein from the ligament. MAST illustrates a critical issue for all innovation in the current setting of resource limitation. Innovations must be made with not just a consideration to efficacy and potential market, but also cost.
The large sheaths used in MAST are commonly available and cheaper by multiples of tens compared to the thrombectomy systems and catheters.
The patient can expect to have excellent patency in the short to mid term reference 1. References Chung HH et al.TECHNIQUE: Using duplex and color flow Doppler, the common femoral, superficial femoral and popliteal veins were evaluated in the (right or left) lower extremity.
(or bilateral lower extremities). It then passes through the right femoral vein, right external iliac, common iliac, inferior vena cava, right atrium, right ventricle. From right ventricle it enters the lung circulation through pulmonary artery & .
Blood is pushed out of the right ventricle and travels to the lung via the pulmonary artery.
The aortic semilunar valve is located between the left ventricle and the aorta. When the left ventricle contracts, the blood is forced into the aorta and the aortic semilunar valve closes. Trace the path of blood from: where it picks up oxygen in lung capillaries and flows back to heart via pulmonary vein to be pumped to rest of body via aorta systemic circulation blood pumped from heart, through aorta to tissues/organs of body, back to heart node 4.
right atrium 5. atrioventricular node 6. posterior vena cava 7. The course is going to be charted starting with the right femoral vein, passing through the external iliac, then the common iliac vein, head through the inferior vena cava, right atrium, right ventricle, pulmonary artery, and reaching the right lower lobe of the lung.
(Innerbody, ) This will be exciting! The Journey back to the heart The Journey back to the Heart The blood then moves into the popleateal vein then as it travels up the leg it progresses to the femoral vein the blood then moves up the body into to the external illiac vein as it moves back up to the heart it enters the heart via the inferior venae cava and again enters the right.