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Lesson # 34

TOPOGRAPHY AND DISTRIBUTION OF BRANCHES OF FEMORAL AND


POPLITEAL ARTERIES. ARTERIES OF LEG AND FOOT.
ANASTOMOSES BETWEEN THE ARTERIAL BRANCHES OF LOWER
EXTREMITY. SUPERFICIAL AND DEEP VEINS AND LYMPHATIC NODES AND
VESSELS OF LOWER EXTREMITY
THEME 1. TOPOGRAPHY AND DISTRIBUTION OF BRANCHES OF FEMORAL
AND POPLITEAL ARTERIES. ARTERIES OF LEG AND FOOT.
ANASTOMOSES BETWEEN THE ARTERIAL BRANCHES OF LOWER
EXTREMITY

Femoral artery is continuation of external iliac artery, which passes under inguinal ligament through
lacuna vasorum laterally from femoral vein. Then femoral artery runs downward in iliopectineal sulcus and
anterior femoral sulcus. It enters into adductorial canal and exits from canal in popliteal fossa where
contines into popliteal artery.

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Femoral artery gives off:


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superficial epigastric artery passes on anterior abdominal wall and supplies a inferior portion of
external oblique muscle aponeurosis and skin;
superficial circumflex iliac artery passes laterally and ramifies in muscles and skin near superior
anterior iliac spina;
deep femoral artery gives off medial circumflex femoral artery and lateral circumflex artery, three
perforating arteries, that supply posterior group of thigh muscles;
descending genu artery begins from femoral artery in adductorial canal, passes through the tendinous
hiatus of this canal and passes down together with saphenus nerve to knee-joint, where takes hand in
formation of articulate knee net (rete articulare genus).

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The femoral artery.


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Popliteal artery is continuation of femoral artery, passes in advance of tibial nerve and popliteal vein
and on level of inferior margin of popliteal muscle divides into anterior tibial artery and posterior tibial
artery.

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Popliteal artery gives off the following branches:

superior medial and lateral genu arteries;

middle genu artery;

inferior medial and lateral genu arteries.


All these arteries participate in feeding of knee-joint and muscles around it.

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Circumpatellar anastomosis.

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Posterior tibial artery continues from popliteal artery, passes in cruropopliteal canal, under musculus
soleus, behind medial malleolus, passes in separate fibrous canal under flexors tendom retinaculum on sole,
where subdivides into medial plantar artery and lateral plantar artery.

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The popliteal, posterior tibial, and peroneal arteries.


Branches of posterior tibial artery:

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fibular artery passes in inferior musculfibular channel, supplies peroneal muscles and behind lateral
malleolus divides into lateral maleolar branches and calcaneal branches;
medial malleolar branches take hand in formation of medial maleolar rete;
muscular branches supply deep and superficial muscles of posterior group in shin;
fibular circumflex branch runs laterally from beginning of tibial artery and rounding a head of fibula
joins to articulate knee net;

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lateral plantar artery is a terminal branch of posterior tibial artery, lies in lateral plantar sulcus,
passes medially and, anastomosing with deep plantar branch (from dorsal pedis artery), forms plantar
arc. Lateral plantar artery gives off four plantar metatarsal arteries, which continue into common
plantar digital arteries. Last subdivide into two proper plantar digital arteries, which supply skin of
both sides of each finger on sole;
medial plantar artery is second terminal branches of posterior tibial artery (has a deep branch and
superficial branch), lies into medial plantar sulcus and supplies muscles of medial plantar group,
anastomosing with first dorsal metatarsal artery.

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The plantar arteries. Superficial view.


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Anterior tibial artery begins from popliteal artery in popliteal fossa, runs at cruropopliteal canal and
makes perforating in superior portion of interossea membrane. Artery lies on anterior surface of interossea
membrane between muscles of anterior shin group and, passing under retinaculum of extensor muscles,
continues on foot under name of dorsal pedis artery.
Anterior tibial artery gives off the following branches:

posterior recurrent tibial artery takes hand in formation of articulate knee net;

anterior recurrent tibial artery takes hand in formation of articulate knee net;

muscular branches supply anterior shin muscles group;

anterior medial maleolar artery takes hand in formation medial maleolar net;

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Anterior tibial and dorsalis pedis arteries.

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SUPERFICIAL AND DEEP VEINS AND LYMPHATIC NODES AND VESSELS


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OF LOWER EXTREMITY
The Veins of the Lower Extremity
Just as with the upper extremity, the veins of the lower extremity are divided into deep and superficial,
or subcutaneous, veins, which pass independently of the arteries (Fig. 63).
The deep veins of the foot and crus are binary and they accompany arteries of the same name. V.
poplitea, which is comprised of all the deep veins of the crus, constitutes a single trunk lying in the
popliteal fossa posteriorly and somewhat laterally of the artery of the same name. V. femoralis is single; it
originates laterally of the femoral artery but, then, passes gradually to the posterior surface of the artery,
and as it rises higher, it passes onto the medial surface. From this position the vein runs under the inguinal
ligament into the lacuna vasorum. The veins flowing into v. femoralis are all binary.

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The largest of the subcutaneous veins of the lower extremity are two trunks: v. saphena magna and v.
saphena parva. The long saphenous vein (vena saphena magna) originates on the dorsal surface of the foot
from rete venosum dorsale pedis and the arcus venosus dorsalis pedis. Having received a few small
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branches from the side of the sole, it passes upward along the medial side of the crus and femur. In the
upper one-third of the femur, it bends onto the anteromedial surface and, lying on the broad fascia, runs
toward the hiatus saphenus. At this point, it drains into the femoral vein, passing over the lower horn of the
crescent-shaped edge. V. saphena magna

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quite often is binary with both its trunks draining separately into the femoral vein. Among the other
subcutaneous veins flowing into the femoral vein, mention should be made of v. epigastrica superficialis, v.
circumflex a ilium superficialis, and vv. pudendae externae, which accompany arteries of the same name.
Some of them drain directly into the femoral vein; others drain into v. saphena magna as it flows into the
region of the hiatus saphenus. The short saphenous vein (v. saphena parva) originates on the lateral side of
the dorsal surface of the foot, passes below and behind the lateral malleolus, and then rises along the
posterior surface of the crus. At first it runs along the lateral edge of Achilles tendon and then proceeds
upward along the middle of the posterior segment of the crus corresponding to the groove between the
heads of mm. gastrocnemii. When it reaches the lower angle of the popliteal fossa, v. saphena parva drains
into the popliteal vein. V. saphena parva is joined by branches to v. saphena magna.
DISTRIBUTION OF THE VEINS
1.

In the veins the blood flows through the greater part of the body (the trunk and limbs) against the

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force of gravity and, therefore, slower than in the arteries. The balance in the heart is achieved because
most of the venous bed is much wider than the arterial bed. The greater width of the venous bed is the
result of the following anatomical adaptations: the larger calibre of the veins, their greater number, the
paired attendance of the arteries, the presence of veins not accompanying arteries, the greater number of
anastomoses, the denser venous network, the formation of venous plexuses and sinuses, and the presence
of a portal system in the liver. Because of this, venous blood flows to the heart along three large vessels
(two venae cavae and the coronary sinus, in addition to the small veins running to the heart), while from the
heart blood flows only along the aorta.
2. Deep veins accompanying the arteries (venae commitantes) are distributed according to the same
laws as the arteries they accompany (see p. 93). Moreover, most of them accompany the arteries in pairs.
Where the venous outflow is most hampered, i.e., in the extremities, the veins are mainly paired, since this
arrangement is the result of evolution in four-legged animals whose torsos are horizontal, while both pairs
of limbs are perpendicular to the ground.
3. Many superficial veins lying under the skin accompany the nerves of the skin, although a significant
number form subcutaneous venous plexuses with no connection to either the nerves or the arteries.
4. Venous plexuses are mainly encountered in internal organs that change in volume in cavities with
inflexible walls. The plexuses facilitate the flow of venous blood when the organs increase in size and are
compressed by the walls. This explains the abundance of venous plexuses around the organs of the small
pelvis (urinary bladder, uterus, rectum), in the vertebral canal, where the pressure of the cerebrospinal fluid
constantly fluctuates, and in similar places.
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In the cranial cavity where the slightest impediment to the venous outflow has an immediate effect
on brain functions, there are, besides the veins, venous sinuses with inflexible walls formed by the dura
mater. These spherical adaptations lie mainly where the processes of the dura mater are
attached to the bones of the skull (at the seams of tegmental bones and bone sulci of analogous
sinuses).
6. Among the special adaptations are the diploic veins, venae diploicae.
5.

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HAEMATO-LYMPHATIC RELATIONS
As stated above, the thoracic duct drains into the left jugular vein or into the angle of its confluence
with .the left subclavian vein (angulus venosus sinister), while the right lymphatic duct drains into the right
subclavian vein. Lymph flowing through these ducts, therefore, mixes with the blood flowing in the veins
so that a mixture of venous blood and lymph flows into the heart.
According to the latest data, lymph flows into the venous paths not only where the lymphatic ducts
join the large veins running to the heart, but also in the lymph nodes.
An exchange of fluid between blood and lymph occurs in the nodes. Forty per cent of the lymph
(afferent) flowing into the node transfers into the venous paths of the lymph nodes. In phlebohypertonia
the reverse phenomenon is observed in the drained organs: part of the blood plasma flows into the
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lymphatic sinuses of the nodes. This reverse flow serves as one of the compensatory mechanisms in
venous hypertension.

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THE DEVELOPMENT OF LYMPHATIC VESSELS


The development of the lymphatic system in the process of phylogenesis is closely related to the
development of blood circulation, which, in turn, is determined by the adaptation of the respiratory organs
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to the environment (Fig. 76).


In aquatic fauna (fish which breathe with gills and have a dual-chamber venous heart), iymph is
propelled by the pulsations of the lymphatic heart, a dilated lympthatic vessel that propels lymph into the
venous bed. Fish have no lymph nodes, and the lymphatic tissue is diffuse. In amphibians the number of
lymphatic hearts increases, and they are situated in pairs on the border between the trunk and the
extremities (anterior and posterior pairs). The diffuse lymphatic tissue becomes concentrated in follicles
located in the mucous membranes.
When gills are finally replaced by lungs in terrestrial animals and pulmonary circulation develops in
addition to systemic circulation, the movement of lymph is facilitated by the throbbing of the heart. As a
result the role of lymphatic hearts diminishes, and they gradually disappear to be preserved only in a single
(posterior) pair. At the same time the overall number of lymphatic vessels increases.
In birds lymphatic hearts are present only in the foetus, and the number of lymphatic vessels increases.
Valves appear inside the vessels, preventing the reverse flow of lymph. Several lymph nodes make their
appearance. With the appearance of a muscular diaphragm in mammals and the further development of the
heart and blood vessels as well as the skeletal musculature, the movement of lymph is eased by the suction
action of the thoracic cage and the contraction of the heart, blood vessels, and muscles. There is no longer
any need for the lymphatic hearts, and they disappear completely. At the same time, the number of
lymphatic vessels, in which many valves develop, increases. The lymph ducts passing along the aorta
merge into a large unpaired trunk, the ductus thoracicus. The number of lymph nodes increases sharply,
particularly in primates.
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Since human beings walk erect, the number of valves in the lymphatic vessels of human extremities
increases, particularly in the lower limbs. Humans have the greatest number of lymph nodes of any species,
which testifies to the increased importance of the lymphatic system in limiting the spread of pathological
processes. A Soviet scientist Zhdanov maintains that the increase of lymph nodes in man (even, in
comparison with monkeys) is connected with diet.
There are two theories regarding the embryonic development of the lymphatic system. According to
the centrifugal development theory, as the first theory is called, the lymphatic system develops out of the
venous system. The second, theory contends that the system originates separately out of the mesenchyme
and only later joins the veins; this theory is called the theory of centripetal development. Most authors
currently recognize the latter theory, according to which the lymphatic system develops independently of
the system of blood circulation and establishes connections with the venous system secondarily. The
lymphatic system originates as detached germs, which grow, branch out, and form canals,
or lymph capillaries. Expanding and merging, these capillaries, in their second month, form six lymph
sacs: two by the jugular veins, one retroperitoneal at the base of the mesentery, near the adrenals, one
neighbouring the preceding one (this is the cisterna chyli), and two by the iliac veins.
The lymphatic vessels of the head, neck, and upper extremity (these last from supplementary sacs
occurring by the subclavian veins) develop from jugular sacs. The retroperitoneal S3C gives rise to
vessels of the mesentery collecting lymph from the intestine. The iliac sacs are the source for vessels of
the lower limbs and pelvis. Moreover, the jugular sacs grow in the direction of the thoracic cavity and join
in a single trunk, which meets the growing cisterna chyli. As a result a thoracic duct uniting the systems of
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the iliac, retroperitoneal and jugular sacs is formed. Thus, a single system of lymphatic vessels is created,
which makes contact with the venous system only near the jugular sacs at the confluence of the jugular
and subclavian veins on both sides of the body.
The initially symmetrical structure of the lymphatic system is disturbed later, however, because the left
duct (thoracic) develops to a greater extent than the right. This greater development is explained by the
asymmetrical position of the heart and large veins which creates more favourable conditions for the flow
of lymph and blood through the left side in the region of the left venous angle. On the right side, because
of the proximity to the venous half of the heart, there is a greater periodical increase of pressure in the
vena cava superior as the result of heart contractions, which hampers the stream of lymph from freely
joining the flow of venous blood. This functional difference in the circulation through the right and left
main lymph trunks of the body also explains their unequal development. A dual thoracic duct, common in
lower vertebrates, is sometimes preserved as a developmental variant in humans. Besides the lymphatic
vessels and sacs, the lymph nodes also develop, but somewhat later (in the third month).
THE LYMPHATIC SYSTEM IN VARIOUS PARTS OF THE BODY
The lymphatic vessels of the trunk, head, and limbs (i.e., of the soma) are divided into superficial and
deep vessels, separated by the deep fascia of the given region. Thus, the lymphatic vessels of the skin,
subcutaneous tissue, and part of the fascia, are superficial, while all other vessels, i.e., the lymphatic
vessels lying under the fascia, are deep. The deep lymphatic system of the soma is built as follows.

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The deep lymphatic vessels arising from the capillary lymph networks of joint capsules, muscles,
tendons, fasciae, nerves, and so on run, at first, as components of the neurovascular bundles of these
organs and then drain into the lymph collectors of the given part of the body. In their turn the lymph
collectors accompany large arterial and venous trunks and drain into the regional lymph nodes.
THE LOWER EXTREMITY
The lymph nodes of the lower extremity are located in the following places (Fig. 77).

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1. Popliteal fossapopliteal lymph glands (nodi lymphatici poplitet).

Inguinal regioninguinal lymph glands (nodi lymphatici inguinales). They lie immediately under the
inguinal ligament and are divided into superficial and deep inguinal lymph glands.
a) superficial inguinal glands (nodi lymphatici inguinales superficiales) are located on the wide fascia
2.

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of the femur below its perforation by v. saphena magna;

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b)deep

inguinal glands (nodi lymphatici.inguinales profundi) are locatea in the same region as the
superficial glands although under the wide fascir.

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The superficial lymphatic vessels drain into two groups of collect os running the length of v.
saphena magna to the medial group of the superficial inguinal nodes and along v. saphena parva to the
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popliteal nodes of the posterolateral group.


The posterolateral group of collectors and the popliteal nodes, receive lymph from the skin,
subcutaneous tissue, and superficial fasciae of a small region of the leg (the fourth and fifth toes, the lateral
edge of the foot, the inferior lateral surface of the crus, and the lateral part of the gastrocnemius region).
From all other parts of the leg, the lymph flows into the medial group of collectors and then into the
inguinal nodes without interruption in the popliteal nodes.

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This explains the reaction of the inguinal nodes (tumescence and tenderness) in purulent inflammation
of the skin of the ungual phalanx of the big toe, for example. The superficial lymphatic vessels of the upper
one-third of the thigh drain into the inguinal nodes, which also receive the superficial vessels of the gluteal
region, the anterior abdominal wall, and the external sexual organs.

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The deep lymphatic vessels of the foot and crus, including the articular sac of the knee joint, drain into
the popliteal nodes. From there the lymph flows through the deep collectors attendant to the femoral artery
until it reaches the deep inguinal nodes. These same collectors also receive lymph from the deep tissues of
the thigh. As a result, the large group of nodes located in the inguinal region collects lymph from the entire
lower limb, the anterior wall of the abdomen (below the navel), the gluteal region, the perineum and external
sexual organs, and partly from the internal sexual organs (uterus).

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The efferent vessels of the inguinal nodes run the length of the external iliac artery and vein to the iliac
lymph nodes from where the lymph passes into the truncus lumbalis.
THE PELVIS
In the pelvis the lymph nodes are mainly located along the blood vessels, as well as on the surface of
the internal organs. The following groups are found there: 1) external and common iliac lymph glands (nodi
lymphatici iliaci externi and commune) along the external artery and the common iliac artery; their efferent
ducts are directed towards nodi lymphatici lumbales; 2) internal iliac lymph glands (nodi lymphatici iliaci
interni) (9-12) on the lateral wall of the pelvic cavity; their efferent ducts pass to the nodes located along
the common iliac artery; 3) sacral lymph glands (nodi lymphatici sac- rales), small nodes along a. sacralis
mediana; their efferent ducts run towards nodi lymphatici iliaci, located near the promontorium. The
efferent lymphatic vessels of the organs of the minor pelvis drain into these nodes (see also the section on
splanchnology) (Fig. 77).
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External iliac vein is continuation of femoral vein and receives blood from all veins of lower limb.
Inferior epigastric vein and deep circumflex ilei vein empties into external iliac vein under inguinal
ligament.

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The veins of lower limb subdivide into superficial and deep. Deep veins are double and accompany
same name artery (only a popliteal vein and femoral vein are odd).
Follow veins belong to superficial veins of lower limb:

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1. Vena saphena magna has numerous valves, starts in front of medial malleolus, where receives
influxes from plantar surface of foot, passes along saphenus nerve on medial leg surface upward,
than on medial surface on thigh to saphaenus hiatus, where transfixes cribriform fascia and empties
into femoral vein. Vena saphena magna has the numerous subcutaneous tributaries from anteromedial
surface of leg, thigh and external genitals.
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2. Vena saphena parva has the numerous valves and collects blood from dorsal venous arch of foot,
passes behind lateral malleolus, lies into sulcus between lateral and medial heads of gastrocnemius
muscle and in popliteal fossa empties into popliteal vein.

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The great saphenous vein and its tributaries at the fossa ovalis.
3.
Follow vessels belong to deep veins of lower limb:

femoral vein;

deep femoral vein;

popliteal vein;

anterior tibial veins;

posterior tibial veins;

fibular veins.
The Superficial Veins of the Lower Extremity
The superficial veins of the lower extremity are the great and small saphenous veins and their
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tributaries.

On the dorsum of the foot the dorsal digital veins receive, in the clefts between the toes, the
intercapitular veins from the plantar cutaneous venous arch and join to form short common digital
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veins which unite across the distal ends of the metatarsal bones in a dorsal venous arch. Proximal to this
arch is an irregular venous net-work which receives tributaries from the deep veins and is joined at the sides
of the foot by a medial and a lateral marginal vein, formed mainly by the union of branches from the
superficial parts of the sole of the foot.
On the sole of the foot the superficial veins form a plantar cutaneous venous arch which extends
across the roots of the toes and opens at the sides of the foot into the medial and lateral marginal veins.
Proximal to this arch is a plantar cutaneous venous net-work which is especially dense in the fat beneath
the heel; this net-work communicates with the cutaneous venous arch and with the deep veins, but is chiefly
drained into the medial and lateral marginal veins.
The great saphenous vein (v. saphena magna; internal or long saphenous vein) (581), the longest vein
in the body, begins in the medial marginal vein of the dorsum of the foot and ends in the femoral vein about
3 cm. below the inguinal ligament. It ascends in front of the tibial malleolus and along the medial side of the
leg in relation with the saphenous nerve. It runs upward behind the medial condyles of the tibia and femur
and along the medial side of the thigh and, passing through the fossa ovalis, ends in the femoral vein.
Tributaries.At the ankle it receives branches from the sole of the foot through the medial marginal vein;
in the leg it anastomoses freely with the small saphenous vein, communicates with the anterior and posterior
tibial veins and receives many cutaneous veins; in the thigh it communicates with the femoral vein and
receives numerous tributaries; those from the medial and posterior parts of the thigh frequently unite to
form a large accessory saphenous vein which joins the main vein at a variable level. Near the fossa ovalis
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(580) it is joined by the superficial epigastric, superficial iliac circumflex, and superficial external pudendal
veins. A vein, named the thoracoepigastric, runs along the lateral aspect of the trunk between the
superficial epigastric vein below and the lateral thoracic vein above and establishes an important
communication between the femoral and axillary veins.
The valves in the great saphenous vein vary from ten to twenty in number; they are more numerous in the
leg than in the thigh.
The small saphenous vein (v. saphena parva; external or short saphenous vein) (582) begins behind
the lateral malleolus as a continuation of the lateral marginal vein; it first ascends along the lateral margin of
the tendocalcaneus, and then crosses it to reach the middle of the back of the leg. Running directly upward,
it perforates the deep fascia in the lower part of the popliteal fossa, and ends in the popliteal vein, between
the heads of the Gastrocnemius. It communicates with the deep veins on the dorsum of the foot, and
receives numerous large tributaries from the back of the leg. Before it pierces the deep fascia, it gives off a
branch which runs upward and forward to join the great saphenous vein. The small saphenous vein
possesses from nine to twelve valves, one of which is always found near its termination in the popliteal
vein. In the lower third of the leg the small saphenous vein is in close relation with the sural nerve, in the
upper two-thirds with the medial sural cutaneous nerve.
The Deep Veins of the Lower Extremity
The deep veins of the lower extremity accompany the arteries and their branches; they possess numerous
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valves.

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The great saphenous vein and its tributaries.

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The small saphenous vein.


The plantar digital veins (vv. digitales plantares) arise from plexuses on the plantar surfaces of the
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digits, and, after sending intercapitular veins to join the dorsal digital veins, unite to form four
metatarsal veins; these run backward in the metatarsal spaces, communicate, by means of perforating
veins, with the veins on the dorsum of the foot, and unite to form the deep plantar venous arch which
lies alongside the plantar arterial arch. From the deep plantar venous arch the medial and lateral plantar
veins run backward close to the corresponding arteries and, after communicating with the great and small
saphenous veins, unite behind the medial malleolus to form the posterior tibial veins.
The posterior tibial veins (vv. tibiales posteriores) accompany the posterior tibial artery, and are joined
by the peroneal veins.
The anterior tibial veins (vv. tibiales anteriores) are the upward continuation of the ven comitantes of
the dorsalis pedis artery. They leave the front of the leg by passing between the tibia and fibula, over the
interosseous membrane, and unite with the posterior tibial, to form the popliteal vein.
The Popliteal Vein (v. poplitea) (583) is formed by the junction of the anterior and posterior tibial veins
at the lower border of the Popliteus; it ascends through the popliteal fossa to the aperture in the Adductor
magnus, where it becomes the femoral vein. In the lower part of its course it is placed medial to the artery;
between the heads of the Gastrocnemius it is superficial to that vessel; but above the knee-joint, it is close
to its lateral side. It receives tributaries corresponding to the branches of the popliteal artery, and it also
receives the small saphenous vein. The valves in the popliteal vein are usually four in number.
The femoral vein (v. femoralis) accompanies the femoral artery through the upper two-thirds of the
thigh. In the lower part of its course it lies lateral to the artery; higher up, it is behind it; and at the inguinal
ligament, it lies on its medial side, and on the same plane. It receives numerous muscular tributaries, and
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about 4 cm. below the inguinal ligament is joined by the v. profunda femoris; near its termination it is joined
by the great saphenous vein. The valves in the femoral vein are three in number.
The Deep Femoral Vein (v. profunda femoris) receives tributaries corresponding to the perforating
branches of the profunda artery, and through these establishes communications with the popliteal vein
below and the inferior gluteal vein above. It also receives the medial and lateral femoral circumflex veins.

The popliteal vein.


The Veins of the Abdomen and Pelvis (585, 586, 587)
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The external iliac vein (v. iliaca externa), the upward continuation of the femoral vein, begins behind
the inguinal ligament, and, passing upward along the brim of the lesser pelvis, ends opposite the sacroiliac
articulation, by uniting with the hypogastric vein to form the common iliac vein. On the right side, it lies at
first medial to the artery: but, as it passes upward, gradually inclines behind it. On the left side, it lies
altogether on the medial side of the artery. It frequently contains one, sometimes two, valves.
Tributaries.The external iliac vein receives the inferior epigastric, deep iliac circumflex, and pubic
veins.
The Inferior Epigastric Vein (v. epigastrica inferior; deep epigastric vein) is formed by the union of
the ven comitantes of the inferior epigastric artery, which communicate above with the superior epigastric
vein; it joins the external iliac about 1.25 cm. above the inguinal ligament.
The Deep Iliac Circumflex Vein (v. circumflexa ilium profunda) is formed by the union of the ven
comitantes of the deep iliac circumflex artery, and joins the external iliac vein about 2 cm. above the
inguinal ligament.
The Pubic Vein communicates with the obturator vein in the obturator foramen, and ascends on the back
of the pubis to the external iliac vein.
The hypogastric vein (v. hypogastrica; internal iliac vein) begins near the upper part of the greater
sciatic foramen, passes upward behind and slightly medial to the hypogastric artery and, at the brim of the
pelvis, joins with the external iliac to form the common iliac vein.

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The femoral vein and its tributaries.

Tributaries.With the exception of the fetal umbilical vein which passes upward and backward from the
umbilicus to the liver, and the iliolumbar vein which usually joins the common iliac vein, the tributaries of
the hypogastric vein correspond with the branches of the hypogastric artery. It receives (a) the gluteal,
internal pudendal, and obturator veins, which have their origins outside the pelvis; (b) the lateral
sacral veins, which lie in front of the sacrum; and (c) the middle hemorrhoidal, vesical, uterine, and
vaginal veins, which originate in venous plexuses connected with the pelvic viscera.

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The Lymphatics of the Lower Extremity


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The superficial and deep vessels are distinguished in lower limb. The superficial vessels are situated over
superficial fascia and deep vessels positioned closely to deep blood vessels. Popliteal nodes and inguinal
nodes are distinguished in lower limb. Last one subdivide into deep inguinal nodes and superficial inguinal
nodes. Superficial inguinal nodes dispose along inguinal ligament and lie on superficial sheet of fascia lata
femoris. Their efferent vessels pass to external iliac nodes, which accompany same name artery.
The superficial vessels of lower limb formed from capillary skin networks and subcutaneous cellular
tissue and form medial, lateral and posterior vessel groups.
Medial group of superficial vessels formed in skin of I, II and III fingers, medial part of foot and medial
surface of shin. These vessels run along vena saphena magna and empty into superficial inguinal nodes.
Lateral group of superficial vessels of lower limb formed laterally in area of fingers in dorsal foot
surface and lateral surface of shin. These vessels beneath knee join to medial group.
Posterior group of superficial vessels of lower limb starts in skin of heel and plantar surface of lateral
foot margin, passes along the vena saphaena parva and runs into popliteal lymphatic nodes.
Deep vessels of lower limb drainage muscles, joints, synovial sheaths, bones, nerves, accompany deep
arteries and veins and empty into deep inguinal nodes.
The Veins of the Lower Extremity
Just as with the upper extremity, the veins of the lower extremity are divided into deep and superficial,
or subcutaneous, veins, which pass independently of the arteries .
The deep veins of the foot and crus are binary and they accompany arteries of the same name. V.
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poplitea, which is comprised of all the deep veins of the crus, constitutes a single trunk lying in the
popliteal fossa posteriorly and somewhat laterally of the artery of the same name. V. femoralis is single; it
originates laterally of the femoral artery but, then, passes gradually to the posterior surface of the artery,
and as it rises higher, it passes onto the medial surface. From this position the vein runs under the inguinal
ligament into the lacuna vasorum. The veins flowing into v. femoralis are all binary.

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The largest of the subcutaneous veins of the lower extremity are two trunks: v. saphena magna and v.
saphena parva. The long saphenous vein (vena saphena magna) originates on the dorsal surface of the
foot from rete venosum dorsale pedis and the arcus venosus dorsalis pedis. Having received a few small
branches from the side of the sole, it passes upward along the medial side of the crus and femur. In the
upper one-third of the femur, it bends onto the anteromedial surface and, lying on the broad fascia, runs
toward the hiatus saphenus. At this point, it drains into the femoral vein, passing over the lower horn of the
crescent-shaped edge. V. saphena magna

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quite often is binary with both its trunks draining separately into the femoral vein. Among the other
subcutaneous veins flowing into the femoral vein, mention should be made of v. epigastrica superficialis, v.
circumflex a ilium superficialis, and vv. pudendae externae, which accompany arteries of the same name.
Some of them drain directly into the femoral vein; others drain into v. saphena magna as it flows into the
region of the hiatus saphenus. The short saphenous vein (v. saphena parva) originates on the lateral side
of the dorsal surface of the foot, passes below and behind the lateral malleolus, and then rises along the
posterior surface of the crus. At first it runs along the lateral edge of Achilles tendon and then proceeds
upward along the middle of the posterior segment of the crus corresponding to the groove between the
heads of mm. gastrocnemii. When it reaches the lower angle of the popliteal fossa, v. saphena parva drains
into the popliteal vein. V. saphena parva is joined by branches to v. saphena magna.

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DISTRIBUTION OF THE VEINS


In the veins the blood flows through the greater part of the body (the trunk and limbs) against the
force of gravity and, therefore, slower than in the arteries. The balance in the heart is achieved because
most of the venous bed is much wider than the arterial bed. The greater width of the venous bed is the
result of the following anatomical adaptations: the larger calibre of the veins, their greater number, the
paired attendance of the arteries, the presence of veins not accompanying arteries, the greater number of
anastomoses, the denser venous network, the formation of venous plexuses and sinuses, and the presence
of a portal system in the liver. Because of this, venous blood flows to the heart along three large vessels
(two venae cavae and the coronary sinus, in addition to the small veins running to the heart), while from the
heart blood flows only along the aorta.
2. Deep veins accompanying the arteries (venae commitantes) are distributed according to the same
laws as the arteries they accompany (see p. 93). Moreover, most of them accompany the arteries in pairs.
1.

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Where the venous outflow is most hampered, i.e., in the extremities, the veins are mainly paired, since this
arrangement is the result of evolution in four-legged animals whose torsos are horizontal, while both pairs
of limbs are perpendicular to the ground.
3. Many superficial veins lying under the skin accompany the nerves of the skin, although a significant
number form subcutaneous venous plexuses with no connection to either the nerves or the arteries.
4. Venous plexuses are mainly encountered in internal organs that change in volume in cavities with
inflexible walls. The plexuses facilitate the flow of venous blood when the organs increase in size and are
compressed by the walls. This explains the abundance of venous plexuses around the organs of the small
pelvis (urinary bladder, uterus, rectum), in the vertebral canal, where the pressure of the cerebrospinal fluid
constantly fluctuates, and in similar places.
5. In the cranial cavity where the slightest impediment to the venous outflow has an immediate effect
on brain functions, there are, besides the veins, venous sinuses with inflexible walls formed by the dura
mater. These spherical adaptations lie mainly where the processes of the dura mater are
attached to the bones of the skull (at the seams of tegmental bones and bone sulci of analogous
sinuses).
6. Among the special adaptations are the diploic veins, venae diploicae.
HAEMATO-LYMPHATIC RELATIONS
As stated above, the thoracic duct drains into the left jugular vein or into the angle of its confluence
with .the left subclavian vein (angulus venosus sinister), while the right lymphatic duct drains into the right
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subclavian vein. Lymph flowing through these ducts, therefore, mixes with the blood flowing in the veins
so that a mixture of venous blood and lymph flows into the heart.
According to the latest data, lymph flows into the venous paths not only where the lymphatic ducts
join the large veins running to the heart, but also in the lymph nodes.
An exchange of fluid between blood and lymph occurs in the nodes. Forty per cent of the lymph
(afferent) flowing into the node transfers into the venous paths of the lymph nodes. In phlebohypertonia
the reverse phenomenon is observed in the drained organs: part of the blood plasma flows into the
lymphatic sinuses of the nodes. This reverse flow serves as one of the compensatory mechanisms in
venous hypertension.
THE DEVELOPMENT OF LYMPHATIC VESSELS
The development of the lymphatic system in the process of phylogenesis is closely related to the
development of blood circulation, which, in turn, is determined by the adaptation of the respiratory organs
to the environment (Fig. 76).
In aquatic fauna (fish which breathe with gills and have a dual-chamber venous heart), iymph is
propelled by the pulsations of the lymphatic heart, a dilated lympthatic vessel that propels lymph into the
venous bed. Fish have no lymph nodes, and the lymphatic tissue is diffuse. In amphibians the number of
lymphatic hearts increases, and they are situated in pairs on the border between the trunk and the
extremities (anterior and posterior pairs). The diffuse lymphatic tissue becomes concentrated in follicles
located in the mucous membranes.
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When gills are finally replaced by lungs in terrestrial animals and pulmonary circulation develops in
addition to systemic circulation, the movement of lymph is facilitated by the throbbing of the heart. As a
result the role of lymphatic hearts diminishes, and they gradually disappear to be preserved only in a single
(posterior) pair. At the same time the overall number of lymphatic vessels increases.
In birds lymphatic hearts are present only in the foetus, and the number of lymphatic vessels increases.
Valves appear inside the vessels, preventing the reverse flow of lymph. Several lymph nodes make their
appearance. With the appearance of a muscular diaphragm in mammals and the further development of the
heart and blood vessels as well as the skeletal musculature, the movement of lymph is eased by the suction
action of the thoracic cage and the contraction of the heart, blood vessels, and muscles. There is no longer
any need for the lymphatic hearts, and they disappear completely. At the same time, the number of
lymphatic vessels, in which many valves develop, increases. The lymph ducts passing along the aorta
merge into a large unpaired trunk, the ductus thoracicus. The number of lymph nodes increases sharply,
particularly in primates.
Since human beings walk erect, the number of valves in the lymphatic vessels of human extremities
increases, particularly in the lower limbs. Humans have the greatest number of lymph nodes of any species,
which testifies to the increased importance of the lymphatic system in limiting the spread of pathological
processes. A Soviet scientist Zhdanov maintains that the increase of lymph nodes in man (even, in
comparison with monkeys) is connected with diet.
There are two theories regarding the embryonic development of the lymphatic system. According to
the centrifugal development theory, as the first theory is called, the lymphatic system develops out of the
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venous system. The second, theory contends that the system

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originates separately out of the mesenchyme and only later joins the veins; this theory is called the theory
of centripetal development. Most authors currently recognize the latter theory, according to which the
lymphatic system develops independently of the system of blood circulation and establishes
connections with the venous system secondarily. The lymphatic system originates as detached germs,
which grow, branch out, and form canals,
or lymph capillaries. Expanding and merging, these capillaries, in their second month, form six lymph
sacs: two by the jugular veins, one retroperitoneal at the base of the mesentery, near the adrenals, one
neighbouring the preceding one (this is the cisterna chyli), and two by the iliac veins.
The lymphatic vessels of the head, neck, and upper extremity (these last from supplementary sacs
occurring by the subclavian veins) develop from jugular sacs. The retroperitoneal S3C gives rise to
vessels of the mesentery collecting lymph from the intestine. The iliac sacs are the source for vessels of
the lower limbs and pelvis. Moreover, the jugular sacs grow in the direction of the thoracic cavity and join
in a single trunk, which meets the growing cisterna chyli. As a result a thoracic duct uniting the systems of
the iliac, retroperitoneal and jugular sacs is formed. Thus, a single system of lymphatic vessels is created,
which makes contact with the venous system only near the jugular sacs at the confluence of the jugular
and subclavian veins on both sides of the body.
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The initially symmetrical structure of the lymphatic system is disturbed later, however, because the left
duct (thoracic) develops to a greater extent than the right. This greater development is explained by the
asymmetrical position of the heart and large veins which creates more favourable conditions for the flow
of lymph and blood through the left side in the region of the left venous angle. On the right side, because
of the proximity to the venous half of the heart, there is a greater periodical increase of pressure in the
vena cava superior as the result of heart contractions, which hampers the stream of lymph from freely
joining the flow of venous blood. This functional difference in the circulation through the right and left
main lymph trunks of the body also explains their unequal development. A dual thoracic duct, common in
lower vertebrates, is sometimes preserved as a developmental variant in humans. Besides the lymphatic
vessels and sacs, the lymph nodes also develop, but somewhat later (in the third month).
THE LYMPHATIC SYSTEM IN VARIOUS PARTS OF THE BODY
The lymphatic vessels of the trunk, head, and limbs (i.e., of the soma) are divided into superficial and
deep vessels, separated by the deep fascia of the given region. Thus, the lymphatic vessels of the skin,
subcutaneous tissue, and part of the fascia, are superficial, while all other vessels, i.e., the lymphatic
vessels lying under the fascia, are deep. The deep lymphatic system of the soma is built as follows. The
deep lymphatic vessels arising from the capillary lymph networks of joint capsules, muscles, tendons,
fasciae, nerves, and so on run, at first, as components of the neurovascular bundles of these organs and
then drain into the lymph collectors of the given part of the body. In their turn the lymph collectors
accompany large arterial and venous trunks and drain into the regional lymph nodes.
THE LOWER EXTREMITY
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THE LOWER EXTREMITY


The lymph nodes of the lower extremity are located in the following places (Fig. 77).
1. Popliteal fossapopliteal lymph glands (nodi lymphatici poplitet).

Inguinal regioninguinal lymph glands (nodi lymphatici inguinales). They lie immediately under the
inguinal ligament and are divided into superficial and deep inguinal lymph glands.
2.

a)superficial inguinal glands

(nodi lymphatici inguinales superficiales) are located on the wide fascia


of the femur below its perforation by v. saphena magna;
b)deep

inguinal glands (nodi lymphatici.inguinales profundi) are locatea in the same region as the
superficial glands although under the wide fascir.
The superficial lymphatic vessels drain into two groups of collect os running the length of v.
saphena magna to the medial group of the superficial inguinal nodes and along v. saphena parva to the
popliteal nodes of the posterolateral group.
The posterolateral group of collectors and the popliteal nodes, receive lymph from the skin,
subcutaneous tissue, and superficial fasciae of a small region of the leg (the fourth and fifth toes, the lateral
edge of the foot, the inferior lateral surface of the crus, and the lateral part of the gastrocnemius region).
From all other parts of the leg, the lymph flows into the medial group of collectors and then into the
inguinal nodes without interruption in the popliteal nodes. This explains the reaction of the inguinal nodes
(tumescence and tenderness) in purulent inflammation of the skin of the ungual phalanx of the big toe, for
example. The superficial lymphatic vessels of the upper one-third of the thigh drain into the inguinal nodes,
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which also receive the superficial vessels of the gluteal region, the anterior abdominal wall, and the external
sexual organs.
The deep lymphatic vessels of the foot and crus, including the articular sac of the knee joint, drain into
the popliteal nodes. From there the lymph flows through the deep collectors attendant to the femoral artery
until it reaches the deep inguinal nodes. These same collectors also receive lymph from the deep tissues of
the thigh. As a result, the large group of nodes located in the inguinal region collects lymph from the entire
lower limb, the anterior wall of the abdomen (below the navel), the gluteal region, the perineum and external
sexual organs, and partly from the internal sexual organs (uterus).
The efferent vessels of the inguinal nodes run the length of the external iliac artery and vein to the iliac
lymph nodes from where the lymph passes into the truncus lumbalis.

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THE PELVIS
In the pelvis the lymph nodes are mainly located along the blood vessels, as well as on the surface of
the internal organs. The following groups are found there: 1) external and common iliac lymph glands (nodi
lymphatici iliaci externi and commune) along the external artery and the common iliac artery; their efferent
ducts are directed towards nodi lymphatici lumbales; 2) internal iliac lymph glands (nodi lymphatici iliaci
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interni) (9-12) on the lateral wall of the pelvic cavity; their efferent ducts pass to the nodes located along
the common iliac artery; 3) sacral lymph glands (nodi lymphatici sac- rales), small nodes along a. sacralis
mediana; their efferent ducts run towards nodi lymphatici iliaci, located near the promontorium. The
efferent lymphatic vessels of the organs of the minor pelvis drain into these nodes.

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