Pathophysiology of chronic venous disease
- Patrick C Alguire, MD, FACP
Patrick C Alguire, MD, FACP
- Senior Vice President for Medical Education
- American College of Physicians
- Barbara M Mathes, MD, FACP, FAAD
Barbara M Mathes, MD, FACP, FAAD
- Clinical Associate, Dermatology
- University of Pennsylvania
- Secretary Treasurer
- American Academy of Dermatology
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Chronic venous disease is a common medical problem that can result in significant morbidity and mortality. The clinical presentation of this disorder spans a spectrum from asymptomatic but cosmetically troublesome small blue ectatic veins and varicosities, to severe fibrosing panniculitis, dermatitis, edema, and ulceration. (See "Clinical manifestations of lower extremity chronic venous disease".)
The final common pathway that leads to chronic venous insufficiency is the development of venous hypertension. In most cases, venous hypertension results from obstruction to venous flow, dysfunction of venous valves, and/or failure of the "venous pump." In these situations, flow is directed abnormally from the deep to the superficial system, producing local tissue inflammation fibrosis, and occasionally ulceration.
This topic will review normal venous anatomy and physiology, and the pathophysiology of venous hypertension with its clinical consequences. Other aspects of chronic venous insufficiency are discussed separately.
NORMAL VENOUS ANATOMY AND PHYSIOLOGY
Three major vascular pathways are responsible for draining blood away from the superficial vessels of the skin and subcutaneous fat and include: (See "Classification of lower extremity chronic venous disorders", section on 'Anatomy (The "A" component of CEAP)'.)
- Superficial veins – The superficial veins are a network of subcutaneous veins that are superficial to the deep muscular fascia and include the great saphenous and small saphenous veins. (figure 1 and figure 2).
- Deep veins – The deep veins are located deep to the muscle fascia (figure 3). Deep veins are either within the muscle (ie, intramuscular, such as the gastrocnemius and soleus) or between the muscles (ie, intermuscular); the latter are more important in the development of chronic venous insufficiency . The intermuscular veins, which accompany the lower extremity arteries, include the anterior tibial, posterior tibial, peroneal (fibular), popliteal, and femoral veins. The lower leg intermuscular veins are exposed to high subfascial pressures during calf muscle contraction.
- Perforating veins – The perforating veins communicate between the deep and superficial venous systems. One very important group of perforating veins, “Cockett’s perforators,” connect the posterior tibial veins to the posterior accessory great saphenous vein (ie, vein of Leonardo), indirectly draining into the deep venous system.
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