Venous valves in subclavian and internal jugular veins. Frequency, position, and structure in 100 autopsy cases

Valves in the subclavian and internal jugular veins were studied in 100 autopsy cases (52 men and 48 women; range, 18 to 91 years old; mean, 67 years). In 87 cases, valves were present in all 4 veins, and in 13 cases, valves anatomically were absent from 16 veins, 9 of which were the left internal jugular vein. The average distance from the valve to the junction with the innominate vein was 1.7 cm for the subclavian vein and 0.3 cm for the internal jugular vein. Cuspid height averaged 0.9 cm. Valves were bicuspid in 347 (90%) and unicuspid in 39 (10%); unicuspid valves were more common in the internal jugular vein than in the subclavian vein. Catheter-induced trauma was observed in 4 cases and implied in 4 more. These findings may have important implications concerning the failure, in some cases, of closed-chest cardiac resuscitation to maintain forward blood flow at adequate pressure.     

Architecture and structure of canine veins with special reference to confluences

The occurrence of cell-infiltrated intimal lesions at the confluence of many small tributaries with canine jugular and femoral veins suggested that these areas (confluences) might 1) differ structurally from the rest of the receiving vein and 2) serve as initiation sites for thrombi. To explore these possibilities, the number of tributaries was determined by careful blunt dissection, and the architecture of confluences was studied by light and scanning and transmission electron microscopy. In addition to confluences formed by a named tributary (omobrachial), canine jugular veins averaged 11 confluences formed with small (0.2 to 2.5 mm diameter) unnamed tributaries that had not been previously described. Femoral veins averaged eight confluences of which four were formed with small unnamed tributaries. Double-leafed valves were found at 90% of jugular and 76% of femoral vein confluences. Previously such valves were described only at the confluence of superficial with deep leg veins. Corrosion casts of iliac, saphenous, azygous, costocervical, and maxillary veins as well as cranial and caudal vena cava demonstrated a similar pattern of tributaries and valves. The three structures (receiving vein, tributary, valves) that formed the confluence differed, necessitating considerable modification as they approached the area of fusion. Jugular and femoral vein walls contained 5 to 10 layers of smooth muscle, abundant collagen, and a small amount of elastin. Tributary walls contained 0 to 2 discontinuous smooth muscle cell layers, limited collagen, and no elastin. As receiving veins approached a confluence, the thickness decreased by 15 to 77% except at valve attachment sites, which were thickened. A cluster of smooth muscle cells formed the junction of valve leaflets with vein. Endothelium was continuous over the luminal surface of all three structures. Calculations showed that these small-valved tributaries make only a small contribution to venous return. On the other hand, there is considerable information to support the concept that local attenuation of the vein wall would lead to localized vessel dilation, resulting in rupture of the endothelium and basement membrane.     

足背浅静脉及其瓣膜的应用解剖

在专供研究用的21具(42侧)成人足标本上,解剖观测了足背浅静脉及其瓣膜,发现大、小隐静脉足背段瓣膜数分别为2.8个和1.4个;在第一～四跖背静脉汇入口处瓣膜出现率分别为70.0%,53.3%,85.3%,77.8%,在共干型的跖背静脉内瓣膜出现率达100%;在直径小于2mm的跖背静脉也观测到瓣膜。本文认为足背静脉(弓)作为移植体(静脉动脉化)来修复掌浅弓缺损可以减少临床修复掌浅弓手术的复杂性。但应充分重视足背静脉(弓)内及跖背静脉汇入口处的静脉瓣。     

Septum in the external jugular vein

We examined 70 external jugular veins from 35 cadavers. In six veins we observed a septum, 6–25 mm long, which completely divided the lumen of the vein. The septum, which has not been previously described, was located approximately 5 cm superior to the vein's termination into the subclavian vein. Histologically, the septum is composed of tunica intima and tunica media in contrast to venous valves which are composed of tunica intima only.     

Valves in superficial limb veins of humans and nonhuman primates

The venous valves are believed to play an important role in venous function, but their number, position, and spacing in limb veins are reported to be irregular. In this study, the relationship between the number of valves and the length of veins in which they occur was investigated for humans and nonhuman primates. In addition, valve distributions within the superficial veins of the human upper limb were compared with those of the lower limb. Upper and lower limb veins were dissected from adult humans, and forelimb veins were obtained from seven genera of primates. The mean valve index (number of valves per unit length of vein) of the forelimb lateral superficial vein exhibited relatively little variation between humans and primates of a wide range of body sizes and locomotor repertoires. The mean valve index for the lateral superficial vein of the human upper limb is similar to that of the short saphenous vein of the lower limb, and in both veins, the maximum valve index occurs in the most proximal portion of the vein. The relative constancy of the valve index across a range of primate species, and between the upper and lower limbs of humans, may reflect the known constancy of circulatory pressures in mammals. The minimum numbers of valves in superficial veins are only slightly greater than required to limit capillary pressure to below 10 mm Hg, above which pressure the tissue fluid flow would be compromised.     

经颈外静脉穿刺置管的应用解剖

在80侧成人尸体上进行了颈外静脉应用解剖学研究.它的合成类型共分6型,其中以下颌后静脉后支、耳后静脉后支和耳后静脉合成面静脉后再注入者较多(46.3％);属支除常见的颈横静脉、颈前静脉外,尚有头静脉注入:其末端以注入锁骨下静脉较多(58.7％).颈外静脉自甲状软骨上缘至汇入其它静脉的注入点的平均长为77.5±1.5mm,颈横神经在锁骨上方62.1±1.2mm处横越颈外静脉深面.文中讨论了经颈外静脉穿刺置管的部位和术中注意问题.     

上臂静脉段移植的应用解剖

目的：为采用自体带瓣臂静脉段移植术治疗下肢深静脉功能不全提供解剖学基础。方法：观测４６侧上臂头静脉、贵要静脉及肱静脉外径、瓣膜的数目和分布。结果：各静脉外径均大于３ｍｍ,但头静脉较贵要静脉和肱静脉细。臂中段的静脉瓣膜比臂上、下段多,所有的臂中段都至少有１条适于带瓣移植的静脉段,而在臂上、下段仅分别为７６％和７０％。结论：在臂中段内侧作切口是截取带瓣贵要静脉或肱静脉段的最适位置。     

Surgically important variations of the jugular veins

Knowledge of variations of veins of head and neck in relation to external jugular, anterior jugular, internal jugular, and facial veins is important to surgeons doing head and neck surgery as well as to radiologists doing catheterization and to clinicians in general. In the current case, multiple variations in the veins of the left side of neck are reported. The anterior division of retromandibular vein was absent. The facial vein continued as anterior jugular vein. The internal jugular vein was duplicated above the level of hyoid bone. There was a large communicating vein between the anterior jugular vein and anterior division of internal jugular vein. Lingual vein drained into the communicating vein. Jugular venous arch was abnormally large, doubled, and highly placed. The veins of the right side were normal.     

Anatomic considerations in placement of central venous catheters

A knowledge of anatomy is essential for efficient and skillful placement of central venous catheters in seriously ill patients. The anatomy of the femoral, brachial, axillary, subclavian, external jugular, and internal jugular veins is described, and landmarks useful in achieving successful cannulation are discussed. Infectious and thrombotic complications of long-term cannulation are reviewed. Catheterization of the umbilical vein in the newborn infant is a very useful alternative approach to central venous cannulation in this age group.     

An angiographic study of the carotid arterial and jugular venous systems in the cat

Standard techniques for performing carotid angiography in dogs and in man were adapted to the cat in order to study the vascularization of both intracranial and extracranial structures. Venous drainage was examined by venography of selected vessels. The carotid-cerebral and the vertebral-basilar arterial systems of the cat were studied, although no attempt was made to define the territory supplied by each system. In serial angiograms, vascularization of the rete mirabile conjugatum was visualized, and distinct arterial and venous retia were delineated. Large facial veins were seen approximately one second after the intra-arterial injection of radio-contrast material. The early filling of the large facial veins appeared to be the result of an artery-to-venous shunt. Contrast material flowed posteriorly in these veins and drained into the venous rete. When contrast material was injected either into the sagittal sinus or retrograde in the external jugular vein, the internal jugular vein was visible in four of ten cats. This vessel drained blood directly from intracranial contents before anastomosis with the vertebral and external jugular veins.     

Onset and progression of experimental bioprosthetic heart valve calcification

Calcification, the major cause of bioprosthetic heart valve failures, is a serious clinical problem with uncertain pathogenesis. The objectives of the present study were to define the progressive chemical and morphologic sequence of mineralization in glutaraldehyde-treated porcine aortic valve cusps implanted subcutaneously in rats and to compare the pathology and pathophysiology of calcification in subcutaneous implants with that of orthotopic valve replacements in calves. Cusps were implanted subcutaneously in 3-week-old rats for 24 hours to 18 weeks. Cuspal calcium was 114 +/- 18 micrograms/mg of dry weight (mean +/- SEM) at day 21 and 218 +/- 6 at day 56 of implantation and unchanged thereafter. The earliest mineral deposits, noted at 48 hours, were associated with devitalized porcine connective tissue cells, but by 7 days, mineral deposits also involved collagen bundles. Scanning electron microscopy with energy-dispersive x-ray analysis demonstrated predominant accumulation in the spongiosa with a spongiosa to fibrosa energy-dispersive x-ray analysis count ratio of calcium of 15 at 21 days. In stent-mounted glutaraldehyde-preserved porcine valves implanted in five calves as mitral replacements for 69 to 142 days, cuspal calcium was 86 micrograms/mg (mean) (range 47 to 128). Calf implants also had cell oriented and collagen calcification predominating in the valvar spongiosa. In both rat subcutaneous and calf mitral valve models, early diffuse calcific microcrystals evolved into confluent nodules that disrupted tissue architecture. It is concluded that calcification of glutaraldehyde-preserved porcine aortic valves implanted subcutaneously in rats begins within 48 hours, earliest deposits are localized to residual porcine connective tissue cells, but latter deposits also involve collagen fibrils, mineralization is most prominent in the spongiosa, the pathology of calcification in rat subcutaneous implants and calf mitral replacements is comparable, suggesting a common pathophysiology, and calcific nodule formation most likely initiates clinical features.     

Morphological and clinical aspects of scapular fasciocutaneous free flap transfer for treatment of venous insufficiency in the lower extremity

We have recently shown that free scapular fasciocutaneous flaps transferred to the lower extremities of patients with chronic venous insufficiency and cutaneous ulcers have resulted in improvement in venous refilling times measured by photoplethysmography in the flap areas and that recurrent ulceration does not recur for up to 7 years. We hypothesized that the transferred flaps contained valves in their microvascular bed, which facilitated venous return, and using scanning electron microscopy of vascular corrosion casts and light and transmission electron microscopy of tissue sections prepared from human dorsal thoracic fascia, we showed that valves were most abundant in veins with a luminal diameter of 30–120 μm (59.3% of 905 valves). The depth of these valves increased with venous diameter, but the size of valve sinuses was not different for individual valves. Except for veins >1,000 μm in diameter, there was no significant difference in the number of valves in different parts of an individual flap or between different flaps. Most valves were bicuspid; only in the vein Category 30–120 μm were unicuspid valves encountered. Valves were sometimes located in series in a short segment of a vein; occasionally they were found at the merging of two veins. Transmission electron microscopy showed that valve leaflets had collagen fibers that ascended toward the tip of the leaflet and were occasionally accompanied by elastic fibers. Myofibroblasts were regularly present in the valve leaflets. The present report reviews and updates these anatomic data about the human scapular region, focusing on venous valvular microstructure, and suggests that the high number of smaller-size valves contributes to improved hemodynamic of the leg and thus the clinical success of free scapular flaps used to treat cutaneous ulcerations in the lower extremity. Clin. Anat. 11:38–46, 1998. © 1998 Wiley-Liss, Inc.     

Mesh-constricted varicose and dilated veins used as arterial bypass grafts.

To avoid non-autogenous vascular prostheses in coronary and peripheral vascular procedures, otherwise unusable dilated, varicose or thin-walled veins can be implanted as naturally endothelialized grafts after being calibrated by insertion into mesh tubes. In six sheep the 14 mm diameter jugular vein was inserted into a 12 cm long, 6 mm diameter Dacron mesh tube and implanted as a femoropopliteal graft. On the contralateral side the femoral vein with a maximal diameter of 7 to 8 mm was implanted. At control angiography after two months all grafts were patent, none of the wrapped grafts showed wrinkles or signs of anastomotic hyperplasia. Segments of wrapped veins were casted in paraffin under physiological pressure and cut transversely. In all cases the vein wall was pressed against the mesh tubes without forming folds. Mesh-wrapped varicose veins were used for three femorocrural and seven femoropopliteal reconstructions. All grafts showed a smooth flow surface at control angiography. Indentations occurred only at sites where thick-walled side branches had been ligated rather than oversewn. One popliteo-pedal reconstruction occluded after two months and one patient with a crural reconstruction died two months after surgery with a patent graft. The remaining grafts were patent after 11 (2-32) months. Oversized veins can be considerably constricted by tubes without forming wrinkles. By this technique varicose veins can be used as bypass grafts and in general vein grafts can be matched in size to the recipient vessel.     

Micro-venous valves in the superficial veins of the human lower limb

It is commonly believed that venous valves are not present in veins smaller than 2 mm in diameter. Venous valves, however, have been identified recently in small veins in several regions of the body. This study was undertaken to determine the size distribution of venous valves in the human lower limb micro-venous circulation. Vascular casts were made from six adult lower limbs and the sampled areas were viewed by scanning electron microscopy. In total, 2,376 valves were identified from 410 cm(3) of subcutaneous tissue. The vast majority (94%) of the valves were in veins less than 300 microm in luminal diameter, with 65% of the valves present in venous channels less than 100 microm in luminal diameter. The smallest valves identified were present in venous channels 18 microm in diameter. All valves were bicuspid and often associated with a tributary. Endothelial cells on the vein wall not associated with a valve were fusiform and arranged parallel to the long axis of the vessel, however, the endothelial cells on the luminal and valve sinus surfaces of the cusp were more polyhedral in shape and showed no obvious pattern of alignment. This study provides direct evidence to show that small superficial veins of the human lower limb do contain abundant venous valves and, for the first time, shows that the majority of these valves are present within venous channels less than 100 microm in luminal diameter.     

Anatomy of arm veins: Significance for vein valve transplantation

Vein valve transplantation is a recently described operation to treat the sequelae of lower extremity venous hypertension resulting from valvular dysfunction. The operation involves harvesting a segment of an arm vein contianing a competent valve and transplanting it into a lower extremity vein. To determine the optimal incisions for obtaining a suitable valve-containing segment of vein, 20 cadaver arms were dissected. Cephalic, basilic, and brachial veins were examined for size, distribution of valves, and presence of tandem valves (defined as valves separated by 2 cm or less). Because patency rates are low in vascular grafts < 4 mm in diameter, only veins of this size or greater were considered adequate for transplantation. Cephalic veinswere found to have a consistently smaller diameter than basilic or brachial veins (P < 0.0001). Incisions for exposure of the basilic and brachial veins were evaluated. When exposure was limited to the middle third of the arm, an adequate vein, either the basilic or one of the brachial veins, was found in all cases. When either the distal or proximal third of the arm was exposed, however, an adequate vein was found in only 70% of the cases (P < 0.02). Tandem valves, although potentially useful, were present in only 5%, 25%, and 20%, respectively, of distal, middle, and proximal arm segments. Based on the results of this study, a medial incision along the middle third of the arm, exposing a basilic or brachial vein, is recommended as the optimal approach for vein harvesting in vein valve transplantation.     

Vascular anatomy of a dicephalic cat

Summary The arterial and venous systems of the neck and heads of a dicephalic iniodymic monosomic cat are described. In the arterial system, an anomalous lingual branch of the right external carotid formed a large subhyoid arch, extending to the midline between both heads, giving off branches supplying the medial aspect of both heads and terminating in two medial internal carotid arteries each for the right or left head. This vessel was considered as an anomalous supernumerary common carotid artery. In the venous system, each lingual branch of linguofacial veins united and formed an anomalous venous arch. It received rostrally a long midline vein running between both heads and connecting with the medial internal jugular system. This vein received tributaries from the left and right heads and was considered as a supernumerary jugular vein. From these observations, and those of others in the literature, it can tentatively be suggested that, in congenital cephalic duplications in domestic mammals, the arterial blood supply for the medial aspect of both heads tends to come from the lingual branch of the external carotid artery, with an unexplained prevailing contribution of the right external carotid system. Two different venous patterns have been observed. In animal especies exhibiting a hyoid venous arch, such as carnivores, a midline supernumerary external jugular vein draining at the anomalous junction between lingual veins of both heads is formed, whilst in animals lacking a constant hyoid venous arch, such as ruminants, an asymmetrical supernumerary external jugular vein draining into the right normal external jugular vein has been repeatedly described.     

Development of smaller artificial ventricles and valves made by vacuum forming

Implantable prosthetic ventricles and trileaflet valves made by vacuum forming have been developed and implant tested. All components are made from Pellethane. Recognizing the need for smaller as well as larger ventricles, designs with effective stroke volumes of 50, 85, 100 and 130 cc have been tested with several valve types. The pneumatically driven Utah ventricular assist device (UVAD) can be used as a total artificial heart (TAH) or ventricular assist device (VAD) by using the appropriate inflow and outflow adapters. In vitro durability testing has demonstrated ventricular lifetime beyond two years and valve lifetime to nearly one and one half years. The polymer valves have lower regurgitation than mechanical valves. Animal implantation experience includes 21 TAH implants and 16 left ventricular assist device (LVAD) implantations. TAH survival ranges from 2 to 210 days. LVAD animals have lived up to 116 days before elective termination. The animal were healthy and grew normally. The devices exhibit a "Starling's Law" response. One TAH animal survived 72 days before successful explantation followed by transplantation. At autopsy, this animal had no renal infarcts. Hematology data has demonstrated the existance of little or no intravascular hemolysis (PF Hb less than 5 mg%). The "Philadelphia" version of the UVAD vacuum formed ventricles are small enough to be implanted without thrombus provoking connectors. Eight animals have received this TAH and survived up to 120 days. Vacuum forming offers a rapid and inexpensive way to produce reliable and effective total artificial hearts and valves for widespread, temporary clinical application in any size adult human.     

Number and location of venous valves within the popliteal and femoral veins: a review of the literature

Although deep venous insufficiency is common and important, the anatomy of deep vein valves is poorly understood. The aim of this study was to investigate the location, number and consistency of venous valves in the femoral and popliteal veins in normal subjects. A detailed literature search of PubMed was performed. Abstracts and selected full text articles were scrutinised and relevant studies published between 1949 and 2010 reporting anatomical details of deep vein valves were included. From 7470 articles identified by the initial search strategy, nine studies with a total of 476 legs were included in this review. All studies were cadaveric and subjects ranged from stillborn fetuses to 103 years of age. Studies suggested that femoral veins contain between one and six valves, and popliteal veins contain between zero and four valves. Deep vein valves were consistently located in the common femoral vein (within 5 cm of the inguinal ligament), the femoral vein (within 3 cm of the deep femoral vein tributary) and in the popliteal vein near the adductor hiatus. Valves are consistently located at specific locations in the deep veins of the leg, although there is often significant variability between subjects. Further anatomical and functional studies using new imaging modalities available should target these areas to identify whether certain valves play a more important role in venous disease. This may guide us in the development of new treatment options for patients with deep venous disease.     

A case of right partial and double internal jugular veins

We present a very rare case of right partial and double internal jugular veins, found in an 86-year-old Japanese female cadaver during a student dissection practice session in 2002 at Osaka Dental University. In this case, the right internal jugular vein separated into medial and lateral branches at a level with the middle of the fifth cervical vertebra. Both branches had the same thickness as an internal jugular vein and poured into the right subclavian vein. A slender venous space slit was formed by these two branches and the right subclavian vein. The inferior belly of the right omohyoid muscle and the inferior root of the right ansa cervicalis passed through the superior region in this venous space. To our knowledge, this case has never been reported previously. Therefore, we attempted to investigate the incidence based on existing references for similar cases and speculated on the development based on our findings. We considered the medial branch was the right internal jugular vein and the lateral branch was the communicating branch between the external and internal jugular veins.     

足背深浅静脉交通支的瓣膜朝向与皮瓣移植的关系

解剖研究了30例成人下肢标本的足背浅静脉与深静脉间的交通支,重点观察了这些交通支内瓣膜存缺情况及其朝向。这些交通支的静脉瓣可以分为三类:第一型的静脉瓣膜朝向引导血流由浅入深,第二型则引导血流由深至浅,第三型静脉交通支内没有瓣膜。足背皮瓣移植术中,沟通深浅两套静脉系统的关键性交通支是浅弓支。浅弓支属第三型,其出现率占70%,这是大多数足背皮瓣移植时只吻合浅静脉或深静脉均能引导血液回流,保证皮瓣成活的解剖学基础。但对30%缺乏浅弓支的个体,手术时必须同时吻合浅深两套静脉,才能保证回流通畅。