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You are watching: Dorsal venous arch of foot

StatPearls . Treasure Island (FL): StatPearls Publishing; 2021 Jan-.


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Introduction

The venous drainage the the foot involves several vessels, consisting of the plantar and dorsal venous arches, the an excellent saphenous vein, and the little saphenous vein. Similarly to what takes location in the hand, the plantar and dorsal venous arcs of the foot have actually digital veins the extend between each toe and also drain into the arches. The foot also contains large medial and lateral plantar veins that at some point join posteriorly to type the deep tibial veins and anteriorly type the anterior tibial veins. These veins contribute to the plantar pump, a physiological device to propel blood back toward the heart.<1> The veins the the foot room susceptible to number of pathologies, including corona phelbectatica, varicose veins, and venous ulcers.<1> The an excellent saphenous vein is likewise a usual graft resource for specialized conduit/bypass surgeries to controlled various cardiac, thoracic, neurovascular, and urological pathologies.<2>


Structure and Function

The venous drainage that the reduced limb starts mostly on the dorsum that the foot, v proximal venous blood return emerging in both a superficial and also deep venous pattern. The bulk of the foot is drained through the small saphenous vein. The small saphenous vein begins at the lateral finish of the dorsal venous arch. It then process posterior come the lateral malleolus, ascending on the posterior next of the leg, running through the sural nerve before emptying into the popliteal vein. The good saphenous vein starts at the medial end of the dorsal venous arch that the foot. It then passes anterior to the medial malleolus and also runs top top the medial next of the reduced limb before emptying into the femoral vein. The femoral vein then drains right into the outside iliac vein, which combines through the interior iliac vein to type the usual iliac vein; this climate drains into the inferior vena cava and right atrium the the heart.


Embryology

The limb buds of the embryo begin to type about 5 weeks after fertilization as the lateral key mesoderm migrates into the limb bud region and condenses along the central axis to eventually type the vasculature and skeletal components of the reduced limb.<3><4><5> Several determinants influence the formation of the body bud vasculature and also musculature, including retinoic acid, sonic hedgehog (SHH), HOX genes, apical ectodermal ridge (AER), and the zone that polarizing task (ZPA).

Retinoic acid is a global organizing gradient that initiates the manufacturing of transcription factors that specify regional differentiation and limb polarization. The apical ectodermal ridge (AER) produces a fibroblast expansion factor (Fgf), cultivating the outgrowth of the limb buds by stimulating mitosis.<3><4><5> The certain fibroblast development factor affiliated in hindlimb advance is Fgf10, i beg your pardon is stimulated by Tbx4.<6> The zone of polarizing activity (ZPA) produces SHH, which disclosure the company of the body bud along the anterior-posterior axis. SHH activates details HOX gene – Hoxd-9, Hoxd-10, Hoxd-11, Hoxd-12, Hoxd-13 – which are necessary in body polarization and regional specification.<3><4><5> this genes control patterning and, consequently, the morphology that the emerging limb in the human embryo.<6> Errors in Hox gene expression can lead come malformations in the limbs.<6>


Blood Supply and Lymphatics

The circulation of lymphatic vessels of the lower limb is similar to the circulation of the veins of the lower limb and also can divide right into two significant groups: superficial and deep. The superficial vessels are the good saphenous vein (medial) and lesser saphenous vein (lateral). The good saphenous vein drains right into the inguinal lymph nodes, when the lesser saphenous vein drains into the popliteal nodes. The deep lymphatic ship contain the anterior tibial, posterior tibial, and peroneal vessels, which follow every of their particular arteries and drain into the popliteal nodes.


Nerves

The innervation that the foot entails two terminal branches of the tibial nerve, consisting of the medial plantar nerve and also the lateral plantar nerve. The medial plantar nerve innervates the abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, and also the very first lumbrical. The lateral plantar nerve supplies every one of the various other foot muscles and has a superficial and also deep branch. The superficial branch offers muscular and cutaneous innervation, while the deep branch only offers muscular innervation.<7>


Muscles

The foot can be divided into a dorsal and also plantar aspect, each containing unique musculature, blood supply, and also innervation. The foot"s dorsal facet contains the extensor hallucis brevis and also extensor digitorum brevis muscles and also receives that is innervation indigenous the deep fibular nerve. The plantar element of the foot have the right to be divided into four layers, each containing different muscles and also tendons. The many superficial great (1st layer) contains the abductor hallucis, flexor digitorum brevis, and abductor digiti minimi muscles. The 2nd layer includes the flexor hallucis longus tendon, flexor digitorum longus tendon, quadratus plantae muscle, and also four lumbrical muscles. The third layer consists of the flexor hallucis brevis, adductor hallucis (oblique and also transverse heads), and also the flexor digiti minimi brevis muscles. The deepest layer (fourth layer) contains the fibularis longus tendon, tibialis anterior tendon, tibialis posterior tendon, and the interosseous muscles (three plantar interosseous muscles, four dorsal interosseous muscles).<7>


Physiologic Variants

The lesser saphenous vein and also greater saphenous vein commonly terminate in the popliteal vein and also femoral vein, respectively. However, change connections in between these veins space common, for this reason the flow patterns must never be thought about absolute. In a study of 200 reduced extremities utilizing Doppler sonography, 107 (53.5%) subjects had a lateral accessory branch of the good saphenous vein, and also 33 (16.5%) had a medial accessory branch that the good saphenous vein.<8> In the very same study, the authors found variations in the termination suggest of the small saphenous vein. In 108 topics (54%), the little saphenous vein terminated in the popliteal vein; however, in 32 subjects (16%), that terminated over the popliteal vein.<8> each of this variations in branching and also termination allude merits noting in clinical and surgical venous operations.  


Surgical Considerations

Occlusive arterial an illness is the leading reason of fatality worldwide.<9> one of the most commonly performed revascularization methods to law occlusive arterial an illness is coronary artery bypass graft surgery. The great saphenous vein is a common resource for a conduit because that surgical revascularization.<9> The great saphenous vein have the right to be harvested utilizing an open up or minimally invasive technique.<10> The vein then gets sewn come the aorta ~ above one end and also past the obstruction right into the coronary artery top top the other end.<10>

Another surgical consideration of the veins that the foot involves varicose vein surgery. Varicose vein surgery is just one of the most usual forms of surgery.<11> There room several ways to remove or close off varicose veins surgically, but the two most common ways to eliminate varicose veins are via vein stripping and phlebectomy.<11> Vein stripping involves completely removing the varicose vein through making two incisions proximal and distal to the varicose vein and also pulling the vein out v the top incision.<11> A phlebectomy involves making small incisions of a few millimeters along the influenced vein and using a tiny hook to pull the vein out through the incisions come cut and also remove pieces of it.<11> over there are several other means to surgically treat varicose veins, consisting of endovenous thermoablation, radiofrequency ablation, and also foam sclerotherapy.<12>


Clinical Significance

The veins of the foot space susceptible to numerous pathologies, including corona phelbectatica, varicose veins, deep vein thrombosis, and venous ulcers.<1> Corona phelbectatica is the existence of abnormally visible cutaneous blood ship at the ankle through four distinct components: “venous cups,” blue and also red telangiectasias, and capillary “stasis spots.”<1><13> The veins current in corona phelbectatica are commonly referred to together “ankle spider veins” and also are a clear sign of major chronic venous insufficiency the requires clinical attention because of your potential to an outcome in more serious conditions, consisting of blood clots and/or leg ulcers.<1><13>

Varicose veins are a usual pathology seen in the veins the the foot and ankle. They are ectatic, tortuous vessels of the superficial venous mechanism that are at the very least 3 mm in size that arises from the failure of venous valves come close correctly to permit the backward flow of blood.<14>  The two main superficial foot veins – the good saphenous vein and the little saphenous vein – and their branches room the most usual sites the varicose veins.<14> Patients with varicose veins may present with no symptoms other than the enlarged vein itself, but some might experience pain, burning, itching, and/or foot swelling. These varicose veins need to be taken seriously due to the fact that they existing a cosmetics problem and also increase the danger for the advancement of superficial vein thrombosis and venous thromboembolic disease.<14> The treatment of varicose veins contains conservative and surgical treatments. Conservative therapy of varicose veins includes elastic compression stockings to control swelling, load loss, and topical steroid cream to manage inflammation. Surgical treatment contains varicose vein stripping, phlebectomy, endovenous thermoablation, radiofrequency ablation, and foam sclerotherapy.<12>

Deep vein thrombosis (DVT) is a frequent complication watched in orthopedic surgery and can cause significant morbidity and mortality.<15> The incidence the DVT is short in foot and ankle surgery. However, a DVT leading to a pulmonary embolism (PE) deserve to still cause mortality following foot and ankle surgery.<15> over there are number of risk determinants for venous thromboembolism, including household history, larger age, cancer, an extensive surgical procedure, tobacco use, and also immobilization.<15> each of these components merits consideration following foot and also ankle surgery to assist prevent DVT and PE.

Lastly, the veins in the foot deserve to be associated in abscesses and also ulcers due to diabetic complications and also intravenous medicine use. In every case, it is critical to act the basic medical concern such as diabetes or seeks while likewise providing subject wound care therapies, antibiotics, and/or anti-platelet or anti-clotting medicines to prevent a blood clot.  


Review Questions


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Figure

Vasculature the the lower limbs. Added from Clker-Free-Vector-Images (Public Domain)


References

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