D The arteries of the sole of the foot

Right foot, plantar view.

E The arteries of the popliteal fossa and leg

Right leg, posterior view.

A The deep and superficial veins of the right lower limb

a Thigh, leg, and dorsum of the foot, anterior view.

b Leg, posterior view.

c Sole of the foot, plantar view.

For clarity, only the most important veins are demonstrated here.

D Varices of the superficial leg veins

a Spider veins (tiny intradermal varices).

b Reticular varices (weblike dilations of small subcutaneous veins).

c Great saphenous varicosity.

d Small saphenous varicosity.

Varicose disease of the superficial leg veins is the most common chronic venous disease, affecting 15% of the adult population. Varicose veins can be classified as primary idiopathic varices (75%) or as secondary symptomatic varices. Primary varices generally result from degeneration of the vein wall leading to incompetence of the venous valves. Secondary varices result from chronic occlusion of the deep venous system with incompetence of the perforator veins and a reversal in the direction of venous flow. Besides chronic conditions, there are also important acute diseases that may affect the superficial venous system (e.g., thrombophlebitis) and deep venous system (e.g., venous thrombosis).

E Clinically important perforating veins

Right leg, medial view. Numerous perforating veins interconnect the deep and superficial venous systems of the leg. Their venous valves normally prevent blood flow from the deep veins to the superficial cutaneous veins. The clinically important members of this system are located between the deep veins and the tributary region of the great saphenous vein:

• Dodd veins: located between the great saphenous vein and femoral vein at the level of the adductor canal.

• Boyd veins: located between the great saphenous vein and posterior tibial veins on the medial side of the proximal leg.

• Cockett veins (I–III): located between a curved branch of the great saphenous vein behind the medial malleolus (the posterior arch vein) and the posterior tibial veins. The Cockett veins on the medial side of the distal leg are of special clinical importance because of this region’s susceptibility to ulceration.

A The superficial lymphatic system of the right lower limb

a Anterior view, b posterior view. (The arrows indicate the main directions of lymphatic drainage.)

The lymph in the lower limb is drained by a superficial (epifascial) system and a deep (subfascial) system, similar to the arrangement in the arm. The largest lymph vessels, called collectors, basically follow the course of the superficial veins (great and small saphenous veins) and deep veins (popliteal vein, femoral vein) and are interconnected by anastomoses located mostly in the popliteal and inguinal regions. While the superficial lymph vessels primarily drain the skin and subcutaneous tissue, the deep system drains lymph from the muscles, joints, and nerves. The superficial lymphatics consist of an anteromedial bundle and a posterolateral bundle. The anteromedial bundle runs along the great saphenous vein to the superficial inguinal lymph nodes. It drains all of the skin and subcutaneous tissue of the lower limb except for the lateral border of the foot and a narrow strip on the calf. Those areas are drained by the posterolateral bundle (see b), which thus receives drainage from a considerably smaller region. The lymph in the posterolateral bundle first passes along the small saphenous vein to the superficial popliteal lymph nodes and then drains through the deep popliteal lymph nodes to the deep inguinal lymph nodes.

B The deep lymph nodes of the inguinal region

Right inguinal region after removal of the cribriform fascia about the saphenous opening, anterior view. The veins and lymphatic system above the inguinal ligament are shown in light shading. The deep inguinal lymph nodes are located near the termination of the great saphenous vein, medial to the femoral vein. They are important because all the lymph from the limb filters through them before reaching the iliac lymph nodes. The largest lymph node of this group (Rosenmüller’s lymph node) is also the highest, placed at the level of the femoral canal. The group of pelvic lymph nodes, which includes the external iliac nodes, begins just above the inguinal ligament.