[Music] so welcome everyone to the beginning of our 2024 2025 lecture Series so the first lecture of the year is on embryology and Anatomy clearly this is an important topic because we can't do what we do without understanding the underlying anatomy and the embryology part of it is mostly uh so you can recognize anatom variants and also these are test questions on the exam okay so let's uh let's kind of get into it a little bit so today we're going to talk about the embryology of the arterial and the Venus system we're going to go over the abdominal and pelvic Anatomy because we see a lot of deep vein stuff and we do a lot of pelvic work here we're going to go over the upper extremities because I don't think we do enough of it here at CV in the fellowship program and then we'll go over the lower limb stuff which should be quick all right let's start right off with the embryology so when uh you have the zygote there basically is uh it starts out as a clump of cells and then you have an ectodermal layer an endodermal layer and then a misal layer in the misal layer you have the neural tube and then you have these three plates here the paraxial mism intermediate and then the lateral plate the lateral plate is where all of the blood vessels are formed from and so you see here from the endoderm uh veeg gets produced and it stimulates the the lateral plate maderm and from that stimulation you get hypertrophy and then the beginning of blood vessel growth development so what happens is this plate then starts to fold it on itself and over here you see that the lateral maderm is now started to hypertrophy and you see these two tubes here one of these tubes becomes the dorsal aorta and the other tube becomes the hard tube and then when you get folding the heart tube um merges into one tube and then the dorsal aorta are paired until they they fuse uh distally to become the dorsal uh I'm sorry the descending aorta so if we go back a bit if we take this hard tube and we look at it longitudinally it looks like this so the hard tube has these various components to it this bottom part here the SV the sinus venosus is where all of the Venus structures come from PA stands for primitive Atrium PV is primitive ventricle BC is the bulbus ctis ta is the truncus arteriosis and then the aortic sack and then these are your dorsal aortic horn which like I said fuse distantly now if we were to take a transverse section right here between the aortic sack and the trunco osis you would see this so here's your aortic sack here's your dorsal aorta here's your forut tube and your neural tube and then these are ectodermal plates so what happens is cyto production occurs from the aortic sac and then you get these aortic Arch formations that connect the aortic sack to the dorsal aorta these connections become um your your uh SPL your aortic arches right so aortic sack connects to the dorsal aortic horns and you get the these uh these arches now there are actually there are five arches but they're they're numbered one two three four and six because the fifth aortic arch for some reason either never forms or just disintegrates so these aortic arches then become particular arteries so the first aortic Arch becomes the max artery the second aortic Arch becomes the hord artery the third aortic Arch becomes your common and internal cored arteries the fourth aortic Arch becomes your subclavian arter and your aortic Arch and then your sixth artery becomes um the right and left pulmonary arteries and more importantly the this structure the ductus arteriosis connects the pulmonary vasculature to the uh to the aortic vasculature so this is a test question so the six aortic Arch forms the ductus arteriosis okay and then the dorsal aortic Arch is fused to become the descending aorta so now now if we look at the descending aorta you have these structures here you have the dorsal lateral branches the lateral branches the vidalin artery and then the umbilical arteries so your dorsal lateral branches those become your intercostal arteries the lateral branches become arteries that go to organs so specifically it goes to your adrenal gland your renal artery and then your gatal arteries the vidalin artery branches off into the three arteries the Celiac the superior and the inferior mic artery and then your umbilical arteries become your internal aliac arteries and your umbilical arteries so now let's focus in on the Venus side so if we just look at the sinus vosis right here the sinus vosis has many many branches so you see here on the right and the left you have the anterior Cardinal veins you have your posterior Cardinal veins and then there's a common trunk here which is your common Cardinal veins then you have your right and umbilical veins and your right and left V viin veins so another way this is another diagram here showing this is the posterior uh Cardinal veins and then here these veins here these are your Supra sub and um and sacral Cardinal veins which we'll talk about more these red highlighted areas here these are the the veins that become your inferior vena and the branches to the re to the renal vessels so that's really what you need to know about this the posterior Cardinal ve vein this thing disintegrates and then the the Cardinal veins here the Supra sub and sacral Cardinal veins become your inferior vena so let's go over this a little bit so like I said here the posterior Cardinal veins disintegrate and then remember the Venus system is a primarily right-sided system so this portion of the left anterior Cardinal vein disintegrates and it forms an anastomosis to the right interior cardal vein that becomes your left braak calic and then your internal jugular vein and your subclavian veins so the main thing to remember here is that the left anterior Cardinal vein disintegrates and then it connects to the right and that forms your brachio calic vein now the vidalin veins are important for the abdominal vasculature and and specifically for the suar renal empor vava so what happens is in the um developing fetus there is a Yol sack and the right and left viin veins connect to the to the the forga tube and the forga tube then sends a branch to the liver and it forms the sinus the sinuses in the liver and then you have your right hepatic branch and your left hepatic branch which go to the to the sinus vosis now through development the left hepatic Branch then fuses with the right hepatic branch and then the left side disintegrates and then the spanking vessels form so you get the splenic vein the inferior mesenteric and the superior mesenteric and your portal veins form now that's from the vidalin vein and you can see here the left vidin vein disintegrates once the sinus BOS the sinus the liver sinus veins are formed now another structure that happens is so that's the vidalin veins your left umbilical vein is important because it sends a branch that connects directly to the liver uh sinuses but it also forms the ductus vosis so this is your fetal circulation so during birth the ductor vosis shuts down and then blood flow is primarily shunted through the splenic vasculature so then the ductor vosis becomes the ligamentum vosis and then the ligamentum terries and this is the one time in development where a left-sided system remains and the right side of system disintegrates usually it's the other way around okay so now remember I said that the posterior Cardinal veins disintegrate and then you get these structures here you get the Supra sub and sacr Cardinal veins so here in green the Supra Cardinal veins become your azus and your Hemi azus system now the left super Cardinal vein disintegrates and then it forms a connection to the right and this becomes your Supra uh renal inferior vena the subcardinal veins down here do the same thing they form your uh your uh Venus branches to the adrenal gland to the kidneys to your gatal and then this Left sided one again disintegrates fuses with the right side the right side starts to dilate and it becomes your uh renal portion of the inferior vena and then the same thing happens with the sacral portion the left side disintegrates fuses with the right and it becomes the infrarenal portion of the vena then it bifurcates into your iliac system so here again the the Supra Cardinal veins form your azus and Hemi Asus system and the superar renal Vena the subcardinal veins form the renal portion of the vena and the sacral Cardinal veins form the infrarenal portion of the vena so this just another diagram showing it so this is your posterior Cardinal veins that disintegrate you can see they're not there these are your Supra sub and sacr Cardinal veins and they become the the renal portion and then the infrarenal portion and the superar renal portion of the inferior venic so just to show you that when uh you do see this in um in patients so this is a patient whose right uh I'm sorry the the left subcardinal vein did not disintegrate and it's actually the main outflow and you can still see here remnants of the right subcardinal vein here's one where you have a completely left-sided inferior vena this is a a left subcardinal subcardinal vein that did not disintegrate and here the right subcardinal vein uh instead of taking over just didn't form okay so let's go over some pelvic anatomy and this is where gets a bit confusing so again this is your superar renal inferior vena these are your renal veins this is your uh gadal vein this is the left common iliac and this is what it looks like uh in a in a human so again infir Vena aorta left common iliac vein this is your uh your um the your urer thank you this is your gadal vein so if you look at a diagram here this little red line here is where your your diaphragm should be so often times when we do venograms and patients who have iliac vein obstructions you're going to see some of these veins here in particular particular this one here in light blue is an ascending lumbar vein which then uh becomes the aigus and the Hemi Asus above the diaphragm okay and then you have these ilol lumbar veins and your sacral veins these are very common anatomic structures that you see with venography and I'll show you some venograms of that in a moment so again when in the diaphragm when the vein comes off of the iliacs these are ascending lumbars above the diaphragm they become your aigus and your Hemi Asus a system oops okay give me a second I just lost the all right so can you see that guys sorry about that we have't you can see it right okay so uh again other branches that come off of the iliac are your inferior epigastric and then there is a superior epigastric these are the veins that attach through the rectus muscle then you have your deep circumflex which goes into your into your uh iliac crest here as well so now on a venogram this is your inferior vena and your iliac this is what an ascending lumbar vein looks like you can see here there are two filters this patient has an included inferior vena and the main outflow for this patient is their lumbar this is another patient who had post thrombotic disease you can see the sikia here you can see another IVC filter with an included IVC and this is a huge dilated ascending lumbar vein that uh the patient has as her outflow and here's an included IVC and then here's the Hemi Asus and the Aus system and again you can see the the filter here that's including the IVC all right so let's take some time and go over the internal iliac Anatomy this is very complicated because there are many many branches especially of the anterior but you need to know this when you do a physical exam uh because you're going to see uh Escape Bings and I'll show you that in a minute so here is your uh internal aliac vein and the internal aliac vein has a common trunk which splits into two parts there's a anterior and a posterior trunk here's the anterior trunk and this is the I'm sorry this is the aliac and here's the anterior trunck down here and this is the posterior trunk and this is your common uh common iliac your common internal iliac trunk and this front portion here is the external iiac now the posterior trunk has only three branches so let's go into that so one is your IL lumbar branch which goes up the the iliac crest one is your lat lateral sacral which goes down into the S which goes down into the sacrum and then your Superior Glu so this is if you're going to remember anything remember that the superior Glu vein is a branch off of the posterior trunk and you can see here uh the uh the ILO lumbar goes up the iliac crest and then it goes behind the iliac crest and then it ascends up into the into the spine then this is your sacral branches which go to your sacrum and then this one escapes through this through the muscle here and then it goes to your your glutalor so that's your Superior Glu vein that comes off of the posterior trunk now the anterior trunk has eight branches to it and so let's go through this a little slowly so this first one uh right here the orange Branch well these are the eight branches umbilical Superior operator and on so the first one this orange one is your operator Branch so the thing to know about the opat branch and this is a test question is that when it exits the operator faman it exits superiorly to the framan and the reason why that's important is because sometimes vascular surgeons do bypasses through the operator foramen and if you go superiorly you can injure the artery the vein and the nerve so you want to avoid going through the superior portion of the operator Canal you want to go post you want to go inferiorly and posteriorly okay then the next one is the umbilical and the superior vesical branches so this yellow one and green one are your umbilical arteries and the superior vesical arteries and they basically go to your vrine SEO vesicle and to the bladder then uh there is the which this this one this is your middle rectal vein and then the intern internal pendal is the last here's the test question it is the last branch of the anterior branch of the internal iliac and the internal pudendal is often those High thigh varicosities that we have in patients now the ovarian veins the ovarian veins are not single veins so right at the at the uh L2 L3 portion of the spine the three or four branches of the of the ovarian veins actually merge and become a single branch and I'll show you a venogram of that in a moment the left umbilical vein all always comes off of the left renal vein the right umbil I'm sorry umbilical the ovarian vein pardon me the right ovarian vein Anastos is directly into the inferior vena 90% of the time but 5 to 10% of the time it actually comes off the right renal vein the normal diameter of the ovarian vein is 3 mm and they typically have multiple valves to it so here's uh an MRI and you can see here this is a refluxing ovarian vein there's actually stenosis here where it attaches to the to the left renal vein then it comes down here and in an asmosis with the pampiniform plexus and then it gives these branches uh through the per uterin veins and then it actually connects to the right ovarian vein so this is a very um interconnected Network in the pelvis so this is a venogram here you can see uh there's some coils being dropped to the left ovarian vein you can see here this is the peniform plexus this is the par uterum uh Network and then it actually connects over here across the pelvis and this is the right ovarian vein so here's another venogram showing of a huge dilated ovarian vein this is further down to that same patient and now you can see there are multiple branches down here again this is the peniform plexus per uterin veins this is the right ovarian these veins here are normal veins these are pre-sacral veins so if you see this on a venogram it doesn't mean there's an obstruction this is just a normal uh connection in the pelvis so here's a picture this is the uterus this is the ovary and this is what a large dilated verost aarian vein looks like uh live now the internal iliac vein is the valveless system so like I said there's usually a common trunk which splits into an anterior and posterior Branch but remember there are no valves in the uh internal aliac vein there are valves in the anterior trunk and there are no valves in the posterior trunk so that's very very important so this is another venogram kind of showing how the pelvic veins connect to the superficial vein so here is a is a catheter with a balloon including in the internal iliac vein and what you see here is that this internal iliac vein is going through the opor for and right here and it's actually going to connect to the great sap inous vein so another balloon occlusion and right and here this is the internal pudendal vein and this is the great sapidus vein down here so these are coils this is in a a balloon occluder in the posterior branch and this Branch here is the um Superior rectal vein and it's actually connect them to the sciatic blood vessels I'm sorry the inferior gluten pardon me it's in the anterior Branch okay so we're not going to go through this we're just going to quickly go through that all right so this is what it would look like on a physical exam you can't see it but right here in the gluto crease there's a vein emanating from this this is what the internal gluto vein where it emanates from and then it goes laterally across the thigh and it goes down here so this is an escape Vein from an internal Glu vein this is a vvar vein this is from the internal pudendal as well now this vein here that goes across the pelvis this person actually had an occluded external iliac vein and then a branch off of the common femal goes across the pelvis to connect to the common uh external iliac on the other side so this is a Supra pubic varicosity these high thigh varicosities are from the internal pental vein so if you see these high thigh varicosities that are not in the normal distribution of the great saphenous vein this is an escape vein and this person has an obstruction until proven otherwise uh this is just the um the sapidus vein Anatomy so let's go through this a little bit so on venography you can see here the sap FAL Junction the common fmal vein now this an an anatomy here where the poal vein bifurcates into the profunda and the fal vein is the most common uh uh Anatomy that we see here but there are four other variations of this where you don't necessarily have to have a bifurcation like this but this is the most common Anatomy that we see where the pole teal bifurcates into a deep and your superficial femoral or your femoral vein here is a very common anatomic variation this is a duplicated potila vein you can also see duplicated femoral veins and this is very very common you see this in up to 30% of patients and then here you have your tibial veins which are are pared so you have your posterior tibial peral and your anterior tibial veins okay so uh in 2005 there was a conference in Rome uh in which uh it was convenient in order to standardize the terminology so prior to that conference the great and uh small sap veins had many names depending upon what continent you on in Great Britain they called it the long and the short uh we called it the small and the greater so now we all know that the names are the great small and protic veins so the great sapin is V Lies in its own compartment it goes from the dorsum of the foot all the way up to the sapo fal Junction um in the mid portion of the calf the saus nerve is very close to the sapnis vein which is why we never we never ablate below the mid portion of the calf and uh the amount of blood return into the sapis system is only about 5 to 10% it's essentially irrelevant because the Deep veins carry the load of the return of blood flow so again this is just the anatomy we went through this already now the saop femoral Junction has five branches to it so you've got your superficial epigastric superficial circumflex superficial external pendal your and your lateral accessory this is diagram here just shows the various configurations that these branches can come from the one that we talk about all the time is The Superficial epigastric because that drains into the junction and and presumably is what keeps people from getting uh e- hits so just another example of the anatomy at the junction this is what the anatomy looks like topographically so you can see here this is a person who's got sapis tributaries so this is a reflux in the great sapin vein and this is what the tributaries look like typical distribution of the anterior sap its vein typically there's a trunk and then it goes entral laterally down the thigh but it can also go medially as well well and we had a journal Club just a couple weeks ago going over the anatomy of the Interior sapis vein and the fact that it's in its own compartment and therefore for it is an axial vein this is the internal pental again High thigh varicosities you can see here the great saffin vein is intact all of these varicoses are actually coming from an escape Vein from the pelvis non sapis reflux is seen in about 10% of people so I highly recommend that uh for the fellas that you get this paper from the Journal of vascular surgery if you don't have it I I have it but it's also on the the CME share Drive uh this is the configurations you can see here that glutalor that's from the inferior Glu vein poster laterally the volar vein comes from an internal pudendal it wraps around the inter inside of the thigh goes up through the Volva or the or the high thigh varicosities you can have sciatic veins lower posterio tibial the vein of the poop FASA is very common I'm going to show you an example of that in a moment and then you can have veins that come out of perforators particularly the hunterian perforator in the thigh so this is an example of a vein off of the poal vein you can see these two veins that emanate laterally when you look on the duplex Scan they connect directly to the hopal vein so if you just go and you do an evulsion of these veins you may get into some significant bleeding so my recommendation is that if the text inform you that there is a a vein that comes off the poal vein that you liate this vein rather than aulet the small sapis vein has a variable Anatomy uh it connects to the poil fucil in about 75% of patients and then 25% of the time it there is no connection and it just goes up as a thigh Extinction or the vein of jamini so on duplex scan it looks like this this is the common Anatomy that we see in 75% of patients here is one that has a junction but it also has a thigh extension as well and then finally this is just a thigh extension with no Junction so this shows you the basically the same thing in a diagrammatic format now uh in here uh this uh I put this up here to show you the close proximity of the seral nerve the seral nerve is very close to the small saus vein right up to the gastro solal complex at which point then it it kind of uh Dives away from it a little bit so when we culate the the sapis vein or we do an ablation we tend not to go below the this solal gastri complex because of the proximity of the seral nerve this is another diagram of the variations of the thigh extension so number one is a is a complete thigh extension that wraps around the inside of the thigh and connects to the sapino femoral Junction number two is the thigh extension connecting to the profunda you can have a connection to the perforator and then you can also have a connection to the anterior lateral Branch again this is just to emphasize the fact that the catheter here is put below the the um Sol gastro conflict so not to injure the seral nerve Perforating veins Perforating veins connect The Superficial system to the Deep system flow is in the direction from superficial to deep reflux is when you get deep to superficial perating veins you know we used to have a lot of names for them it really doesn't matter anymore uh you know DOD boy Hunter the only one I worry about is the hunterian perforator because it connects to the to the femorals in the thigh and when we do Verena I've had a dvts because I didn't recognize that foam was going into the hunterian perforator into the into the femoral veins so be careful of your hunterian perforators this is just to show you where the cocket and boid and perforators are nobody cares anymore hunterian perforator typically comes right Alpha the mid thigh it's a large branch and you'll see it on duplex scans and your text will tell you about it all right so on duplex when you look at a perforator vein what the text Will Show You Is you see this little white band here that's the fascia so this is the vein uh that's above the fascia when it goes through the fascia that and it technically now becomes your Perforating vein and it's always associated with an artery so when you do uh perforat ablation we typically like to get into the into the vein here get go through the fascia and and ablade it from The Superficial to below the fascia without trying to injure the artery in the old days we used to do subfascial endoscopic perator ligations it's been shown to be ineffective but you do get to see what the anatomy of the perforators look like this is what we used to do we used to clip them and then you know just basically cut them and disconnect them now you're doing it with a with a either a laser or radio frequency catheter and then for historical purposes this is the old Linton procedure which caused more ERS than it cured all right upper extremity Venus Anatomy so clavicle here's your um your sternum the test question that you see on the exams all the time is what is the relationship of the subclavian artery and vein to the scaling muscle so the subclavian vein is anterior to the scaling muscle so that's the answer to the test question okay so your anterior scaling your posterior scaling and in between that comes your brachel plexus so this is your scaling triangle and the um anterior scaling nerve U I'm sorry the anterior scaling muscle connects to the first rib and lying on top of the anterior scaling muscle is the frenic nerve so if you ever have to do a first rib resection and you have to transect the interior scaling be careful to identify the frenic nerve and move it out of the way so that you don't cause a frenic nerve paralysis so you can see here this is where fan thrombosis occurs if the if this this triangle is very narrow you can injure the subclavian vein as it tries to anesos to the superior vena and this is what it looks like uh on a venogram when it becomes thrombos and you can see here after thrombolysis you see the stenosis then you dilate it and you stent it but if you stent it without removing the first rib this is what happens you get a stent fracture so you want to avoid that you want to do the the first rib resection first and then stent the lesion if you think it needs to be stented now the anatomy of the upper extremity Venus system there is also a superficial in the Deep system you have a Palmer and interdigital veins so the veins are on the uh medial and lateral sides uh just like the arteries are and then there's a Palmer Arch and then there's a dorsal Arch so your calic vein emanates from the the thear part of the of the hand and then it goes up the lateral portion of the arm and then your basilic vein comes off of the pinky side of the hand and it goes up the medial side and then there's various forms of anastomosis at the end of cubital fossa so the median cubital vein is the most common configuration but there are many other configurations and then uh this just show you how this is used when I was doing arterial surgery uh I was doing a basilic vein to radial artery transposition for dialysis so this is the the radial artery this is what the basil vean looks like when you dissect it out then you make a tunnel you bring the vein through subcutaneously through the tunnel then you anastomosis to the artery and then you've got your radial basilic fistula and then this is what it looks like over time when it dilates and you can see it's it it it dilates pretty pretty well okay so then when it gets into the arm the calic vein continues up the arm it goes through the Delta pectoral Groove and then it anastomoses to the subclavian ve up here near your shoulder the basilic vein an asmos is to the axillary vein I'll show you that later uh and but then then here you get your internal jugular ve your subclavian your superior vena and your brachio I'm sorry your brachio ofal then your Superior vnea this is still the subclavian vein here where it an asmosis with the internal then for the Deep veins uh the Deep veins basically follow the arteries and they're paired up here on you the arm and get your brachial vein which then continues up to your axillary vein and then your axillary vein connects and becomes your subclavia vein up near the Delta pectoral Groove where when the axer vein and asmosis with the internal jugul it now becomes a subclavian and Bre esoph palic so that was uh very quick I did that a lot faster than I thought I was going to do it so one second let me stop sharing very good so does anybody have any questions regarding the anatomy I know I did that kind of quickly but a lot of these things are important to know because they end up being test questions on the abvm so for those so for Dr CAD who's got only a couple more months this is important for you sir Ro because I guarantee you there will be two to four questions on embryology as well as embryological remnants on the examination okay so I have a question but it's not actually Anatomy it's about one one point that you mentioned why cing is not working in the perforator because what we found is that other perforators open up so when you clip it and then you go to look at them postopera they're successfully included but then other perforators open so sometimes their entry and re-entry perforators it just it just didn't work and actually caused more damage than it did any good and you pass the fascia when you're blatant it right you're above the fascia below the skin and that was one of the difficulties a lot of these people had severe scar tissue in their legs it was very hard to dilate the balloon and it caused lymphatic leaks and it caused a whole bunch of other problems too and it didn't really solve a a lot of issues okay anybody else so this talk is on the CM share Drive I know I went through it very very quickly I would behoove you to kind of just on your own take a look at it if there are areas that you need clarification on please talk to your attendings they'll be more than happy to go over with you there is also a book by Dr Jose almea in which he goes through all of this Anatomy but shows you the ultrasound correlates to it so I would strongly recommend that if you don't have that book go on Amazon find the book from Dr alme and buy it it's a very very good fellow's book to kind of show you duplex Anatomy as it correlates to to to humans it's got very good illustrations and diagrams in it I loaned it to a fellow and they never gave it back so I don't have my copy anymore but get the book hey Dr pepers do we have this do we have this uh presentation in the form of downloadable PowerPoint just curious so there so there's the book s has it um if you go onto the share drives right so one second I'll tell you what it says so it says CVR CME talks if you click on that you can see a whole bunch of folders every one of them is the lectures number three is embryology okay so uh what I'm going to do is I'm going to drop this presentation in there just so you guys have it but almost every presentation that we've done in the past or will do will be in the CME share drive so if you're for example if you're preparing a case presentation or you're doing a grand rounds rather than starting from scratch you can go here into the CME Drive look at what some other people have done just to kind of give you some ideas also you know feel free to share your presentations with your attendings or just send it to me and I'll review it very quickly and I'll give you suggestions on how to improve it and what to add and if there are things that are missing like articles and stuff I can send it to you so don't worry about sending it to me you're not going to inundate me it only takes me five or 10 minutes to go through your presentations and then to give you suggestions as well but this is a resource for you also in addition one of the folders up here uh it should say Journal AR articles where is it yeah so below 23 it says Journal articles if you look at this these are all classic Journal articles that you can also use for your presentations as well since we don't have access to electronic journals but most of the papers that you're going to need either I have them or somebody in in the in the company has it but most of the classic articles I've already uploaded for you here in the share Drive okay so if you don't have a drive that says CBR CME talks just call it and they'll give you access to it else guys all right so this was the first lecture of the year um I'm actively working on getting guest lecturers to come as well uh so uh we don't have to put the full burden on the CVR staff but uh going forward up until June uh every Friday unless we have like the avls meeting or some or Christmas or some holiday there's going to be a talk every Friday morning at 7 okay all right so you guys have a good day and we'll see you next week than thank you [Music] [Music]