Anatomical study of valves in the gastrocnemius trunk in human cadavers

Abstracts

BACKGROUND: Valves are characteristic structures of veins and are important to guide blood flow. Their presence in the superficial venous system of lower limbs has been well studied. However, there is a lack of published literature on deep veins, such as the gastrocnemius vein. OBJECTIVE: To carry out an anatomical study of the veins in the main gastrocnemius trunk in adult human cadavers. METHODS: The main gastrocnemius trunks of 80 gastrocnemius muscle heads of 20 adult cadavers were dissected. The cadavers were males, aged between 40 and 68 years, and fixed in 10% formaldehyde solution. Trunks and net types were classified according to Aragão et al.'s proposal. The valves were studied as to quantity, distribution, location and type with regard to trunk, leg, muscle head and type of gastrocnemius net. RESULTS: Of 80 gastrocnemius muscle heads, there were 95 main gastrocnemius trunks, and 17 were duplicated. There were 65 valves in 60 gastrocnemius trunks, all of them bicuspid: 35 in type I net, 23 in type II and seven in type III net. Valves were located in the proximal third of the main gastrocnemius trunk in 74% of cases. CONCLUSION: Valves were found in all net types that had main gastrocnemius trunk. These valves were bicuspid and predominantly located in the proximal third of main gastrocnemius trunks.

Venous insufficiency; veins; anatomy

CONTEXTO: As válvulas são estruturas características das veias, importantes na orientação do fluxo sangüíneo. Sua presença no sistema venoso superficial dos membros inferiores tem sido bastante estudada. No entanto, nas veias profundas, como a veia gastrocnêmia, a literatura é escassa. OBJETIVO: Realizar um estudo anatômico das válvulas do tronco gastrocnêmio principal em cadáveres humanos adultos. MÉTODOS: Foram dissecados os troncos gastrocnêmios principais de 80 cabeças de músculos gastrocnêmios de 20 cadáveres adultos do sexo masculino, com idade entre 40 e 68 anos, após fixados e mantidos em solução de formol a 10%. Os troncos e tipos de redes foram classificados de acordo com o proposto por Aragão et al. As válvulas foram estudadas quanto ao número, distribuição, localização e tipo com relação ao tronco, perna, cabeça do músculo e tipo de rede gastrocnêmia. RESULTADO: Em 80 cabeças de músculos gastrocnêmios, foram encontrados 95 troncos gastrocnêmios principais, sendo que 17 deles eram duplicados. Foram encontradas 65 válvulas em 60 troncos gastrocnêmios principais, todas elas do tipo bicúspide, sendo 35 na rede tipo I, 23 na do tipo II e sete na rede tipo III. Em 74% dos casos, as válvulas estavam localizadas no terço proximal do tronco gastrocnêmio principal. CONCLUSÃO: As válvulas foram encontradas em todos os tipos de redes que possuíam tronco gastrocnêmio principal, eram todas do tipo bicúspide e se localizaram predominantemente no terço proximal dos troncos gastrocnêmios principais.

Insuficiência venosa; veias; anatomia

ORIGINAL ARTICLE

Anatomical study of valves in the gastrocnemius trunk in human cadavers

José Aderval Aragão^I; Francisco Prado Reis^II; Luis Francisco Poli de Figueiredo^III; Fausto Miranda Junior^IV; Guilherme Benjamin Brandão Pitta^V

^IAssistant professor, Universidade Federal de Sergipe (UFS), Aracaju, SE, Brazil. Associate professor III, Universidade Tiradentes (UNIT), Aracaju, SE, Brazil. PhD student, Graduate Program in Angiology and Vascular Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil

^IIProfessor, UNIT, Aracaju, SE, Brazil. Coordinator, Laboratório de Morfologia e Biologia Estrutural, Instituto de Tecnologia e Pesquisa (ITP), UNIT, Aracaju, SE, Brazil

^IIIProfessor, Department of Surgery, UNIFESP, São Paulo, SP, Brazil

^IVProfessor, UNIFESP, São Paulo, SP, Brazil

^VAssociate professor, Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), Maceió, AL, Brazil

^{Correspondence}

ABSTRACT

BACKGROUND: Valves are characteristic structures of veins and are important to guide blood flow. Their presence in the superficial venous system of lower limbs has been well studied. However, there is a lack of published literature on deep veins, such as the gastrocnemius vein.

OBJECTIVE: To carry out an anatomical study of the valves in the main gastrocnemius trunk in adult human cadavers.

METHODS: The main gastrocnemius trunks of 80 gastrocnemius muscle heads of 20 adult cadavers were dissected. The cadavers were males, aged between 40 and 68 years, and fixed in 10% formaldehyde solution. Trunks and net types were classified according to Aragão et al.'s proposal. The valves were studied as to quantity, distribution, location and type with regard to trunk, leg, muscle head and type of gastrocnemius net.

RESULTS: Of 80 gastrocnemius muscle heads, there were 95 main gastrocnemius trunks, and 17 were duplicated. There were 65 valves in 60 gastrocnemius trunks, all of them bicuspid: 35 in type I net, 23 in type II and seven in type III net. Valves were located in the proximal third of the main gastrocnemius trunk in 74% of cases.

CONCLUSION: Valves were found in all net types that had main gastrocnemius trunk. These valves were bicuspid and predominantly located in the proximal third of main gastrocnemius trunks.

Keywords: Venous insufficiency, veins, anatomy.

Introduction

Presence of valves is a characteristic of veins.¹ On their base, valves are implanted in the venous wall, have fibrous elements in their structure, have a higher number in fetuses, when they sometimes appear with an aspect of incomplete and tend to disappear in adults.² Valves are more frequent in lower limb veins, in which they guide the flow, also avoiding blood reflux.^2,3 The first studies about valves go back to 1854 and are attributed to Houlé.⁴

The importance of valve influence on varicose vein pathogenesis is known, and this has led many authors to study valve anatomy in lower limbs.^4-9 For most of these authors, muscle veins have valves, possibly except for soleal and gastrocnemius veins. Thiery¹⁰ attributed base inversion of blood flow from deep to superficial veins to valve destruction. Hobbs¹¹ stressed that gastrocnemius veins dilated by venous insufficiency were phlebographically visible.

According to Browse,³ large variation in number of valves in calf muscle veins has compromised or avoided the establishment of their systematization. Few authors have referred presence of valves in gastrocnemius veins.^3,12-15 Verberck¹⁶ and Stritecky-Kahlek¹⁷ claimed that there was a valve in the terminal portion of the gastrocnemius vein. Tretbar¹⁸ described that gastrocnemius veins have more valves than soleal veins. Villallonga¹⁹ stressed the importance of gastrocnemius valves in blood flow guidance during muscle movements of contraction and relaxation. Marques²⁰ claimed that gastrocnemius veins have no valves.

Although most authors stress the morphofunctional role played by venous valves, it is observed that a systematic description of valves is rare or inexistent, both for gastrocnemius veins and for the main gastrocnemius trunk. For that reason, the present study was performed, with the aim of describing the anatomy of the main gastrocnemius trunk valves, considering the following aspects: number, type, distribution and location.

Methods

Forty lower limbs of 20 adult human cadavers were used. All of them were male, aged between 40-68 years, fixed in 10% formaldehyde solution for more than 1 year. The cadavers belonged to the anatomy laboratories of Universidades Federal de Sergipe, Tiradentes, Federal da Bahia and Estadual de Ciências da Saúde de Alagoas. The material was used in conformity with Act 8501, from November 30, 1992, which deals with the use of cadavers for study or scientific research. The project was approved by the ethics committees of Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), protocol number 038/02 and Universidade Federal de São Paulo (UNIFESP), protocol number 1.475/03.

Presence, number, distribution, location and type of gastrocnemius trunk valve were assessed in relation to leg, gastrocnemius muscle head and type of gastrocnemius network. The main gastrocnemius trunk and types of network were classified according to Aragão et al.'s²¹ proposal. These authors classified four different types of network, in which the whole system of gastrocnemius veins drained directly or through collateral and axial trunks to the main gastrocnemius venous trunk. The data obtained from anatomical dissections were registered using digital photography and tables.

Results

In the 80 heads of 40 gastrocnemius trunks, there were 95 main gastrocnemius trunks distributed by muscle leg and head. Of these trunks, 61 were single and 17 were duplicated (Table 1). There were also 65 valves distributed in a number that was approximately equal in both legs (Table 2). All the valves were bicuspid (Figure 1).

As to location, the valves were predominantly located in the proximal segment (approximately 74% of cases) and occurred in a higher number in the medial head of the left leg. In the medial segment, there were about 17% of cases, and only 9% in the distal segment. In the latter segment, attention was drawn to the fact that all heads of the gastrocnemius muscle had the same number of valves, except for the medial head of the left leg, in which there was presence of more than one valve in the gastrocnemius trunk (Table 3).

Distribution of valves in the main gastrocnemius trunks, considering type of network and gastrocnemius muscle head (Table 4), showed 35 valves in type I network, 23 in type II network, and seven in type III network (Table 5). The number of trunks without valves in type I and II networks was similar, whereas in type III network there were seven trunks without valves. Considering trunks without valves and duplicated trunks, the number of trunks with valves per type of network had the following distribution: 31 in type I network, 22 in type II network and seven in type III network.

There were valves in all types of network. As to distribution per type of network, gastrocnemius muscle head and leg, the highest number of valves was found in type I muscle head and legs. Independently, there was a higher number of valves in type I network in the right leg. The number of valves was always higher in lateral heads, except for gastrocnemius trunks of medial heads of the left and right legs in type II network (Table 6).

Of the 35 valves found in type I network, most were located in the proximal segment of the main gastrocnemius trunk. Only in the trunk medium segment of the gastrocnemius muscle lateral head of the left leg there was no presence of valve. In type II network, its 23 valves were predominantly located in the proximal segment of trunks. In the distal segment, there were valves only in the left medial head of the gastrocnemius muscle. The seven valves present in type III network were located in the proximal segment of all the main gastrocnemius trunks (Table 7).

Discussion

Our study showed that, out of 95 main gastrocnemius trunks, there were 65 valves in 60 trunks. Authors such as Vandendriessche,¹² Schinder, Ramelet,¹³ Mello,¹⁴ Hobbs¹⁵ and Tretbar¹⁸ admitted the presence of valves in the gastrocnemius vein. For Verberck¹⁶ and Stritecky-Kahler¹⁷ there could be a valve in the terminal portion of the gastrocnemius vein. Most of those authors, however, did not quantify neither established the topography of these valves both in veins and in the main gastrocnemius trunk.

There were valves in 70.4% of the main gastrocnemius trunks in type I network, in 59.0% of trunks in type II network, and in 50% of trunks in type III network. As to the relationship between number of valves per network and main gastrocnemius trunk, 79.5% occurred in type I network; 62.1% in type II network and 50% in type III network. Type I and II networks had almost the same number of trunks without valves. Type III networks had the same number of trunks with and without valves. Aragão et al.'s²¹ original proposal about gastrocnemius venous networks and classification of their veins allowed us to observe the anatomical characteristics of distribution of valves in gastrocnemius trunks according to type of network. However, similar findings in the literature seem to be rare or inexistent.

According to Aragão,^22,23 out of 438 dissected gastrocnemius veins, 231 belonged to type II network, 174 to type I network and 28 to type III network. These data revealed us that number of valves was not directly related to number of network veins.

Due to the lack of similar studies, we believe that our anatomical findings represent an interesting contribution to help understand the complex venous drainage of the lower limbs, especially the soleus and gastrocnemius system. It is hard to establish the role of our findings in physiology and pathophysiology based on this type of anatomical study. Nevertheless, we believe that, in the future, they can be useful for hemodynamic studies using phlebography, ultrasonography and plethysmography. This can also help vascular surgeons and imaging specialists interpret their findings.

Conclusion

The number of valves present in the main gastrocnemius trunks varied in relation to type of gastrocnemius network, head of gastrocnemius muscle and leg. The valves were present in all types of network, were predominantly located in the proximal third of the main gastrocnemius trunk and were all bicuspid.

References

Manuscript received March 5, 2007, accepted April 27, 2007.

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Publication Dates

• Publication in this collection
  20 Sept 2007
• Date of issue
  June 2007

History

• Accepted
  27 Apr 2007
• Received
  05 Mar 2007