Inguinal ligament

Classically, the venous approach establishes where the device will be implanted. Historically, the venous approach used for lead implantation was the ileofemoral vein. Once a small incision immediately below the inguinal ligament was performed, the operator had to carry the dissection down to the fascia above the vein. At this point, the iliac vein was entered with a standard puncture technique, and after lead implantation, it was tunneled to the abdominal pocket. For this venous approach, the device was actually housed in the abdominal region. The pocket was created lateral to the umbilicus and superficial to the rectus sheath [30, 31]. This is not the standard method for PM implantation used today, but it is important to know this approach in the event that more com-... 

Fig. 12.8a,b. Injection above (a) and at (b) the mid R ISV, demonstrates the typical parallel collaterals and multiple channels at the level of the inguinal ligament that make complete treatment with coil placement or surgical ligation challenging... 

Therefore, this chapter will focus upon the use of POBA and other intravascular therapeutic interventions above and below the level of the inguinal ligament. Adjunctive techniques to POBA that allow for dilatation of resistant calcified lesions such as atherectomy or allow for improved balloon dilatation of compliant lesions or treatment of complications of angioplasty such as intravascular metallic stents, and finally therapy to improve the results of balloon dilatation for occlusions with thrombolytic therapy will be discussed. 

The superficial venous system of the lower extremities is composed of innumerable subcutaneous collecting veins, the saphenous trunks and their tributaries. The CSV begins on the anterior and medial portion of the foot, runs anterior to the medial malleolus, and ascends the medial aspect of the calf and thigh to ultimately join the femoral vein at the fossa ovale (saphenofemoral junction, SFJ) several centimeters below the inguinal ligament (Fig. 9.1). The CSV is adjacent to the saphenous nerve (sensory)... 

Rather than exist in a segregated fashion, the various fasciae show continuous communication. Suspensory ligaments of the heart and other organs represent continuities. The recently discovered connection between the dura and the rectus capitis posterior minor is an example of the continuity and interrelatedness of bodily structures. The inguinal ligament is a reflection of the in-rolled lower edge of the external oblique muscle aponeurosis. 

FIG. 62-4 Counterstrain treatment for an inguinal ligament tender point. 

FIG. 66-2 PINS sacrum and pelvis point patterns. Anterior 6, rectus abdomlnus muscle/pubic 7, Inguinal ligament 8, lateral femoral cutaneous nerve 9, adductor (gracilis) muscle 70, sartorius. 

Lower limbs, including everything below the inguinal ligament, including hip, thigh, knee,... 

The lateral femoral cutaneous nerve courses more lateral relative to the femoral nerve. It arises from the L2 and L3 spinal nerve roots, emerges from the lateral border of the psoas muscle and crosses the iliacus muscle passing through a tunnel formed by a small split in the lateral end of the inguinal ligament in close proximity with the anterior superior iliac spine (Fig. 12.10b). This nerve is purely sensory and supplies the skin of the anterior and lateral aspects of the thigh. 

Fig. 12.16. Lateral femoral cutaneous nerve. Transverse 12-5 MHz US image obtained over the anterior superior iliac spine (ASIS) in a healthy subject depicts the nerve (arrow) as it passes through the tunnel formed by a split in the lateral end of the inguinal ligament (arrowheads)...

Fig. 12.42. Lateral femoral cutaneous neuropathy in a patient with chronic sensory symptoms irradiated over the anterolateral region of the thigh. Long-axis 12-5 MHz US image of the lateral femoral nerve (arrows) demonstrates a fusiform hypoechoic swelling (asterisks) of the nerve at the point where it crosses the anterior superior iliac spine (ASIS) below the inguinal ligament...

Two fingerbreadths lateral to the femoral artery (FA) and one fin-gerbreadth below the inguinal ligament (IL). 

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