Pulsatile varicose veins caused by tricuspid valve regurgitation

20 Αυγούστου, 2012

ΑΓΓΕΙΑ, Φλέβες

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Introduction

“Pulsatile veins” have been observed in the neck, forearm and forehead, and less commonly in other areas of the body. Venous pulsation is exaggerated when the pressure in the pulmonary artery is highly elevated as it happens when mitral stenosis coexists with tricuspid valve regurgitation.

“Pulsatile varicose veins” may occur either in arteriovenous (AV) fistulae or in tricuspid valve insufficiency when it is combined with an incompetent valve at the sapheno-femoral junction. In the later case the wave of ventricular systole is conducted backwards along the inferior vena cava to the superficial venous system of the lower limb resulting in visible pulsation of the varicosities. The cardiac origin of the pulsatile varices necessitates differential diagnosis from an AV fistula, especially when cardiac catheterization has been performed via the ipsilateral femoral vessels. Furthermore the presence of a murmur does not exclude the cardiac component in cases of pulsating varicosities as Hollins and Engeset have reported.

We report an uncommon case of pulsatile varicose veins in a young woman caused by tricuspid valve insufficiency of rheumatic origin combined with an incompetent valve at the sapheno-femoral junction. She was treated with limited stripping of the great saphenous vein and local varicosities were excised. Postoperative recovery was complicated by a large haematoma in the thigh. Following our recent experience we believe that patients like this, with elevated venous pressure and requiring anticoagulant therapy for prosthetic valves, should be treated with sapheno-femoral dissociation alone.

Discussion

Although the clinical picture and etiology of pulsatile varicose veins have been fully described in previous reports, there is no information regarding the indications for surgical therapy, the preferable type of surgery and any possible complications thereof. Patients of this category with huge varicosities, complicated with bleeding, venous ulcer, eczema, lipodermatosclerosis, extensive hemochromatosis and ankle edema, should be offered surgical therapy. The postoperative haematoma in the thigh experienced by our patient following limited stripping of the long saphenous vein has convinced us that the therapy of choice has to be a “sapheno-femoral dissociation along with removal of local varicosities” and meticulous hemostasis only. Although limited stripping of the long saphenous vein is the treatment of choice for primary varicose veins, the elevated venous pressure in pulsatile varicosities along with the anticoagulant therapy given compulsorily to patients with prosthetic valves can cause serious postoperative haematoma in spite of preoperative discontinuation of anticoagulants and proper bandaging.

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο: [ Phlebology (1990) 5; 189-191 ]

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Για το πλήρες άρθρο «Pulsatile varicose veins caused by tricuspid valve regurgitation» πατήστε:  Εδώ (.pdf αρχείο).

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