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Pulsating varicose veins
CASE REPORT
Case report
Pulsating varicose veins
M R Moawad, S D Blair A 64-year-old woman visited her general practitioner in January, 1997, with large bilateral varicose veins that were visibly pulsating. She was otherwise well, but 20 years before had had a mitral-valve replacement for rheumatic valve disease. As part of her preoperative assessment for that procedure she had had a percutaneous cardiac catheterisation via her femoral artery. This had been an uncomplicated procedure and she had no symptoms in her legs after it. 10 years previously, she had pain in the right hypochondrium, which was thought to be due to gallstones. Abdominal ultrasonographic examination at that time showed no evidence of gallstones, but both the inferior vena cava and the hepatic veins were dilated. There was hepatomegaly. This appearance suggested a degree of right-ventricular failure. Her abdominal pain was then considered to be secondary to distension of her liver capsule. 5 years previously she had had transitional-cell carcinoma of the bladder, which had been treated by fulguration. She was referred to hospital for an angiogram to see if there was an arteriovenous fistula arising from the site of previous angiography. The arteriogram showed a normal aorta and normal iliac, femoral, and popliteal arteries, but the runoff on the left anterior tibial artery was poor. There was no evidence of an arteriovenous communication. She was then referred to the vascular surgical team for further assessment, where she said she had few symptoms from her varicose veins apart from mild aching when she stood for a long time. She had diabetes mellitus, which was controlled by diet. She did not smoke or drink alcohol. On examination, her jugular venous pulse was very high with a prominent V wave. Her liver was enlarged 4 cm below the right costal margin. Visible and palpable pulsation in her varicose veins was obvious in both legs. The distribution of the varicose veins was in both long saphenous systems. There was no lipodermatosclerosis or venous eczema. At first we could not think of any anatomical position for an arteriovenous fistula that would affect both long
Continuous-wave Doppler trace, with simultaneous ECG The peak regurgitation velocity at the tricuspid valve is 2·95 m/sec, the right ventricular/right atrial pressure gradient is 34·8 mm Hg, and estimated pulmonary artery pressure is 45 mm Hg.
saphenous veins and therefore wondered if pulsation was transmitted from the right heart and the patient had bilateral saphenofemoral incompetence. A colour duplex ultrasonographic scan confirmed that there was no arteriovenous communication, and that there was retrograde pulsatile flow all the way down the inferior vena cava into the femoral veins and then into the long saphenous veins. An echocardiogram showed quite marked tricuspid regurgitation with a pulmonary-artery pressure of 45 mm Hg and dyskinetic septal function due to the right-ventricular volume overload (figure). We have been unable to find any similar cases reported in medical journals. However, in the analysis of Abu-Yosef and colleagues’ study of patients who had duplex scans to diagnose deep-venous thrombosis, 17 out of 51 patients had pulsatile flow in the common femoral vein and 33 out of 51 patients had elevated right-atrial pressure.1 Pulsatile varicose veins may be a consequence of elevated right-atrial pressure.
Lancet 1998; 352: 1030 Arrowe Park Hospital, Upton, Wirrall L49 5PE, UK (M R Moawad MD, S D Blair FRCS) Correspondence to: Dr M R Moawad, c/o Dr E R N Morgan, 228 Middlewood Road, Sheffield S6 1TE
1030
References 1
Abu-Yosef MM, KaKish ME, Mufid M. Pulsatile venous doppler flow in lower limbs: highly indicative of elevated right atrium pressure. Am J Radiol 1996; 167: 977–80.
THE LANCET • Vol 352 • September 26, 1998
Case report
Pulsating varicose veins
M R Moawad, S D Blair A 64-year-old woman visited her general practitioner in January, 1997, with large bilateral varicose veins that were visibly pulsating. She was otherwise well, but 20 years before had had a mitral-valve replacement for rheumatic valve disease. As part of her preoperative assessment for that procedure she had had a percutaneous cardiac catheterisation via her femoral artery. This had been an uncomplicated procedure and she had no symptoms in her legs after it. 10 years previously, she had pain in the right hypochondrium, which was thought to be due to gallstones. Abdominal ultrasonographic examination at that time showed no evidence of gallstones, but both the inferior vena cava and the hepatic veins were dilated. There was hepatomegaly. This appearance suggested a degree of right-ventricular failure. Her abdominal pain was then considered to be secondary to distension of her liver capsule. 5 years previously she had had transitional-cell carcinoma of the bladder, which had been treated by fulguration. She was referred to hospital for an angiogram to see if there was an arteriovenous fistula arising from the site of previous angiography. The arteriogram showed a normal aorta and normal iliac, femoral, and popliteal arteries, but the runoff on the left anterior tibial artery was poor. There was no evidence of an arteriovenous communication. She was then referred to the vascular surgical team for further assessment, where she said she had few symptoms from her varicose veins apart from mild aching when she stood for a long time. She had diabetes mellitus, which was controlled by diet. She did not smoke or drink alcohol. On examination, her jugular venous pulse was very high with a prominent V wave. Her liver was enlarged 4 cm below the right costal margin. Visible and palpable pulsation in her varicose veins was obvious in both legs. The distribution of the varicose veins was in both long saphenous systems. There was no lipodermatosclerosis or venous eczema. At first we could not think of any anatomical position for an arteriovenous fistula that would affect both long
Continuous-wave Doppler trace, with simultaneous ECG The peak regurgitation velocity at the tricuspid valve is 2·95 m/sec, the right ventricular/right atrial pressure gradient is 34·8 mm Hg, and estimated pulmonary artery pressure is 45 mm Hg.
saphenous veins and therefore wondered if pulsation was transmitted from the right heart and the patient had bilateral saphenofemoral incompetence. A colour duplex ultrasonographic scan confirmed that there was no arteriovenous communication, and that there was retrograde pulsatile flow all the way down the inferior vena cava into the femoral veins and then into the long saphenous veins. An echocardiogram showed quite marked tricuspid regurgitation with a pulmonary-artery pressure of 45 mm Hg and dyskinetic septal function due to the right-ventricular volume overload (figure). We have been unable to find any similar cases reported in medical journals. However, in the analysis of Abu-Yosef and colleagues’ study of patients who had duplex scans to diagnose deep-venous thrombosis, 17 out of 51 patients had pulsatile flow in the common femoral vein and 33 out of 51 patients had elevated right-atrial pressure.1 Pulsatile varicose veins may be a consequence of elevated right-atrial pressure.
Lancet 1998; 352: 1030 Arrowe Park Hospital, Upton, Wirrall L49 5PE, UK (M R Moawad MD, S D Blair FRCS) Correspondence to: Dr M R Moawad, c/o Dr E R N Morgan, 228 Middlewood Road, Sheffield S6 1TE
1030
References 1
Abu-Yosef MM, KaKish ME, Mufid M. Pulsatile venous doppler flow in lower limbs: highly indicative of elevated right atrium pressure. Am J Radiol 1996; 167: 977–80.
THE LANCET • Vol 352 • September 26, 1998