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Traitement chirurgical d’un gros anévrysme de la veine saphène ayant pour résultat une embolie pulmonaire chez deux patients
Cas clinique vrysme Traitement chirurgical d’un gros ane de la veine saph ene ayant pour r esultat une embolie pulmonaire chez deux patients Grigol Keshelava,1 Kakha Beselia,1 Merab Nachkepia,2 Sophio Chedia,3 Giorgi Janashia,1 Kakha Nuralidze,2 Kutaisi, GA, USA
vrysmes veineux superficiels des membres infe rieurs sont conside re s rares et leur signiLes ane finie. L’embolie pulmonaire re sultant des ane vrysmes veineux superfication clinique est mal de te pre ce demment rapporte e. Dans cet article, nous rapportons deux cas de gros ficiels a e vrysmes de la veine saphe ne qui ont eu comme conse quence une embolie pulmonaire. ane vrysme. Le traitement actuel est l’excision chirurgicale ouverte urgente de l’ane
The traditional definition of a venous aneurysm is dilation of a venous segment 1,5 times the diameter of the normal segments proximal and distal to the diseased segment.1 Venous aneurysms of the lower extremity can be divided into aneurysms of the deep and those that are superficial. Aneurysms of the superficial venous system of the lower extremities were once thought to be exceedingly rare.2
CASE REPORTS Patient 1 A 40-year-old woman was emergently hospitalized for respiratory insufficiency. The diagnosis was pulmonary embolism. Computed tomography (CT) confirmed the
diagnosis. Duplex scan examination of lower extremity vessels revealed the left great saphenous vein aneurysm measuring 2 3 cm2 with thrombus at the saphenofemoral junction (Fig. 1). No reflux or varicosities of the middle and distal portions of great saphenous vein were observed. Deep venous system was normal. Open resection of the aneurysm at the saphenofemoral junction and ligation of the great saphenous vein was performed. After the operation, the patient was transferred to the Department of Cardiology and low-molecular-weight heparin therapy was started and extended for 1 week. Acetylsalicylic acid was used as antiplatelet therapy permanently. The postoperative period was uncomplicated. The patient was discharged from the medical center on day 10 after surgery. The 1-, 3-, 6-, and 10-month postoperative follow-up visits revealed normal condition of the patient. Patient 2
DOI of original article: 10.1016/j.avsg.2011.02.003. 1
Department of Cardiovascular Surgery, West Georgian National Centre of Interventional Medicine, Kutaisi, GA, USA. 2 Department of Anaesthesiology And Reanimation, West Georgian National Centre of Interventional Medicine, Kutaisi, GA, USA. 3 Department of Radiology, West Georgian National Centre of Interventional Medicine, Kutaisi, GA, USA.
Correspondence : Grigol Keshelava, MD, PhD, Department of Cardiovascular Surgery, West Georgian National Centre of Interventional Medicine, Javakishvili Street 83, Kutaisi, GA 4600, USA, E-mail: [email protected] Ann Vasc Surg 2011; 25: 700.e13-700.e15 http://dx.doi.org/10.1016/j.acvfr.2012.06.018 Ó Annals of Vascular Surgery Inc. e par ELSEVIER MASSON SAS Edit
A 43-year-old woman was hospitalized for pulmonary embolism. The diagnosis was confirmed with CT. Duplex scan examination of lower extremity vessels revealed the right great saphenous vein aneurysm measuring 3 3 cm2 with thrombus in the distal one-third of femoral segment (Fig. 2). Deep venous system was normal. No reflux or varicosities of the proximal and distal portions of great saphenous vein were observed. Venous aneurysm was excised and great saphenous vein was ligated. The patient was transferred to the Department of Cardiology. Postoperatively, low-molecularweight heparin therapy was started and extended for 9 days. Acetylsalicylic acid was used as antiplatelet 747.e9
747.e10 Cas cliniques
Fig. 1. Left great saphenous vein aneurysm measuring 2 3 cm2 at the saphenofemoral junction.
Fig. 2. Right great saphenous vein aneurysm measuring 3 3 cm2 in the distal one-third of the femoral segment. therapy permanently. The postoperative period was uncomplicated. The patient was discharged from the medical center on day 10 after surgery. The 1-, 3-, and 6month postoperative follow-up visits revealed normal condition of the patient.
Annales de chirurgie vasculaire
aneurysms of the short saphenous system were found and were classified as type IV (6%).2 The aneurysms of the deep system seem to have a greater association with thromboembolism and more severe venous morbidity than those of the superficial system. Patients with superficial venous aneurysms frequently manifest pain, edema, and a mass in the affected extremity.3 Pulmonary embolism is thought to be less common in superficial than deep venous aneurysms.4 Perhaps, this occurs because of vigorous emptying of the deep system associated with contraction of the muscular venous pump.5 Such rapid emptying has been hypothesized to play a role in dislodging thrombus that may accumulate in deep venous aneurysms. Rupture is a noted complication in arterial aneurysms, but is rare in those of the venous system.6 The causes of venous aneurysms are nebulous hypertension and venous hypertension.3 Other proposed causes include processes causing venous wall weakening, such as trauma, and hereditary factors.7 The histology of venous aneurysms is a thickened intima and deficient, or absent, smooth muscle layers.4,8 Moreover, a recent report examining venous aneurysm tissue suggested that the focal structural changes may be related to increased expression of select matrix metalloproteinases.9 Duplex imaging can determine aneurysm size and identify thrombus and the color flow function.10 Other noninvasive modalities include CT and resonance imaging.3 Indications for treatment of superficial venous aneurysms of the lower extremity are dictated by symptoms of reflux, edema, and varicosities, in addition to prevention of venous thromboembolism.1 Treatment is primarily surgical. For the cases reported in this article, the indication for excision of the superficial venous aneurysms was prevention of pulmonary embolism.
REFERENCES
DISCUSSION Aneurysms of the saphenous systems were classified into four types. Type I aneurysms (52%) were located in the proximal one-third of the saphenous vein, not at the saphenofemoral junction but instead just distal to the subterminal valve. Type II aneurysms were located in the shaft of the saphenous vein in the distal one-third of the thigh (35%). The third classification (type III) of superficial saphenous vein aneurysms was an occurrence of types I and II in the same lower extremity. Superficial venous
1. Gillespie DL, Villavicencio JL, Gallagher C, et coll. Presentation and management of venous aneurysms. J Vasc Surg 1997;26:845-852. 2. Pascarella L, Al-Tuwaijri, Bergan JJ, Mekenas LM. Lower extremity superficial venous aneurysms. Ann Vasc Surg 2005;19:69-73. 3. Chen SI, Clouse WD, Bowser AN, Rasmussen TE. Superficial venous aneurysms of the small saphenous vein. J Vasc Surg 2009;50:644-647. 4. Sessa C, Nicolini P, Perrin M, Farah I, Magne JL, Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and review of the literature. J Vasc Surg 2000;32:902-912.
Vol. 25, No. 5, 2011
5. Cox MA, Krishnan S, Aidinian G. Fatal pulmonary embolus associated with asymptomatic popliteal venous aneurysm. J Vasc Surg 2008;48:1040. 6. Friedman SG, Krishnasastry KV, Doscher W, Deckoff S. Primary venous aneurysms. Surg 1990;108:92-95. 7. Schatz IJ, Fine G. Venous aneurysms. N Engl J Med 1962;266: 1310-1312.
Cas cliniques 747.e11
8. Wali MA, Dewan M, Eid RA. Histopathologic changes in the wall of varicose veins. Int Angiol 2003;22:188-193. 9. Irwin C, Synn A, Kraiss L, Zhang Q, Griffen MM, Hunter GC. Metalloproteinase expression in venous aneurysms. J Vasc Surg 2008;48:1278-1285. 10. Ekim H, Kutay V, Tuncer M. Management of primary venous aneurysms. Saudi Med J 2004;25:303-307.
vrysmes veineux superficiels des membres infe rieurs sont conside re s rares et leur signiLes ane finie. L’embolie pulmonaire re sultant des ane vrysmes veineux superfication clinique est mal de te pre ce demment rapporte e. Dans cet article, nous rapportons deux cas de gros ficiels a e vrysmes de la veine saphe ne qui ont eu comme conse quence une embolie pulmonaire. ane vrysme. Le traitement actuel est l’excision chirurgicale ouverte urgente de l’ane
The traditional definition of a venous aneurysm is dilation of a venous segment 1,5 times the diameter of the normal segments proximal and distal to the diseased segment.1 Venous aneurysms of the lower extremity can be divided into aneurysms of the deep and those that are superficial. Aneurysms of the superficial venous system of the lower extremities were once thought to be exceedingly rare.2
CASE REPORTS Patient 1 A 40-year-old woman was emergently hospitalized for respiratory insufficiency. The diagnosis was pulmonary embolism. Computed tomography (CT) confirmed the
diagnosis. Duplex scan examination of lower extremity vessels revealed the left great saphenous vein aneurysm measuring 2 3 cm2 with thrombus at the saphenofemoral junction (Fig. 1). No reflux or varicosities of the middle and distal portions of great saphenous vein were observed. Deep venous system was normal. Open resection of the aneurysm at the saphenofemoral junction and ligation of the great saphenous vein was performed. After the operation, the patient was transferred to the Department of Cardiology and low-molecular-weight heparin therapy was started and extended for 1 week. Acetylsalicylic acid was used as antiplatelet therapy permanently. The postoperative period was uncomplicated. The patient was discharged from the medical center on day 10 after surgery. The 1-, 3-, 6-, and 10-month postoperative follow-up visits revealed normal condition of the patient. Patient 2
DOI of original article: 10.1016/j.avsg.2011.02.003. 1
Department of Cardiovascular Surgery, West Georgian National Centre of Interventional Medicine, Kutaisi, GA, USA. 2 Department of Anaesthesiology And Reanimation, West Georgian National Centre of Interventional Medicine, Kutaisi, GA, USA. 3 Department of Radiology, West Georgian National Centre of Interventional Medicine, Kutaisi, GA, USA.
Correspondence : Grigol Keshelava, MD, PhD, Department of Cardiovascular Surgery, West Georgian National Centre of Interventional Medicine, Javakishvili Street 83, Kutaisi, GA 4600, USA, E-mail: [email protected] Ann Vasc Surg 2011; 25: 700.e13-700.e15 http://dx.doi.org/10.1016/j.acvfr.2012.06.018 Ó Annals of Vascular Surgery Inc. e par ELSEVIER MASSON SAS Edit
A 43-year-old woman was hospitalized for pulmonary embolism. The diagnosis was confirmed with CT. Duplex scan examination of lower extremity vessels revealed the right great saphenous vein aneurysm measuring 3 3 cm2 with thrombus in the distal one-third of femoral segment (Fig. 2). Deep venous system was normal. No reflux or varicosities of the proximal and distal portions of great saphenous vein were observed. Venous aneurysm was excised and great saphenous vein was ligated. The patient was transferred to the Department of Cardiology. Postoperatively, low-molecularweight heparin therapy was started and extended for 9 days. Acetylsalicylic acid was used as antiplatelet 747.e9
747.e10 Cas cliniques
Fig. 1. Left great saphenous vein aneurysm measuring 2 3 cm2 at the saphenofemoral junction.
Fig. 2. Right great saphenous vein aneurysm measuring 3 3 cm2 in the distal one-third of the femoral segment. therapy permanently. The postoperative period was uncomplicated. The patient was discharged from the medical center on day 10 after surgery. The 1-, 3-, and 6month postoperative follow-up visits revealed normal condition of the patient.
Annales de chirurgie vasculaire
aneurysms of the short saphenous system were found and were classified as type IV (6%).2 The aneurysms of the deep system seem to have a greater association with thromboembolism and more severe venous morbidity than those of the superficial system. Patients with superficial venous aneurysms frequently manifest pain, edema, and a mass in the affected extremity.3 Pulmonary embolism is thought to be less common in superficial than deep venous aneurysms.4 Perhaps, this occurs because of vigorous emptying of the deep system associated with contraction of the muscular venous pump.5 Such rapid emptying has been hypothesized to play a role in dislodging thrombus that may accumulate in deep venous aneurysms. Rupture is a noted complication in arterial aneurysms, but is rare in those of the venous system.6 The causes of venous aneurysms are nebulous hypertension and venous hypertension.3 Other proposed causes include processes causing venous wall weakening, such as trauma, and hereditary factors.7 The histology of venous aneurysms is a thickened intima and deficient, or absent, smooth muscle layers.4,8 Moreover, a recent report examining venous aneurysm tissue suggested that the focal structural changes may be related to increased expression of select matrix metalloproteinases.9 Duplex imaging can determine aneurysm size and identify thrombus and the color flow function.10 Other noninvasive modalities include CT and resonance imaging.3 Indications for treatment of superficial venous aneurysms of the lower extremity are dictated by symptoms of reflux, edema, and varicosities, in addition to prevention of venous thromboembolism.1 Treatment is primarily surgical. For the cases reported in this article, the indication for excision of the superficial venous aneurysms was prevention of pulmonary embolism.
REFERENCES
DISCUSSION Aneurysms of the saphenous systems were classified into four types. Type I aneurysms (52%) were located in the proximal one-third of the saphenous vein, not at the saphenofemoral junction but instead just distal to the subterminal valve. Type II aneurysms were located in the shaft of the saphenous vein in the distal one-third of the thigh (35%). The third classification (type III) of superficial saphenous vein aneurysms was an occurrence of types I and II in the same lower extremity. Superficial venous
1. Gillespie DL, Villavicencio JL, Gallagher C, et coll. Presentation and management of venous aneurysms. J Vasc Surg 1997;26:845-852. 2. Pascarella L, Al-Tuwaijri, Bergan JJ, Mekenas LM. Lower extremity superficial venous aneurysms. Ann Vasc Surg 2005;19:69-73. 3. Chen SI, Clouse WD, Bowser AN, Rasmussen TE. Superficial venous aneurysms of the small saphenous vein. J Vasc Surg 2009;50:644-647. 4. Sessa C, Nicolini P, Perrin M, Farah I, Magne JL, Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and review of the literature. J Vasc Surg 2000;32:902-912.
Vol. 25, No. 5, 2011
5. Cox MA, Krishnan S, Aidinian G. Fatal pulmonary embolus associated with asymptomatic popliteal venous aneurysm. J Vasc Surg 2008;48:1040. 6. Friedman SG, Krishnasastry KV, Doscher W, Deckoff S. Primary venous aneurysms. Surg 1990;108:92-95. 7. Schatz IJ, Fine G. Venous aneurysms. N Engl J Med 1962;266: 1310-1312.
Cas cliniques 747.e11
8. Wali MA, Dewan M, Eid RA. Histopathologic changes in the wall of varicose veins. Int Angiol 2003;22:188-193. 9. Irwin C, Synn A, Kraiss L, Zhang Q, Griffen MM, Hunter GC. Metalloproteinase expression in venous aneurysms. J Vasc Surg 2008;48:1278-1285. 10. Ekim H, Kutay V, Tuncer M. Management of primary venous aneurysms. Saudi Med J 2004;25:303-307.