Varizes Pulsáteis
Varizes Pulsáteis
Varizes Pulsáteis
CASE REPORT
Abstract
Varicose veins of the lower limbs are common. However, pulsatile varicose veins are unusual. They could be an indicator
of a sinister underlying pathology, such as severe cardiac dysfunction. It is easy to miss these rare cases during clinical
workup, which can result in futile treatment with potentially dangerous consequences. In this report, we describe
2 cases of pulsatile varicose veins that highlight different etiologies and management strategies for this condition.
Keywords: pulsatile varicose veins; Parkes Weber syndrome; tri-cuspid regurgitation; secondary varicose veins.
Resumo
Varizes dos membros inferiores são comuns. Entretanto, varizes pulsáteis são raras, podendo ser indicadoras de uma
patologia subjacente sombria como disfunção cardíaca grave. É fácil deixar passar esses casos raros durante exames
clínicos, o que pode resultar em tratamento fútil com consequências potencialmente perigosas. Neste relato, descrevemos
dois casos de varizes pulsáteis que evidenciam as diferentes etiologias e estratégias de manejo para essa condição.
Palavras-chave: varizes pulsáteis; síndrome de Parkes Weber; regurgitação tricúspide; varizes secundárias.
How to cite: Gunawardena T, Godakandage M, Saseekaran B, Cassim R, Wijeyaratne M. Pulsatile varicose veins: an
uncommon presentation of a common condition. J Vasc Bras. 2021;20: e20210075. https://doi.org/10.1590/1677-
5449.210075
1
The Royal Liverpool University Hospital, Liverpool, United Kingdom.
2
National Hospital of Sri Lanka, Colombo, Sri Lanka.
3
Royal Free Hospital, London, United Kingdom.
Financial support: None.
Conflicts of interest: No conflicts of interest declared concerning the publication of this article.
Submitted: April 28, 2021. Accepted: May 24, 2021.
The study was carried out at the National Hospital of Sri Lanka, Colombo, Sri Lanka.
Copyright© 2021 The authors. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Figure 1. (A), (B) Right lower limb VV; (C) engorged neck veins; (D) pulsatile flow in the GSV at the SFJ; (E) pulsatile flow in the
femoral vein.
Figure 2. (A) Abnormal right lower limb VV; (B) arterial type flow at the SFJ; and (C) superficial veins; (D) CT angiogram depicting
the AVM.
recurrent bleeds from the VV, the patient was referred circumference as a result of soft tissue hypertrophy.7
for angioembolization of the AVM. This second phenomenon was seen in our patient.
VV in PWS is a consequence of hyperdynamic
DISCUSSION flow caused by the AVMs.8 Failure to identify the
correct etiology in our patient who presented with
Pulsatile varicose veins are extremely rare.
VV at a very young age led to futile therapy with
Severe TR and AVMs are the predisposing causes
sclerotherapy and SFL and stripping of the GSV. As
described in the literature.2,3 Unless extreme care is
a result, for several years he suffered recurrent bleeds
taken, it is easy to miss a case of pulsatile varicose
from engorged superficial veins.
veins and a treatment approach similar to a case of
Treatment for PWS is indicated when there are
uncomplicated, primary varicose veins can result in
symptoms, functional impairment or cosmetic concerns.
disastrous consequences.1 A case has been reported in
At present, transarterial embolization of AVMs is an
which SFL was attempted in a patient with varicose
increasingly used treatment option. Sometimes more
veins caused by severe TR and the surgeon had to
than one treatment session may be required to achieve
abandon it because of the friable nature of the veins
desired outcomes.9 Surgery also has a secondary role
and the resultant haemorrhage.4 Another interesting
and excision of AVMs, corrective surgery for limb
vignette by Klein et al. reports a patient with pulsatile
VV due to undiagnosed TR, who was subjected to hypertrophy, and amputation for intractable symptoms
unnecessary aortic exploration looking for an arterio- have been used as options.8
venous communication.5
In severe TR, the regurgitating blood through the CONCLUSIONS
incompetent TV sets up a venous pressure wave which Pulsatile VV are rare and it is easy to miss the
is transmitted along the inferior vena cava and down diagnosis. An abnormal distribution pattern in the
the lower limb deep and superficial veins.2,3 Although VV should alert the physician to the possibility of
transmission of venous pressure occurs bilaterally, secondary causes. The etiology of the pulsatility of the
some patients can have the VV confined to a single veins should be confirmed by clinical and radiological
limb.6 The venous valve dysfunction in these patients methods before embarking on treatment, which should
may be secondary to the severe TR, or VV caused by be individualized for each case.
primary valve dysfunction can progress due to the
high venous pressures. Some of these patients may REFERENCES
have a history of femoral vein cannulation for cardiac
catheterization or cardiopulmonary bypass, so it is 1. Li X, Feng Y, Liu Y, Zhang F. Varicose veins of the lower extremity
secondary to tricuspid regurgitation. Ann Vasc Surg. 2019;60:477.
important to exclude a potential arteriovenous fistula.3
e1-6. http://dx.doi.org/10.1016/j.avsg.2019.02.052. PMid:31075472.
A simple test to differentiate TR from arteriovenous
2. Chihara S, Sawada K, Tomoeda H, Aoyagi S. Pulsatile varicose
fistulae in this situation is to occlude to SFJ with a veins secondary to severe tricuspid regurgitation: report of a case
finger and observe for the disappearance of pulsatility successfully managed by endovenous laser treatment. Ann Vasc
in the VV. If this sign is positive, then the possibility Surg. 2017;39:286.e11-4. http://dx.doi.org/10.1016/j.avsg.2016.06.026.
of arterio-venous communication is unlikely.6 PMid:27666801.
Another physical finding that may point towards 3. Dayantas J, Liatas AC, Lazarides M. Pulsatile varicose veins caused
the presence of an arteriovenous fistula is the by tricuspid valve regurgitation. Phlebology. 1990;5(3):189-91.
http://dx.doi.org/10.1177/026835559000500307.
Nicoladoni-Branham sign or slowing of the heart
4. Badger SA, Makar RR, Chew EW, Lee B. Recurrent bilateral
rate upon compression of the inflow to the fistula.7
varicose veins secondary to tricuspid regurgitation. Ir J Med Sci.
There is an inclination for conservative management 2012;181(3):405-7. http://dx.doi.org/10.1007/s11845-010-0547-6.
of pulsatile VV secondary to TR, as the patients PMid:20706799.
affected tend to be elderly with significant cardiac 5. Klein HO, Shachor D, Schneider N, David D. Unilateral pulsatile varicose
comorbidities.2 However, there are cases where SFL veins from tricuspid regurgitation. Am J Cardiol. 1993;71(7):622-3.
and GSV laser ablation have been utilized as treatment http://dx.doi.org/10.1016/0002-9149(93)90528-K. PMid:8438758.
options with satisfactory outcomes.2,6 6. Abbas M, Hamilton M, Yahya M, Mwipatayi P, Sieunarine K.
PWS is a congenital disorder characterized by Pulsating varicose veins!! The diagnosis lies in the heart. ANZ J Surg.
2006;76(4):264-6. http://dx.doi.org/10.1111/j.1445-2197.2006.03597.x.
high-flow AVMs and limb hypertrophy. Bleeding
PMid:16681546.
from VV is a rare presentation of this syndrome. The
7. Burchell HB. Observations on bradycardia produced by occlusion
disorder generally tends to affect a single extremity. of an artery proximal to an arteriovenous fistula (Nicoladoni-
The limb asymmetry can be a discrepancy in the Branham sign). Med Clin North Am. 1958;42(4):1029-35. http://
length due to bony overgrowth or an increase in limb dx.doi.org/10.1016/S0025-7125(16)34255-9. PMid:13564989.
Author contributions
Conception and design: TG
Analysis and interpretation: N/A
Data collection: TG, MG, BS
Writing the article: TG, MG, BS
Critical revision of the article: RC, MW
Final approval of the article*: TG, MG, BS, RC, MW
Statistical analysis: N/A
Overall responsibility: TG
*All authors have read and approved of the final version of the article
submitted to J Vasc Bras.