EJVES Extra
Volume 18, Issue 5 , Pages e53-e56, November 2009

Venous Aneurysms – An Uncommon but Potentially Life-Threatening Disease: A Case Report

Aristotle University of Thessaloniki, 2nd Surgical Department, Division of Vascular Surgery, General Hospital “G. Gennimatas”, Thessaloniki, Greece

Received 8 January 2009; accepted 15 April 2009. published online 27 August 2009.

Article Outline

Abstract 

Venous aneurysms are rare, but they can have devastating consequences, including pulmonary embolism (PE) and death. We present a case of a male patient with venous aneurysms of both his legs treated surgically.

Patient and methods

A 24-year-old patient appeared with varicosities of both his legs. Magnetic resonance venography (MRV) revealed partial thrombosis of the vena cava and venous aneurysms of the left popliteal and calf vein and also of the right small saphenus vein (SSV). The patient was treated with tangential excision and lateral venoraphy of the popliteal venous aneurysm (PVA), resection and ligation of the aneurysms of the left SSV with an excellent result.

Conclusion

Our results are in agreement with the literature. Surgical resection is recommended whenever possible, because there is a significant risk of pulmonary embolism and death if left untreated.

Keywords: Venous aneurysms, Popliteal vein, Pulmonary embolus

 

Primary venous aneurysms are rare, but can have devastating consequences, including pulmonary emboli (PE) and death if left untreated.1, 2, 3 Most venous aneurysms are congenital and are discovered incidentally.4 A strong association with PE or post-thrombotic syndrome has been reported.3, 5 We present our experience in the treatment of a patient with symptomatic aneurysms in the left popliteal vein and right small saphenous vein (SSV).

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Case report 

A 24-year-old man reported to the Vascular Unit of the 2nd Surgical Clinic of Aristotelian University of Thessaloniki, with varicose veins and a history of mild swelling in both limbs. Symptoms had begun 3 years earlier and had become more prominent during usual daily activities.

Venous reflux was detected in both popliteal fossas on Doppler examination. Colour duplex revealed incompetence and dilatation of both SSVs and aneurismal dilatation of the left popliteal vein with luminal thrombus.

In view of these findings, the venous system was further investigated. Computed tomography angiography (CTA) of the abdomen revealed dilatation of the vena cava and the presence of endoluminal thrombus (Fig. 1).

Magnetic resonance venography (MRV) of the abdomen revealed a partial thrombosis of the vena cava 6cm below the renal veins (Fig. 2) and two venous aneurysms in the SSV close to the sapheno-popliteal junction of the ‘right’ lower limb with endoluminal thrombus and maximum diameter of 3.5–4.0cm (Fig. 3). Two aneurysms were also seen in the ‘left’ popliteal vein with endoluminal thrombus and a maximum diameter of 1.5–2.0cm (Fig. 4).

The patient underwent extensive investigations to exclude the possibility of the co-existence of malignancy or hypercoangulable condition.

Therefore, the patient underwent surgical exploration through a posterior approach to the popliteal fossa of both his legs.

On the right side, the double SSV aneurysm was excised after proximal and distal ligation of the SSV (Fig. 5).

On the left side, the SSV was dilated with varicosities. The popliteal vein was aneurismal. It bifurcated 5cm from the knee joint. The medial branch was aneurismal. The lateral root, which was not aneurismal, reached the popliteal vein at the upper edge of the aneurysm (Fig. 6).

The dilated SSV segment and the popliteal vein aneurysm (PVA) have been resected, while preserving the lateral branch of the popliteal vein (Fig. 7).

The patient received low-molecular-weight heparin (LMWH) 100IUkg−1×2 postoperatively for a week. He was discharged on 100IUkg−1×1 thereafter for the next 4 weeks and knee-length graduated elastic stocking class II.

Partial thrombosis of the vena cava was considered to be a spurious finding as neither thrombophilia nor malignancy was detected. So the patient was advised to undergo regular follow-up with clinical examination and MRV.

During the follow-up period, the patient complained of right limb heaviness and swelling after standing and walking. These symptoms gradually improved and 3 months later the patient was completely asymptomatic.

The histopathological examination revealed attenuation of the venous wall and replacement of its structures with fibrous connective tissue, compared with normal venous tissue (Fig. 8).

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Discussion 

May and Nissel described a true venous aneurysm of the popliteal vein in 1968. The definition of venous aneurysm still remains controversial, and there are no size criteria to definitively label a venous dilatation as an aneurysm. Mac Devitt et al. defined venous aneurysm as “a persistent isolated venous dilatation twice the normal diameter.”2, 4, 6

A venous aneurysm is best described as a solitary area of venous dilation that communicates with a main venous structure by a single channel, occurs in a non-varicose vein and is not associated with pseudo-aneurysms or arteriovenous communications.1, 2, 3, 4, 5

The pathogenesis of popliteal venous aneurysm (PVA) is unknown. Trauma, inflammation, localised degenerative changes and congenital weakness have been implicated.1, 3, 5, 9

The majority of the patients reported are symptomatic. The most common symptoms are PE or post-thrombotic syndrome.3

Although large or saccular aneurysms are considered to be more prone to Thrombo-embolic complications, small aneurysms carry this risk as well. Rupture of PVAs has never been reported.3, 7

Venous aneurysms may look like soft-tissue masses clinically, and aneurysms of the femoral vein could be misdiagnosed as inguinal or femoral hernias.2

PVAs can be detected by duplex scanning, which is the first-line investigation and is able to determine the size of the aneurysm and the presence of thrombus. Further non-invasive imaging with CTA or MRV may give useful anatomical information.3, 4, 6 Large aneurysms are associated with a high rate (almost 80%) of PE despite adequate anticoagulation. The treatment of symptomatic PVAs is surgical.2, 3, 4, 5

The long-term patency rate of venous repairs ranges from 40% to 93%, depending on the type of repair. The best long-term patency rates are obtained with tangential excision and lateral venoraphy.2, 8

PVAs are rare, but the true incidence is probably underestimated. As it is well known that these might be a source of recurrent PE, surgical repair of this entity is recommended, whenever possible.1, 4

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References 

  1. Herrera LJ, Davis JW, Livesay JJ. Popliteal vein aneurysm presenting as a popliteal mass. Tex Heart Inst J. 2006;33(2):246–248Houston, Texas, USA
  2. Gillespie DL, Villavicencio JL, Gallagher C, Chang A, Hamelink JK, Fiala LA, et al. Presentation and management of venous aneurysms. J Vasc Surg. 1997 Nov;26(5):845–852Washington, USA
  3. 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 Nov;32(5):902–912Grenoble, France
  4. May R, Nissel R. Aneurysma der vena poplitea. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr. Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr. 1968;108:402–403
  5. Williamson JM, Dalton RS, Chester JF. Popliteal venous aneurysm causing pulmonary embolism and paradoxical embolisation in a patient with antiphospholipid syndrome. Eur J Vasc Endovasc Surg. 2008 Aug;36(2):227–229Somerset, UK
  6. McDevitt DT, Lohr JM, Martin KD, Welling RE, Sampson MG. Bilateral popliteal vein aneurysms. Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio Ann Vasc Surg. 1993 May;7(3):282–286
  7. Chahlaoui J, Julien M, Nadeau P, Bruneau L, Roy P, Sylvestre J. Popliteal venous aneurysm: a source of pulmonary embolism. AJR Am J Roentgenol. 1981 Feb;136(2):415–416
  8. Pappas PJ, Haser PB, Teehan EP, Noel AA, Silva MB, Jamil Z, et al. Padberg :outcome of complex venous reconstructions in patients with trauma. J Vasc Surg. 1997 Feb;25(2):398–404
  9. Irwin C, Synn A, Kraiss L, Zhang Q, Griffen MM, Hunter GC. Metalloproteinase expression in venous aneurysms. Division of Vascular Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA J Vasc Surg. 2008 Nov;48(5):1278–1285

PII: S1533-3167(09)00016-8

doi:10.1016/j.ejvsextra.2009.04.003

Refers to article:

  • Venous Aneurysms – An Uncommon but Potentially Life-Threatening Disease: A Case Report , 28 August 2009

    D. Papadimitriou, M. Tachtsi, G. Pitoulias, S. Atmatzidis, P. Fycatas, D. Christopoulos
    European Journal of Vascular & Endovascular Surgery December 2009 (Vol. 38, Issue 6, Page 780)

EJVES Extra
Volume 18, Issue 5 , Pages e53-e56, November 2009

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