Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 290-293

A rare case of perforator vein aneurysm


Department of Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India

Date of Submission06-Nov-2019
Date of Acceptance10-Dec-2019
Date of Web Publication12-Sep-2020

Correspondence Address:
B Nishan
Department of Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_92_19

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  Abstract 


We report the case of a 41-year-old male with a left perforator vein aneurysm (PVA) in the popliteal fossa, with no local symptoms. Early diagnosis is necessary in order to prevent the thromboembolic events or other major complications. Duplex scanning and computed tomography (CT) scanning are considered to be important noninvasive diagnostic methods for the diagnosis of PVA. CT confirmed a fusiform PVA in the left popliteal fossa. Open tangential perforator vein aneurysmectomy was done through a posterior approach in the left popliteal fossa.

Keywords: Aneurysmectomy, perforator vein aneurysm, thromboembolic events


How to cite this article:
Nishan B, Hudgi V, Sivakrishna K, Pavan B K, Anand V. A rare case of perforator vein aneurysm. Indian J Vasc Endovasc Surg 2020;7:290-3

How to cite this URL:
Nishan B, Hudgi V, Sivakrishna K, Pavan B K, Anand V. A rare case of perforator vein aneurysm. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Sep 27];7:290-3. Available from: http://www.indjvascsurg.org/text.asp?2020/7/3/290/294925




  Introduction Top


Venous aneurysms (VAs) can be defined as persistent isolated dilation of twice the normal vein diameter.[1] VAs may be discovered incidentally on imaging studies.[2] Because of their variety in presentation, VAs can frequently be misdiagnosed as soft-tissue masses or even hernias.[3] Patients with perforator vein aneurysm (PVA) are generally asymptomatic (80%–90%), although symptomatic patients present with pain, swelling, itching, and heaviness. Asymptomatic patients are incidentally detected, generally treated with observation and anticoagulation, and others require surgery.[3]

The aim of this study is to present the incidental findings of PVA in a young male and to discuss the clinical outcome.


  Case Report Top


A 41 year old male presented with history of fall on the left knee with no symptoms or signs on clinical evaluation. However an incidental finding of fusiform PVA connecting the popliteal vein and the superficial vein at the level of the left popliteal fossa [Figure 1] was noted on duplex ultrasonography [Figure 2] and computed tomography (CT) angiography [Figure 3] and [Figure 4]. The patient underwent surgery under general anaesthesia. The patient was placed in prone position [Figure 1] - surface marking of PVA] and under aseptic precautions a curvilinear incision was made over the left popliteal fossa and deep fascia opened, following which PVA [Figure 5] connecting popliteal vein to superficial vein was isolated and separated from surrounding artery and nerve. Perforator vein aneurysmectomy was performed by ligation on either sides of the aneurysm and the excised specimen [Figure 6] was sent for histopathological examination [Figure 7] and [Figure 8]. The incision was closed in layers after adequate haemostasis was achieved. A written informed consent was obtained from the patient for publication of this case report and accompanying images.
Figure 1: Surface marking of perforator vein aneurysm at the left popliteal fossa

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Figure 2: Duplex scan showing perforator vein aneurysm (around 2.5 cm × 1.5 cm) between the popliteal vein and superficial vein

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Figure 3: Computed tomography angiogram (axial section) showing perforator vein aneurysm

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Figure 4: Three-dimensional reconstructed image of perforator vein aneurysm

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Figure 5: Intraoperative image of perforator vein aneurysm

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Figure 6: Specimen of perforator vein aneurysm

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Figure 7: Histopathological examination of perforator vein aneurysm – thinned off vein wall

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Figure 8: Histopathological examination of perforator vein aneurysm – reduction in smooth muscle cell component

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  Discussion Top


A VA is described as a solitary area of venous dilation that communicates with a main venous structure by a single channel, and it must have no association with an arteriovenous communication or a pseudoaneurysm.[4] Most importantly, it should not be contained within a segment of varicose vein. VAs were first described in 1928 by Harris.[4] Because of the variation in the presentation and location of VAs, they may be frequently misdiagnosed. Perforator veins allow blood to flow from the superficial to the deep veins.[5] Normal perforator veins have a diameter of <3 mm. As their diameter increases >3.5 mm, there is a >90% chance of being incompetent.[6] Because the perforator veins are located below the deep fascia, patients and physicians usually cannot appreciate PVA on palpation. Most patients with PVA do not have local symptoms, and the diagnosis will be more likely incidental.[7] Those who developed symptoms may be secondary to the PVA's applying pressure to local tissues.[7] Dilation of perforator veins may be related to the re-entry flow of a refluxing superficial vein to the deep venous system. The shape of the VAs may be caused by the local flow patterns and wall behavior. PVAs are fusiform, whereas in the popliteal vein, most aneurysms are saccular.[7],[8]

The pathogenesis of the VAs is unknown; several mechanisms have been proposed ranging from refflux and venous hypertension, infflammation, infection, congenital vein wall weakness, mechanical trauma, and hemodynamic changes to localized degenerative change.[9] The most accepted theory is the focal normal connective tissue component loss of the vein wall. This could be due to a congenital underdevelopment or to a degenerative connective tissue loss with age.[10] This would end into wall weakness, increasing the risk of dilatation.

In one of the first series of VAs, Schatz and Fine described multiple histopathologic findings.[11] Two commonly reported pathologic findings are a reduction of smooth muscle cells and an increase in fibrous connective tissue. A second finding describes either an increase or decrease in the fibrous connective tissue and elastic tissue.[12],[13] The endophlebohypertrophy and endophlebosclerosis are the main histologic features of these processes.[10] Moreover, a recent report examining VA tissue suggested that the focal structural changes of the venous wall may be related to an increased expression of select matrix metalloproteinases.[14]

The most serious complication associated with lower extremity VAs is thromboembolism. Dahl was the first to describe pulmonary embolism (PE) originating from an extremity VA.[15] Most of the PVAs are in close approximation to superficial veins above the deep fascia; few aneurysms in close approximation to the deep veins below the deep fascia are reported.[15] Data from literature describe the incidence of VAs with concomitant PE at 24%–32% and chronic venous disease associated with VAs at 76%.[8] Occasionally, superficial VA could be associated with thromboembolism, but the real estimation is unknown.[3],[16] VA rupture is a very rare complication.[17] The diameter or the aneurysm shape cannot be considered a solid parameter to predict these complications. Duplex imaging is the method of choice for diagnosis, and it easily allows to evaluate VAs of the extremities and to define the size and the morphology of the aneurysm. However, we believe that before surgical repair, a CT scan is mandatory to investigate the venous system assessment and to define the venous anatomy.[18] Aneurysmectomy and lateral venorrhaphy are valid options to treat VA. After surgical repair, Bergqvist et al., recommend therapeutic anticoagulation for at least 3 months.[19]

Surgical repair has to be preferred in most of the patients with symptomatic (pain, severe edema, and thromboembolism) superficial or deep VA, and it can even be recommended in asymptomatic patients with saccular deep-vein aneurysms (any size) and large fusiform aneurysms to prevent further thromboembolic events.[20]

Numerous types of surgical repair have been described. The method of treatment is usually dictated by the anatomical location. Aneurysms of the superficial venous system should be excised. Aneurysms of the deep system present a more complex challenge. Surgical procedures described include tangential excision and ligation, with lateral venorrhaphy or autologous vein patch, and complete resection and interposition grafting.[7],[21]


  Conclusion Top


PVAs are unusual vascular malformations that occur equally between the sexes and are seen at any age. Diagnosis is made by duplex ultrasound and CT angiography. This entity is relatively benign, and most of the patients are incidentally detected and asymptomatic. Asymptomatic patients are frequently observed based on the size of aneurysm. Large asymptomatic aneurysms and symptomatic aneurysms (local and systemic) need to be excised. The role of anticoagulation is controversial.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
McDevitt DT, Lohr JM, Martin KD, Welling RE, Sampson MG. Bilateral popliteal vein aneurysms. Ann Vasc Surg 1993;7:282-6.  Back to cited text no. 1
    
2.
Herrera LJ, Davis JW, Livesay JJ. Popliteal vein aneurysm presenting as a popliteal mass. Tex Heart Inst J 2006;33:246-8.  Back to cited text no. 2
    
3.
Gillespie DL, Villavicencio JL, Gallagher C, Chang A, Hamelink JK, Fiala LA, et al. Presentation and management of venous aneurysms. J Vasc Surg 1997;26:845-52.  Back to cited text no. 3
    
4.
Harris R. Congenital venous cyst of mediastinum. Ann Surg 1928;88:953-6.  Back to cited text no. 4
    
5.
Chatterjee SS. Venous ulcers of the lower limb: Where do we stand? Indian J Plast Surg 2012;45:266-74.  Back to cited text no. 5
    
6.
Sandri JL, Barros FS, Pontes S, Jacques C, Salles-Cunha SX. Diameter-reflux relationship in perforating veins of patients with varicose veins. J Vasc Surg 1999;30:867-74.  Back to cited text no. 6
    
7.
Aldridge SC, Comerota AJ, Katz ML, Wolk JH, Goldman BI, White JV. Popliteal venous aneurysm: Report of two cases and review of the world literature. J Vasc Surg 1993;18:708-15.  Back to cited text no. 7
    
8.
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;32:902-12.  Back to cited text no. 8
    
9.
Sigg P, Koella CH, Stöbe C, Jeanneret CH. Popliteal venous aneurysm, a cause of pulmonary embolism. Vasa 2003;32:221-4.  Back to cited text no. 9
    
10.
Lev M, Saphir O. Endophlebohypertrophy and phlebosclerosis. II. The external and common iliac veins. Am J Pathol 1952;28:401-11.  Back to cited text no. 10
    
11.
Schatz IJ, Fine G. Venous aneurysms. N Engl J Med 1962;266:1310-2.   Back to cited text no. 11
    
12.
Perler BA. Venous aneurysm. An unusual upper-extremity mass. Arch Surg 1990;125:124.  Back to cited text no. 12
    
13.
Ross GJ, Violi L, Barber LW, Vujic I. Popliteal venous aneurysm. Radiology 1988;168:721-2.  Back to cited text no. 13
    
14.
Irwin C, Synn A, Kraiss L, Zhang Q, Griffen MM, Hunter GC. Metalloproteinase expression in venous aneurysms. J Vasc Surg 2008;48:1278-85.  Back to cited text no. 14
    
15.
Dahl JR, Freed TA, Burke MF. Popliteal vein aneurysm with recurrent pulmonary thromboemboli. JAMA 1976;236:2531-2.  Back to cited text no. 15
    
16.
Andrea S, Accrocca F, Gabrielli R, Baldassarre E, Siani LM, Pier A, et al. An isolated aneurysm of the thigh anterolateral branch of the saphenous vein in a young patient. Acta Phlebologica 2010;11:27-9.  Back to cited text no. 16
    
17.
Friedman SG, Krishnasastry KV, Doscher W, Deckoff SL. Primary venous aneurysms. Surgery 1990;108:92-5.  Back to cited text no. 17
    
18.
Coffman SW, Leon SM, Gupta SK. Popliteal venous aneurysms: Report of an unusual presentation and literature review. Ann Vasc Surg 2000;14:286-90.  Back to cited text no. 18
    
19.
Bergqvist D, Björck M, Ljungman C. Popliteal venous aneurysm – A systematic review. World J Surg 2006;30:273-9.  Back to cited text no. 19
    
20.
Gabrielli R, Rosati MS, Vitale S, Millarelli M, Siani A, Chiappa R, et al. Pulmonary 'emboli due to venous aneurysm of extremities. Vasa 2011;40:327-32.  Back to cited text no. 20
    
21.
Calligaro KD, Ahmad S, Dandora R, Dougherty MJ, Savarese RP, Doerr KJ, et al. Venous aneurysms: Surgical indications and review of the literature. Surgery 1995;117:1-6.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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