A leg ulcer with pulsating varicose veins – from the legs to the heart

Abstract

We present the case of a 58-year-old man who presented to our wound care centre with a 7 -month history of a progressive unilateral leg ulcer. He reported intermittent, heavy bleeding at the ulcer. The duplex sonography showed a bilateral incompetence of the saphenofemoral junctions and the entire course of the great saphenous veins and, surprisingly, also a bilateral reversed arterial-like pulsating flow in the great and small saphenous veins as well as in the deep veins of the lower extremities. During cardiac examination by auscultation and echocardiography, we detected a previously undescribed severe tricuspid insufficiency with strongly reduced systolic ejection of both the left and the right ventricle and repercussions on the peripheral venous system as a cause for the pulsating veins. This case report highlights that, although infrequent, the presence of pulsating varicose veins points to the presence of cardiac abnormalities, especially severe tricuspid insufficiency, and should direct clinicians to initiate a thorough cardiological examination. Our case highlights that consequent compression therapy can be sufficient for wound healing in such cases and should be initially considered. These patients are at risk of severe bleeding, and therefore, interventions should be carefully planned.

Pulsating hemorrhagic varicose veins caused by tricuspid valve regurgitation: report of a case treated by laser ablation and foam sclerotherapy

“…In previous studies, some cases of pulsatile varicose veins secondary to TVR were treated by approaches, such as EVLA alone and saphenofemoral ligation with foam sclerotherapy; however, other cases were treated conservatively by compression therapy with elastic stockings, in consideration of the bleeding due to venous hypertension and cardiac risk during the operation [ 1 , 8 – 11 ]. Our case has a history of both stripping and EVLA of the GSV; however, EVLA seems to be associated with a lower risk of bleeding, considering the complication of hematoma after stripping of the GSV.…”

“…Most varicose veins are caused by primary valvular insufficiency. It is reported that only about 5–20% of varicose veins occur secondary to conditions, such as deep vein thrombosis, pelvic tumor or arteriovenous fistula [ 1 , 2 ]. In particular, secondary varicose veins caused by tricuspid valve regurgitation (TVR) are extremely rare [ 3 – 5 ].…”

An uncommon presentation of varicose vein: Special manifestations of heart disease

“…Currently, only 5-20% of varicose veins are secondary varicose (1,2). However, pulsating varicose veins caused by tricuspid regurgitation or cardiac insufficiency are relatively uncommon，such as patients summarized in Table 1 (3)(4)(5)(6)(7)(8)(9). Tricuspid regurgitation increases atrial pressure and slows the return of venous blood to the heart, increasing venous pressure, which in turn, leads to venous insufficiency and varicose veins.…”

“…Compression of the saphenous-femoral junction and the perception of pulsation is a common diagnostic solution (2)(3)(4)6,8). If it is misdiagnosed as primary varicose veins and does not treat heart problems, it will recur after a short period and cause intraoperative major bleeding and postoperative hematoma (4,8).…”

“…Secondary varicose veins of the lower extremities are mainly common in stenosis or obstruction of reflux veins, deep vein thrombosis in the following limbs, Cockett syndrome, and Budd-Chiari syndrome (1,2). Changes in venous pressure due to occlusion of the femoral vein, concealed venous valve, and penetration of venous insufficiency play important roles in the progression of chronic venous insufficiency (3). The pulsating varicose veins caused by venous reflux from the heart are rarely reported in the literature and are not recognized by most doctors.…”