Pulsatile bleeding varicose veins due to tricuspid regurgitation successfully treated with foam sclerotherapy

A 65-year-old female with bleeding superficial lower limb varicosities was referred to our vascular unit for definitive treatment. She had a history of bleeding from the same site, for which suture ligation had been done at another hospital. However, she continued to experience bleeding episodes and was wearing compression garments. Known co-morbidities were type-2 diabetes mellitus, hypertension, and severe tricuspid regurgitation (TR). She had previously undergone prosthetic mechanical valve replacement for degenerative severe mitral valve regurgitation and was on chronic anticoagulation.

Clinical examination revealed extensive dilated superficial varicosities in both lower limbs. The jugular venous pulsations (JVP) were prominent, and the upper level was intracranial. On closer inspection, varicosities appeared pulsatile, which was more evident upon standing. There were no signs of pedal oedema, eczema, discoloration, or ulcerations in the lower limbs. Duplex ultrasound examination demonstrated grossly dilated, pulsatile great saphenous vein (GSV). Color duplex imaging showed gross and continuous reflux at the saphenofemoral junction with an arterial flow pattern along the GSV in pulse mode [Figure 1]. Deep veins were patent with no signs of obstruction observed at any level. An echocardiogram showed a normal prosthetic valve function, mild mitral and aortic regurgitation, severe TR, dilation of the right and left atrium, left ventricular global hypokinesia, and mild systolic dysfunction. Echo also showed tricuspid annular plane systolic excursion (TAPSE) of 9 mm suggestive of right ventricular dysfunction. Pulmonary artery hypertension (PAH) by TR was measured as 34 mm Hg + right atrial pressure. The diameter of the inferior vena cava (IVC) was 26 mm, and the study did not reveal any congenital cardiac anomalies. Prior to referral, the patient had been evaluated by a computed tomographic angiography, which revealed only dilated tortuous superficial veins in both lower limbs, with no evidence of arteriovenous malformations or communications.

Figure 1.

Duplex ultrasound showing gross reflux and arterial pattern of flow in the great saphenous vein

A diagnosis of varicosities secondary to severe TR was made. Options of endovenous laser ablation (EVLA) or foam sclerotherapy were discussed, and the patient chose the latter option. Under local anesthesia, ultrasound-guided foam sclerotherapy was administered to the bleeding varicosities using 3% polidocanol diluted to 1% with sterile water. The deep veins appeared normal after the procedure. The postoperative course was uneventful, and at 6-months follow-up, she had not experienced any further bleeding episodes [Figure 2].

Figure 2.

Extensive leg varicosities with a healed ulcer

Bleeding is a common complication in patients with lower limb varicosities. Most commonly, this results from primary venous valve pathology resulting in reflux within the axial veins. However, in the present case, severe TR might have caused the progression of varicosities due to a high retrograde venous pressure in the femoral veins, transmitted from IVC.[1] Secondary causes of varicose veins comprise only a minority of cases, accounting for about 5 to 20%, and among these, TR is an extremely rare cause.[2,3] This presentation is unique in that the pulsations can be felt and even visually observed, as was in the present case. This rare presentation of pulsatile varicosities has been reported only in a handful of cases in the literature.[4] Moreover, such patients present with bilateral significant varicosities, which may be indicative of a central cause, such as an undiagnosed TR.

Local complications like bleeding can be visually dramatic and life-threatening for the patient due to the pulsatile nature of the bleed and the severe amount of blood loss observed.[4] Considering that all such patient groups have a high cardiac risk, conservative management with compression garments can be considered for those presenting with uncomplicated varicosities.[4,5] However, the occurrence of complications like bleeding and leg ulcerations are indications for definitive intervention.

In the past, surgical treatments like saphenofemoral ligation with or without stripping of GSV under local anesthesia to obviate high anesthetic risk have been reported.[2,5] But a higher incidence of postoperative complications like hemorrhage, hematoma formation, and the need for additional procedures have been reported after such interventions.[4,5] Despite concerns about the failure of EVLA in TR-associated varicosities due to associated high central venous pressure, few authors have reported successful occlusion of GSV at 1-year follow-up.[3,4]

Sclerotherapy is an effective technique to chemically ablate a relatively short segment of the vein to manage the local symptoms/complications like bleeding and ulceration.[3] In the present case, we proceeded with sclerotherapy alone given the acute nature of her presentation and the patient's refusal of EVLA. This modality alone resulted in the excellent resolution of the local varicosities with no further bleeding episodes.

In conclusion, we report a rare cause of secondary lower limb varicosities, and it is imperative that physicians are aware of this differential diagnosis, as management is different from primary varicose veins. The presence of bilateral lower limb pulsatile varicosities could be an indication of underlying cardiac pathology. This case demonstrates a rare cause of bleeding varicosities secondary to TR, which was managed successfully with sclerotherapy alone.

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Conflicts of interest

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