Cas cliniques Un cas d’anevrisme vrai de la veine antecubitale gauche Garip Altintas, Anil Ozen, Adem Diken, M. Ali Ozatik, Ankara, Turquie
vrisme veineux est de fini comme une dilatation localise e d’une veine. Il peut inte resser la Un ane rieurs et moins souvent les plupart des veines importantes, affectant surtout les membres infe rieurs. Ces le sions se voient e galement entre les sexes, a n’importe quel a ^ge. Un membres supe tait adresse au de partement de chirurgie cardiovasculaire de notre polyhomme de 62 ans e clinique. Il avait une histoire de 27 ans d’un gonflement de la fosse cubitale gauche. Il se sies. L’exaplaignait de son augmentation de taille, d’une douleur augmentant, et de paresthe men de la fosse cubitale gauche montrait une masse indolore, molle, non pulsatile de 3-4 cm vrisme de 4 3 3 cm de la sans thrill palpable. Un examen duplex de la masse montrait un ane cubitale gauche. Ses ante ce dents me dicaux incluaient des ne phrolithotomies veine ante pe te es. L’ane vrisme fut disse que et excise . Le patient sortit au deuxie me jour postope ratoire. re ^tre faite en pre sence d’une ge ^ne, d’un gonflement, et de paresthe sies locales La chirurgie doit e ^mes. pour soulager les sympto
A venous aneurysm is defined as a dilatation of a localized segment of vein occurring in most major veins. They are unusual malformations affecting the lower extremities the most and the upper extremities the least, occurring equally between sexes at any age.1 Here, we describe a large left antecubital aneurysm causing local discomfort, paresthesia, and pain.
CASE REPORTS A 62-year-old man was referred to our polyclinic’s cardiovascular surgery department. He presented with a 27-year history of a swelling in the left antecubital fossa (Fig. 1). He complained of its increase in size, worsening pain, and paresthesia. Examination of the left antecubital DOI of original article: 10.1016/j.avsg.2009.10.020. Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Egitim Arastirma Hastanesi, Sihhiye, Ankara, Turquie. Correspondence : Anil Ozen, Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Egitim Arastirma Hastanesi, Bulten Sok, 39/8, Ankara, Turkey, E-mail: [email protected]
Ann Vasc Surg 2010; 24: 694.e15-694.e17 DOI: 10.1016/j.acvfr.2010.12.049 Ó Annals of Vascular Surgery Inc. e par ELSEVIER MASSON SAS Edit
Fig. 1. Clinical view of the forearm mass.
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Fig. 2. (A, B) Intraoperative photograph of the antecubital vein aneurysm. fossa revealed a painless, soft, nonpulsatile mass (3-4 cm in size), with no palpable thrill. His past medical history included right nephrolithotomy in 1975, left nephrolithotomy in 1976, repeated left nephrolithotomy in 1986, and extrinsic shock wave lithotripsy in 1997. There was no history of hypertension, connective tissue disorder, or Behc¸et’s disease. On further examination, there was no audible bruit. All upper limb pulses were palpable. The blood pressure was equal in both arms. Complete blood count and other blood tests were within normal limits. A Duplex ultrasound scan of the mass displayed an aneurysm of 4 3 3 cm in the left antecubital vein. Surgery was performed under local anesthetic. The aneurysm was dissected and excised. (Figs. 2A and B). The patient was discharged on the second postoperative day. He made an uneventful recovery, with no complications found on his 1 week postoperative review. Histology of the aneurysmal sac revealed subendothelial fibromuscular hyperplasia with no signs of vasculitis which was suggestive of a true aneurysm.
DISCUSSION Aneurysms can be congenital or acquired, though the exact etiology remains unclear. It has been suggested that aneurysmal dilatation is a response to increased hemodynamic pressures at the site of mural weakness. The published data have reported changes such as endophlebohypertrophy (intimal hypertrophy) and endophlebosclerosis (loss of smooth muscle and elastic tissue with replacement by connective tissue) with age.2 Sites of aneurysms are grouped as (i) central thoracic (e.g., superior vena cava); (ii) visceral
(e.g., portal, superior mesenteric, splenic, renal); (iii) cervical (e.g., jugular, facial, subclavian); and (iv) peripheral (e.g., cephalic, iliac, femoral, saphenous, popliteal).3 Venous aneurysms are mostly responsible for local discomfort. Most complications are minor, but some have also been associated with deep venous thrombosis, pulmonary thromboembolism, and rupture.4,5 Venous aneurysms are difficult to diagnose and may be a source of significant morbidity and mortality. Thromboembolism is much more common in aneurysms of the deep venous system. The majority of cases are managed surgically because of potential morbidity risks. Most patients present with a painful mass of limb, whereas some present with swelling that decompresses with elevation and enlarges with dependency and the Valsalva manoeuvre. In the upper limb, it is most likely to present as a soft-tissue swelling that may or may not result in compressive symptoms.1 Duplex scanning remains the initial investigation of choice for most of the upper limb venous aneurysms. Imaging methods such as phlebography, computed tomography, and magnetic resonance imaging should be reserved for diagnosis of thoracic and abdominal venous aneurysms.6 The treatment of venous aneurysms depends on the site and associated symptoms. Symptom-free, superficial, small fusiform aneurysms without thrombus formation carry a low risk of complications, and therefore may remain under close surveillance with duplex scanning. Symptomatic,
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enlarging, popliteal, and saccular aneurysms of any size or large fusiform aneurysms should undergo surgery. In this case, we performed surgery because of the presence of local discomfort, swelling, and paresthesia. All symptoms resolved after surgery. Surgical options for repairing venous aneurysms include the following: (i) excision, (ii) aneurysmorrhaphy, (iii) resection with end-to-end anastomosis, and (iv) resection with interposition grafting; however, it is difficult to assess efficacy of one procedure over another. Because of the high incidence of postoperative venous thrombosis, particularly in popliteal venous aneurysm resections, anticoagulant therapy should be considered to prevent postoperative venous thrombosis. Our patient did not require anticoagulation because of the low risk of venous thrombosis. Most of the upper limb venous aneurysms are asymptomatic with minor complications.7 We believe that large, disfiguring, or symptomatic upper limb venous aneurysms should be surgically removed. Our patient complained that his left antecubital fossa was the first choice for repeated intravenous cannulations and injections. We do not inform our patients about this rare complication. Although in a
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rare complication of gaining peripheral access, should we warn patients undergoing intravenous cannulation or repetitive injections of the possibility of venous aneurysm and get a written consent?
REFERENCES 1. Gillespie DL, Villavicencio LJ, Gallagher C, et coll. Presentation and management of venous aneurysms. J Vasc Surg 1997;26:845-852. 2. Debnath D, Wallace S, Mylona E, Myint F. Aneurysm of antecubital vein: an unusual complication of peripheral intravenous cannulation. BMC Surg 2007;7:9. 3. Castle JM, Arous EJ. Femoral vein aneurysm: a case report and review of the literature. Cardiovasc Surg 1995;3:317-319. 4. Calligaro KD, Ahmad S, Dandora R, et coll. Venous aneurysms: surgical indications and review of the literature. Surgery 1995;117:1-6. 5. Joseph SP, Sathianathan J. Thrombophlebitis of aneurysmal antecubital vein causing pulmonary embolism: a case report. EJVES Extra 2007;13:47-49. 6. Kassabian E, Coppin T, Combes M. Radial nerve compression by a large cephalic vein aneurysm: case report. J Vasc Surg 2003;38:617-619. 7. Marquardt G, Barduzal Angles SM, Leheta FD, Seifert V. Median nerve compression caused by a venous aneurysm: case report. J Neurosurg 2001;94:624-626.