From the Veins to the Heart: A Rare Cause of Varicose Veins
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Pulsed Doppler ultrasonographic examination of veins in proximity to the heart shows, in normal condition, a multiphasic wave with two anterograde components, one large systolic wave (S) and one smaller diastolic wave (D), as well as two retrograde waves (a and v). The S wave represents the maximum systolic velocity and is caused by the negative pressure from atrioventricular septal movement toward the cardiac apex. The v wave is produced by positive intra-atrial pressure owing to atrial filling. D wave is consequence of negative intra-atrial pressure resulting from opening of the tricuspid valve. The a wave is produced by the positive intra-atrial pressure, secondary to atrial contraction. This typical waveform is less evident in lower limb veins because the high compliance and high capacitance characteristics of lower extremity venous system dampen the pulsatility and the flow in these venous districts is typically described as spontaneous with a respiratory phasicity [1]. In presence of severe tricuspidal regurgitation a pulsatile flow with a retrograde component has been described in the middle suprahepatic vein, but this characteristic flow along the lower limb veins has been rarely described.

Case Report
Here we described a 75-year-old woman presented to the Angiology Unit for the presence of bilateral pulsatile swelling and pain in her groin and along both lower limbs. Her medical history included arterial hypertension and bilateral varices along both great saphenous veins. Patient was taking an ACE inhibitor....