Pulsating hemorrhagic varicose veins caused by tricuspid val
A 69-year-old male patient was admitted for pulsating bleeding from superficial varicose veins of the left dorsal foot. After compression hemostasis, ultrasonography revealed pulsatile regurgitation in the left great saphenous vein (GSV). He had a history of ligation of two incompetent perforating veins in the left thigh and high ligation and stripping of the right GSV. In a previous clinical chart, pulsatile palpation of the right GSV with significant postoperative hematoma was described in the surgical record; however, no further examination was performed at that time.

Dilated superficial varicose veins and pigmentation were observed from the left lower leg to the dorsal foot, equivalent to C4a, as assessed using the clinical, etiological, anatomical and pathological (CEAP) classification. Ultrasonography revealed regurgitation in the left deep veins, from the common femoral to the popliteal, and perforators in the left lower leg, in addition to the left GSV. The authors clinically suspected arteriovenous fistula and the patient was admitted for a detailed hemodynamic examination. Computed tomography revealed the presence of congestive liver and inferior vena cava dilatation; however, no arteriovenous fistula was observed. Subsequent echocardiography showed prominent enlargement of the right atrium and right ventricle and severe TVR. Thus, the pulsatile venous blood flow was considered to be derived from TVR. EVLA was performed on the left GSV of the thigh using a 1470 nm diode laser with a radial 2-ring fiber (ELVeS Radial 2ring™ fiber, CeramOptec GmbH, Germany) under general anesthesia with tumescent local anesthesia (430 mL saline?+?50 mL lidocaine 1%?+?20 mL sodium hydrotricarbonate 7%). Subsequently, three incompetent perforating veins in the left lower leg were identified under ultrasound guidance and then ligated and dissected. The puncture site of the introducer sheath and the incision in the lower leg bled easily; however, hemostasis could be obtained by manual compression. After the operation, the patient rested on the bed with the left lower limb compressed by an elastic bandage. Duplex sonography confirmed the success of EVLA of the left GSV and the patency of the deep vein system. Two days after EVLA, foam sclerotherapy using 1% polidocanol (dilution ratio for sclerosant to air: 1:3) was performed for the superficial varicose veins of the left foot, including the bleb, where the bleeding was encountered at the time of admission.

The patient used a compression stocking and was followed regularly as an outpatient. It was necessary to perform foamed sclerotherapy three times for other superficial varicose veins of the left lower limb; however, the examination using duplex ultrasonography had not detected recanalization of the occluded left GSV and bleeding from the varicose veins was not observed during the 1-year follow-up period.

Source: https://surgicalcasereports.springeropen.com/articles/10.1186/s40792-021-01289-2