Venous aneurysms

An aneurysm is defined as the enlargement or bulging of a particular part of a vessel, and most often such a vessel is an artery: aorta, coronary and cerebral arteries, and so on. Less frequently, but still occurs and aneurysm of veins. Pathology is mostly congenital, but can be a consequence of trauma, infectious or atherosclerotic processes. The most common complication of such a disease is deep vein thrombosis and thromboembolism. Treatment is surgical - by indication.

Epidemiology

Venous aneurysm is a relatively poorly studied disorder described by vascular surgeons. The prevalence of this disease is low, only isolated clinical cases are known, affecting mainly the deep venous vessels of the lower extremities. Most often the pathology is complicated by thromboembolisms.

Single cases of aneurysms affecting superficial saphenous veins have been described. The exact etiologic and pathogenetic mechanisms of the development of such a disorder have not been elucidated to date.

Currently, there are only two hundred cases of reported aneurysms of the saphenous vein in the world. The disease affects both women and men, more often elderly (over 65 years of age).

The first description of a venous aneurysm dates back to 1968. The majority of such pathologies are asymptomatic and become an incidental finding during routine examination of patients with venous thrombosis or arterial thromboembolism. There are descriptions of compression of the peroneal nerve by venous aneurysms, which manifested motor and sensory disorders. The size of pathologic vein dilation varies and sometimes reaches 80 mm.

Causes of the venous aneurysms

A venous aneurysm is considered a congenital vascular pathology and represents an area of bulging of the vessel wall with its gradual thinning. The danger of such an area increases over time, as the risk of rupture increases. If the vein damaged by the aneurysm is located in the brain, then it is possible to develop a hemorrhagic stroke - cerebral hemorrhage. The problem can also manifest itself in the form of constant headaches and seizures.

A venous aneurysm develops as a result of an intrauterine local malfunction that negatively affects the formation of the venous network. The causes are most often unfavorable effects on the fetus during pregnancy due to:

• by exposure to radiation;
• intrauterine infection;
• pathologies accompanying pregnancy (chronic renal failure, asthmatic bronchitis, diabetes mellitus, etc.);
• intoxication, including drug, nicotine, alcohol, medication.

The hereditary factor also plays a role.

Risk factors

The following factors significantly increase the likelihood of vein aneurysm formation:

• Heredity:
  • Any immediate family member has had a similar vascular pathology;
  • previous pregnancies have produced children with venous aneurysms.
• Adverse effects on the fetus (exposure during the first trimester of pregnancy is especially important):
  • Alcohol, nicotine, drug intoxication;
  • infectious pathologies, including influenza, COVID-19, acute respiratory infections;
  • contact with rubella patients;
  • undesirable drug exposure (including antibiotic therapy).
• Other factors:
  • Radiation exposure (both during and before pregnancy);
  • occupational harmful effects, chemical intoxication;
  • chronic pathologies of the mother (hormonal and metabolic disorders, systemic connective tissue diseases, hypertension, diabetes mellitus, chronic infectious and inflammatory processes).

As for infectious pathologies, the risk factor is often asymptomatic carriage by the woman's body of a particular pathogen - for example, cytomegalovirus infection, coxsackie virus, as well as chlamydia, ureaplasma, herpesvirus. In the process of carrying the baby, an infectious agent has a negative impact on the development of the fetus and can cause abnormal formation of some organs and the vascular network, including vein aneurysms.

Pathogenesis

A venous aneurysm is a limited pathology of the venous network, namely the vessels that transport blood toward the heart. The most common is an aneurysm of the saphenous vein, which transports blood from the knee joint through the thigh area. Thoracic and abdominal veins, as well as the venous network of the head and neck, are much less frequently affected.

A venous aneurysm is not diagnosed as often as arterial aneurysms, and in the vast majority of cases it is hidden, or "hides" behind other painful conditions.

Aneurysm of the great saphenous vein in the neck is rare and occurs as a congenital pathology. A small bulge is found in the area of the vessel, without any pronounced symptoms. At the same time, aneurysm of the jugular vein is considered more common: this pathology is relatively benign and practically does not pose any significant threat to human life. If the doctor prescribes surgical intervention on the jugular vein, it is due only to the cosmetic factor. [1]

An abdominal vein aneurysm can occur in almost any part of a venous vessel in the abdomen, with the more common being a portal vein aneurysm, which transports blood to the liver, passing the stomach, intestines, spleen, and pancreas along its course. Aneurysm of the portal vein of the liver is the most dangerous among all types of venous bulges, as it can be complicated by gastrointestinal bleeding. Other names for the pathology are splenic vein aneurysm, or portal vein aneurysm. [2], [3]

An aneurysm of the inferior vena cava is a pathology of a large vessel that opens into the right atrium and collects venous blood from the lower half of the torso. The inferior vena cava is formed by the junction of the left and right iliac veins. [4], [5]

Aneurysm of the superior vena cava affects a short vessel flowing into the right atrium and collecting blood from the upper half of the torso, including the head, neck, arms, as well as the lungs and bronchi. The superior vena cava is formed by the connection of the left and right brachial vessel, localized in the area of the upper mediastinum. [6]

Aneurysm of the internal jugular vein is a lesion of the largest vessel transporting blood from the cranial cavity. This vein continues from the sigmoid sinus of the dura mater, originates from the cranial jugular foramen, and descends to the sternoclavicular junction, sheltered by the sternoclavicular-papillary muscle. Beyond the sternoclavicular junction, the jugular vein joins the subclavian vein to form the brachial venous vessel. [7], [8]

Saphenous vein aneurysm (small or large) is a pathology of the leg venous system. It is most often found in the area of the great saphenous vein, which originates from the internal marginal vein of the foot, rises to the shin, wraps around the inner femoral condyle and runs to the oval opening in the groin, where it flows into the femoral vein. Equally often develops and aneurysm of the femoral vein, which is especially dangerous because of the high incidence of such a complication as pulmonary embolism. The risks increase if the pathologically dilated fragment is localized proximal to the subarticular vein. [9], [10]

A coronary vein aneurysm can manifest as a lesion of the great vein of the heart, middle vein of the heart, anterior veins and small veins. This pathology is fortunately extremely rare. [11], [12]

Aneurysm of the vein of Galen in fetuses and newborns is an extremely congenital pathology in which blood enters the veins of the brain under excessive pressure, bypassing the capillary network. Such a violation often becomes the cause of cerebral hemorrhage, convulsive seizures and other serious neurological problems. The prognosis of the pathology is unfavorable: more than 90% of babies with this diagnosis either die or become disabled. [13]

Another rare pathology is umbilical vein aneurysm, which occurs in about 1 case per 2000 placentas. This disorder is accompanied by a local expansion of the umbilical vein, which requires the determination of a special tactic of pregnancy management and method of delivery. Cesarean section is recommended. [14], [15]

Symptoms of the venous aneurysms

Patients voice complaints of discomfort in the area of the vein aneurysm. The most common localization of pathology is the hamstring area and the posterior surface of the lower leg - it reveals itself by swelling of the extremities after prolonged standing, or in the afternoon.

In some cases, there is a latent course, vein aneurysm is discovered by chance - for example, during the examination of a patient with varicose veins, or after the development of complications in the form of thrombosis and thromboembolism.

External examination sometimes reveals a characteristic venous bulge, but this is not always possible. Large venous aneurysms can reach sizes of up to 80 mm, which is palpatorily manifested by the detection of a soft tumor-like element.

In the vast majority of patients, the problem is asymptomatic.

Complications and consequences

The earliest possible diagnostic measures and timely surgical treatment are the only way to prevent the development of venous aneurysm thrombosis and pulmonary embolism, as well as neuropathology and compression syndrome. It should not be thought that the lack of description of such a complication as vein aneurysm rupture completely excludes its development. Therefore, if there are indications for surgical treatment, it is necessary to perform it as early as possible.

In about two out of three cases, blood clots can be detected inside the vein aneurysm (particularly during ultrasound). Transportation of the thrombus with blood to the pulmonary vein system causes the development of pulmonary embolism, a life-threatening condition. In some cases, thrombus detachment leads to the development of deep vein thrombosis and chronic venous insufficiency, and when nerve fibers are compressed, motor and sensory disorders such as neuropathies occur.

Other possible complications, depending on the localization of the vein aneurysm, include:

• Cerebrovascular disorders, including migraines, transient ischemic attacks, and strokes;
• brain abscesses, endocarditis;
• cerebral, pulmonary bleeds, hemothorax.

Diagnostics of the venous aneurysms

Instrumental diagnosis is used to diagnose venous aneurysms:

• ultrasound vascular angioscan;
• CT scan with contrast;
• contrast phlebography;
• MRI.

During physical examination, attention should be paid to the symmetry of the limbs, the presence of trophic disorders, the preservation of pulsation of the main arteries. The symptoms of Moses (pain on anteroposterior compression of the lower leg and absence of pain on lateral compression), Homans (pain in the calf muscles in the position of the patient on the back, with bent knee joints and dorsal flexion of the feet in the ankle joints) should be checked.

Ascending and retrograde phlebography are performed to assess the length of the vein aneurysm.

Tests are of secondary importance, since instrumental methods are considered the most informative in vein aneurysms.

However, the attending physician may prescribe:

• total blood count with hemoglobin, leukocyte count, COE;
• general urinalysis (density index, presence of sediment);
• Coagulogram (quality of blood clotting);
• Biochemical blood analysis (assessment of the functional capacity of the kidneys, liver, as well as blood glucose and total protein);
• HIV, syphilis, viral hepatitis;
• determination of D-dimer, activated partial thromboplastin time, soluble fibrin-monomer complexes.

The main focus is on assessing the quality of blood coagulation.

Differential diagnosis

A venous aneurysm is differentiated from chronic venous pathologies that include any functional or morphologic abnormality of the venous network, including varicose veins, post-thrombotic disease, and phlebodysplasia (angiodysplasia).

• Varicose veins are characterized by primary varicose changes in the superficial venous vessels.
• Varicose veins are accompanied by a loss of elasticity of the vascular walls, which entails their pathological stretching, the formation of nodular dilatations and bulges, valve dysfunction and inhibition of venous circulation.
• Postthrombotic syndrome is a pathologic condition associated with organic damage to deep veins after thrombosis.
• Angiodysplasia - is a congenital defect of the blood vessels.
• Chronic venous insufficiency is associated with a disorder of blood outflow through the veins, which is manifested by swelling, the appearance of skin problems and, in particular, trophic ulcers.
• Phlebopathies are accompanied by the appearance of a picture of chronic venous insufficiency, or the appearance of subjective signs (pain syndrome, a feeling of heaviness and fatigue) in patients who do not have organic pathologies of the venous network.

Treatment of the venous aneurysms

Therapeutic tactics for vein aneurysms can vary. For example, when it comes to small vascular aneurysms, in most cases they are limited to dynamic observation and conservative symptomatic therapy.

If there is a high probability of thrombosis and/or thromboembolism, the patient is referred for surgery. Intervention is usually planned and performed in a hospital. The indications for surgery are aneurysms with marked pathologic symptoms or asymptomatic venous aneurysms with lumen dilation up to 20 mm or more.

Surgical techniques such as tangential excision, resection with autoimplantation or anastomosis, and resection with aneurysmorrhaphy may be used. [16]

Drug treatment

If a vein aneurysm of any localization is detected, you should not self-treat. It is necessary to consult a doctor beforehand, who, if necessary, will prescribe medications, both external and internal use.

• Actovegin is a drug that activates metabolic processes in tissues, improves trophicity, stimulates repair processes. It is taken 1-2 tablets three times a day for 4-6 weeks. There may be hypersensitivity reactions, dyspepsia. No cases of overdose have been reported.
• Ceraxone is an oral solution based on citicoline. Restores damaged cell membranes, prevents the death of cellular structures. It is effective in the treatment of motor and sensory neurological disorders of vascular origin. It is taken 1-4 tablets per day, at the discretion of the doctor. The drug is usually well perceived by the body, side effects are noted only in isolated cases (pain in the head, changes in blood pressure, nausea).
• Cereton is a nootropic drug, cholinomimetic of central action, enhancing the processes of metabolism and blood circulation in the central nervous system. It is used in cerebral vein aneurysm. Take 2 capsules in the morning and 1 capsule in the afternoon, long term, after meals. The drug is contraindicated in stroke associated with hemorrhage, as well as women during pregnancy.
• Mexidol is an antioxidant based on ethyl-methyl-hydroxypyridine succinate, characterized by pronounced anxiolytic, anticonvulsant and nootropic effects. Improves the adaptation of the body to ischemia, hypoxia, and also reduces blood cholesterol. Dosage is determined individually, from 250 to 800 mg per day (in 2-3 doses). During treatment, fluctuations in blood pressure, drowsiness, headache, nausea may occur.
• Detralex - a drug with venotonizing and angioprotective ability, reduces vein distensibility and venostasis, improves microcirculation, improves lymphatic drainage. Standardly take 1 tablet in the morning and evening, with food. The duration of intake is negotiated with a doctor. Possible side effects: diarrhea, digestive disorders, abdominal pain. The use of the drug in children has not been studied.

Surgical treatment

According to information from practitioners, tangential resection with lateral venography is the most common approach for venous aneurysms: this is the optimal method in most cases. However, recurrences of venous aneurysms after such surgery have been described.

Some patients undergo resection of the pathologically enlarged area with the formation of an end anastomosis, or resection of the vein aneurysm with autovenous implantation of the saphenous vein with a segment of the great saphenous vein. A direct indication for intervention is the presence of a symptomatically active aneurysm, or a hidden aneurysm with venous lumen dimensions of more than 20 mm.

Deep thrombosis becomes an indication for mandatory hospitalization. Heparin is prescribed, followed by anticoagulant treatment. If intense circulatory disorders are noted, thrombectomy is resorted to. Patients with pulmonary embolism perform resuscitation procedures, perform thrombolytic measures. Massive thromboembolism is an indication for thromboembolectomy or catheter embolic fragmentation.

Prevention

Primary prevention is aimed primarily at preventing intrauterine pathologies, to ensure the normal development of the fetus. Attention should be paid to the following recommendations:

• Women planning pregnancy and those who are already pregnant should take vitamin _B9 (folic acid) to prevent the formation of such pathologies as neural tube anomalies, brain hernias, hydrocephalus, vein and arterial aneurysms. At the same time, men planning to become fathers are recommended to take ascorbic acid, zinc and tocopherol in addition for the same purposes.
• Expectant parents should refrain from alcohol, drugs, and smoking (including passive smoking). The correlation between alcohol-nicotine and drug intoxication and the frequency of vascular disorders in newborns has been proved.
• Even before planning to conceive, a woman should be immunized against the most dangerous infections - in particular, rubella, coronavirus infection, influenza.

For couples who are planning to become parents soon, it is important to visit a doctor - obstetrician-gynecologist, geneticist - in advance. A full-fledged preliminary examination will be the key to successful pregnancy and childbirth, and the baby will be born healthy in the end.

Forecast

In many cases, vein aneurysms are detected accidentally, while the patient does not even suspect its presence. In some situations, when it comes to the initial stage of the disease, the problem is put under the control of a cardiologist: a person is recommended to adjust diet and physical activity, prescribe certain drugs. This allows to improve the prognosis, prevent the development of complications and improve the quality of life of the patient without the use of radical surgery.

The main danger of venous aneurysms is the formation of unfavorable consequences in the form of thrombophlebitis (inflammation of the internal venous walls) and thrombosis, in which clots form in the veins. Their detachment leads to the development of pulmonary thromboembolism with blockage of blood flow in the pulmonary artery.