Venous Aneurysms

Heron E. Rodriguez and William Pearce

Venous aneurysms are uncommon. The term aneurysm is used to describe saccular or fusiform dilatations of veins. A varix is defined as the association of dilatation with tortuosity, and phlebectasia is the term used to describe diffuse fusiform venous dilatations.

Aneurysmal dilatation of veins can be found in association with partial venous obstruction, high-flow states, or congenital venous malformations. When a venous dilatation, whether saccular or fusiform, is isolated and not associated with trauma, inflammation, congenital malformations, or high-flow states, it is referred to as a solitary venous aneurysm.

Although these lesions have been described in virtually every vein of the body, solitary venous aneurysms are uncommon. Veins affected with these aneurysms, in decreasing order of incidence, are the popliteal vein, the saphenous vein, and superficial extremity veins. Aneurysms have also been described in the jugular vein, portal vein, azygos vein, superior vena cava, mediastinal veins, inferior vena cava, axillary vein, facial vein, and parotid vein.

Popliteal Venous Aneurysms

Patients with popliteal aneurysms come to the hospital 44% of the time with symptoms suggestive of a pulmonary embolism (PE) followed by 36% having local symptoms in the popliteal space (Figure 1A). The presence of bilateral popliteal aneurysms is uncommon, and rupture has never been reported. Associated symptoms of venous insufficiency are often present.

FIGURE 1 A, Popliteal vein aneurysm causing local pressure symptoms. B, A venogram defines the extent of the aneurysm and helps in planning the intervention. C, A posterior approach was used to expose the aneurysm. The sural nerve is retracted laterally. D, Excision with repair using internal jugular vein was performed. The patient was anticoagulated for 3 months, and the repair is patent 1 year after.

Duplex ultrasonography is the modality of choice for initial diagnosis, although most surgeons rely on venography for preoperative planning (Figure 1B). Ascending phlebography is rarely performed today owing to the sophistication of magnetic resonance venography and computed tomography venography. All popliteal venous aneurysms should be repaired given the high risk for PE. The risk of embolism does not correlate with the size of the aneurysm. Anticoagulation alone has been observed to be ineffective in preventing embolism from venous aneurysms in the popliteal space. The posterior approach to the popliteal fossa is the preferred surgical route for most cases (Figure 1C). Surgical options include resection of the aneurysm with end-to-end anastomosis or with an interposition bypass using nonreversed great saphenous vein, internal jugular vein, saphenous panel composite, or spiral vein (Figure 1D). Alternatively, aneurysmectomy with lateral venorraphy or patch angioplasty repair are options when the entire aneurysm is not completely removed. All surgical options appear to have similar results, although longterm patency rates are not available from the literature. Perioperative intravenous anticoagulation is recommended, followed by oral anticoagulation for 1 to 3 months postoperatively.