1Abdulrahman Abdullah Alharbi, 1Yousof Al Zahrani, 1Shaima Ahmed Abdulrahman, 1Mohammed Alsalman, 1Mohammed Almoaiqel
1King Abdulaziz Medical City, Riyadh, Saudi Arabia
Varicose veins are enlarged and tortuous veins. They are present in around 10%-40% of the population aged 30-70 years. There are many etiologies of varicose veins such as valvular incompetence, venous hypertension, and inflammation1. The symptoms include aching, burning, discomfort and pruritus. These symptoms usually worsen with prolonged standing. Varicose veins can progress into chronic venous disease and patient can present with leg heaviness, fatigue, hyperpigmentation, edema and ulceration. The possible complications are ulcers, thrombosis and infections. Clinical presentation and venous duplex ultrasonography are usually sufficient to make the diagnosis. Varicose veins can be treated surgically or by non-surgically such as compression stockings, sclerotherapy, radiofrequency ablation or laser therapy. Intra-osseous anomalous venous drainage is a rare anomaly with only 48 cases reported in the literature so far. Most of the time it is seen affecting the tibia in one side.
A 38 year-old lady known case of hypothyroidism, dyslipidemia and obesity presented to our emergency department complaining of mild left lower limb pain for one week. The patient denied any history of trauma or pervious surgeries. However, she had the same episode of pain 15 years ago and was unable to bear weight. The episode was treated with local injection and it resolved completely.
On inspection there was erythema and mild swelling over anteromedial aspect of left lower extremity. On palpation of anterior aspect of lower third of left tibia there was a firm mobile mildly tender mass immediately under the swollen erythematous area.
The patient had an x-ray of left lower extremity which showed a small cortical defect at the anteromedial aspect of mid left tibia (Fig. 1). This raised a suspicion for possible osteoid osteoma.
Further evaluation with CT scan revealed a tubular structure crossing through the cortex of anterior mid shaft of left tibia with intramedullary continuation superiorly and exiting through a defect at posterior superior aspect (Fig. 2). It appeared to be connected to subcutaneous varicose veins. The patient had an MRI to confirm the nature of the abnormal vessel which showed diffuse subcutaneous varicose veins with prominent pretibial varices which are directly connected to the anomalous intra-osseous left tibia vein (Fig. 3).
There have been 48 reported cases of intra-osseous venous drainage of varicose veins in the lower extremities so far. Most of the cases were involving the tibia and were unilateral; only one case was reported to be in the fibula2-10. It usually occurs at the tibial draining vein perforating through the anterior cortex11. Our case was similar to the majority of cases in that it was involving unilateral tibia and the perforating vein seen in the anterior cortex.
There are different hypothesis trying to explain the ethology varicosis in the intra-osseous perforating veins. For example, some authors believe that it is pre-existent to the presentation because some patients were asymptomatic and did not complain of pain4. In our case, we didn’t have previous radiographs to evaluate. However, the patient recalled a similar episode 15 years prior which was treated conservatively. Intra-osseous varicose veins can be diagnosed with color Doppler ultrasonography demonstrating reflux. However, cross sectional imaging is important to differentiate varicose veins from other differential diagnoses such as arteriovenous malformation, arteriovenous fistula or hemangioma12. CT scan and MRI usually show a dilated intra-osseous vein with direct connection to surrounding varicose veins. However, MRI is preferred due to better soft tissue resolution and absence of radiation.