Primary Venous Dissecting Aneurysm Arising During Pregnancy: a Case Report and Review of the Literature H M Burnley, D Mccormick, J Hurren, P J Gallagher

634

LETTER TO JCP J Clin Pathol: first published as 10.1136/jcp.56.8.634 on 30 July 2003. Downloaded from Primary venous dissecting aneurysm arising during pregnancy: a case report and review of the literature H M Burnley, D McCormick, J Hurren, P J Gallagher ......

J Clin Pathol 2003;56:634–635

This report describes a case of venous dissecting aneurysm presenting as a popliteal mass, in a 33 year old woman. A1×1×0.5 cm lump developed early in the course of a second pregnancy. Primary venous aneurysms are rare vascular abnormalities that can affect either the superficial or deep veins, and have been described throughout the venous system. Most commonly found in the neck and central thoracic veins, they have also been found in visceral veins and extremities. There is a tendency for vascular disturbances to occur during pregnancy. The haemodynamic changes and hormonal milieu may be the cause of vascular alterations, which can lead to new aneurysm formation, or weakening of pre-existing aneurysms. This is the first reported case of a dissecting venous aneurysm, and has the added interest that it occurred during pregnancy.

33 year old woman presented six weeks postpartum with an aching lump in her right popliteal fossa, which Adeveloped early in the course of her second pregnancy. The lump was uncomfortable and the symptoms exacerbated by walking and driving. On examination, it was tender on pal- http://jcp.bmj.com/ pation, easily moveable in the lateral planes, but did not move in a proximal or distal direction. An ultrasound scan showed a solid echogenic mass measuring 1 × 0.5 × 0.5 cm. There was Figure 1 Intraoperative finding of an aneurysmal dilatation of a no colour doppler flow within the lesion. The lump was vein (upper panel). Dissecting venous aneurysm with the plane of considered to be intradermal. The clinical impression was that dissection towards the outer media (haematoxylin and eosin stain; of a benign lesion, possibly a neurilemmoma. Intraoperatively, lower panel). a blood filled mass was found arising from a superficial vein of on September 25, 2021 by guest. Protected copyright. the short saphenous system (fig 1). This was excised and the extremities.1 Venous aneurysms can result from trauma (acci- vein ligated/transfixed. dental or postoperative), arise in association with varicose veins or arterio-venous shunts, or they can be congenital in PATHOLOGICAL FINDINGS origin. In addition, degenerative changes in the venous wall Macroscopically, there was a blood vessel 8 mm in length and resulting from connective tissue disorders (Marfans, Ehlers- 2 mm in diameter with an attached tan/grey nodule Danlos) can cause aneurysms. Inflammation has also been 10 × 15 × 5 mm in size. On slicing the specimen there was a cited as a possible cause, although in fact inflammation prob- cyst 8 mm in diameter containing brown material. ably results from the mass effect of the aneurysm itself.2 Venous aneurysms arising in the deep veins of the leg Microscopic findings (popliteal) commonly present with pulmonary embolism134 The plane of dissection was towards the outer aspect of the or even sudden death.5 media. There was a uniform infiltrate of mixed chronic inflammatory cells within the media and adventitia. Most of “Venous aneurysms can result from trauma (accidental or these were CD3+ T cells. No eosinophils were identified. There postoperative), arise in association with varicose veins or was no evidence of mural necrosis or adventitial haemorrhage. AV shunts, or they can be congenital in origin” Figure 1 shows the histological appearance of the dissecting aneurysm wall. There is a tendency for vascular disturbances to occur during pregnancy (varices, cutaneous spider naevi, pyogenic DISCUSSION granuloma) and there is a positive correlation between Primary venous aneurysms are rare vascular abnormalities dissecting arterial aneurysms in young women and preg- that can affect either the superficial or deep veins, and have nancy. Between 25% and 50% of cases occurring in women been described throughout the venous system. They occur below 40 years are associated with pregnancy, especially the most often in the neck (jugular vein) and central thoracic third trimester.2 6–8 An increase in cardiac output and blood veins, and have been found in the visceral veins and the volume, usually found in the later months of pregnancy, are

www.jclinpath.com Letters to JCP 635

...... Take home messages Authors’ affiliations J Clin Pathol: first published as 10.1136/jcp.56.8.634 on 30 July 2003. Downloaded from • To our knowledge, we describe the first case of a H M Burnley, D McCormick, J Hurren, Department of Histopathology, Queen Alexandra Hospital, Cosham, Portsmouth PO6 3LY, UK dissecting venous aneurysm P J Gallagher, Department of Pathology, Southampton General • This case occurred as a popliteal mass early in the Hospital, Tremona Road, Southampton SO16 6YD, UK course of a second pregnancy in a 33 year old woman • There is a tendency for vascular disturbances to occur Correspondence to: Dr P Gallagher, Department of Pathology, Southampton General Hospital, Tremona Road, Southampton during pregnancy, but it is unknown whether the aneu- SO16 6YD, UK; [email protected] rysm in our patient was related to her pregnancy Accepted for publication 16 December 2002 important factors in the precipitation of vascular accidents,7 and are probably precipitating factors in the formation and REFERENCES rupture of dissecting aneurysms. The most commonly 1 Aldrigde SC, Comerota AJ, Katz ML, et al. Popliteal venous aneurysm: reported pregnancy associated ruptured aneurysms include report of two cases and review of the world literature. J Vasc Surg the aorta, and the cerebral, splenic, coronary, renal, and ovar- 1993;18:708–15. ian arteries.29One study reviewed three cases of spontaneous 2 Konishi Y, Tatsuta N, Kumada K, et al. Dissecting aneurysm during coronary artery dissection in young patients. One of these pregnancy and the puerperium. Jpn Circ J 1980;44:726–33. 3 Calligaro KD, Ahmed S, Dandora R, et al. Venous aneurysms: surgical occurred in the puerperium. The dissection occurred between indications and review of the literature. Surgery 1995;117:1–6. the tunica media and external elastic lamina, and was 4 Coffman SW, Leon SM, Gupta SK. Popliteal venous aneurysms: report associated with a mixed inflammatory infiltrate rich in of an unusual presentation and literature review. Ann Vasc Surg 10 2000;14:286–90. eosinophils. 5 Donald IP, Edwards RC. Fatal outcome from popliteal venous aneurysm Dissecting venous aneurysms are not documented in the associated with pulmonary embolism. Br J Radiol 1982;55:930–1. literature. It is unknown whether or not the aneurysm in our 6 Al Hilli FA. Primary dissecting hepatic artery aneurysm in pregnancy. patient was related to her pregnancy. There was no history of Cardiovasc Pathol 2001;10:99–101. trauma, varicose veins, AV malformation, hypertension, or 7 Barrett JM, Van Hooydonk JE, Boehm FH. Pregnancy-related rupture of arterial aneurysms. Obstet Gynecol Surv 1982;37:557–66. collagen vascular disorders and the only risk factor for a vas- 8 Stehbens WE, Lie JT. Vascular pathology, 1st ed. New York: Chapman cular disturbance was her pregnancy induced state. Before & Hall Medical, 1995. becoming pregnant for the first time she had been taking the 9 Heggtveit HA. Non-atherosclerotic diseases of the aorta. In: Silver MD, combined oral contraceptive pill for five years, with no adverse ed. Cardiovascular pathology, 2nd ed. New York: Churchill Livingstone, 1991:319–29. effects. Both pregnancies were uneventful, with nothing to 10 Bateman AC, Gallagher PJ, Vincenti AC. Sudden death from coronary suggest occult pulmonary emboli. artery dissection. J Clin Pathol 1995;48:781–4. http://jcp.bmj.com/

Future content

See which articles have just been accepted for publication and preview the table of contents for the next issue a month before it is published www.jclinpath.com