A severe cause of pulsating varicose veins

In June, 2010, a 66-year-old woman presented to us with a 2 month history of a bilateral pulsatile swelling in her groin. On examination she was in chronic atrial fi brillation. She had been on oral anticoagulant therapy since a mitral valve replacement in 1998. Her medical history also included arterial hypertension and bilateral varices along both great saphenous veins, but without oedema, skin dyschromia or phlebostatic ulcers. Physical examination showed abnormal bilateral pulsatile groin swelling, with holosystolic thrill and pulsating varices along the entire course of the great saphenous veins. Cardiac auscultation showed severe tricuspid insuffi ciency, although she was still in class 1 of the New York Heart Association (NYHA) classifi cation system. Doppler sonography showed bilateral incontinence of the saphenofemoral junction and the entire course of the great saphenous vein, with dilatation of the iliaco-caval segment and the suprahepatic veins associated with hepatomegaly. A reversed arteriallike pulsating fl ow was seen in the veins of the abdomen and of the limbs, and in particular in the great saphenous veins. Neither arteriovenous fi stula nor an apparent pulsatile fl ow transmitted by an artery was detected. The arterial trunks were normal. Transthoracic echocardiography showed an ejection fraction of 55%, confi rming the presence of severe tricuspid insuffi ciency (fi gure), with dilatation of the tricuspid annulus (44 mm), the inferior vena cava (39 mm), and the suprahepatic veins with reverse systolic fl ow. On the basis of clinical and sonography fi ndings, we diagnosed severe tricuspid insuffi ciency with reper cussions on the Lancet 2011; 378: 2138