Management of perforator vein aneurysms in the lower extremities

Perforator vein aneurysms (PVAs) of the lower extremity have not been defined or reported. This study reports the clinical presentation of patients, the PVA characteristics, and the clinical outcome of their management.

Patients with signs and symptoms of chronic venous disease who had a PVA were included. Diagnosis of a PVA was made with duplex ultrasound. Normal perforator veins have a diameter of <3 mm. A PVA was defined as a diameter dilation of >9 mm, and it was always found below the deep fascia. The topography and morphology of the aneurysms were described in detail. All PVAs were treated with subfascial ligation with or without aneurysm excision. All patients were followed up for a minimum of 3 months with clinical examination and duplex ultrasound, and complications were noted.

There were 21 aneurysms identified in 19 patients. Fourteen (73.7%) patients were female. The mean age at diagnosis was 49 years with a standard deviation of 9. Aneurysm size ranged from 9.8 to 22.2 mm, with a mean diameter of 15.7 mm and a standard deviation of 3.8. Seventeen aneurysms were fusiform, one was saccular, and one was multilobar. The perforators of the great saphenous vein distribution were most frequently involved, whereas only one involved deep vein disease. Few patients had symptoms, such as pressure and pain directly over the affected perforator. There was no association between the location and size of the PVA and the severity of chronic venous disease. Fourteen patients were treated surgically; five patients preferred conservative treatment with elastic compression stockings. Fourteen patients (73.7%) had ligation with (n = 9) or without (n = 5) excision of the aneurysm. All underwent concomitant phlebectomies, and eight of them also had ultrasound-guided foam sclerotherapy. Endovenous thermal ablation of saphenous veins was performed in seven patients, whereas two had ligation and stripping. There were four minor postoperative complications in four patients, all of which resolved within 6 weeks. The median follow-up was 21 months, ranging from 3 to 52 months. There were no recurrences of a PVA. Five patients preferred conservative treatment. The diameter changed from 0 to 13 mm during the follow-up, and the patients' symptoms remained the same or had mild worsening.

PVAs are rare without causing significant symptoms locally. Diagnosis is made with duplex ultrasound because the affected vein is located below the deep fascia. As only one case in our series of 19 involved the deep veins, we believe that PVAs originate from superficial veins. The condition is relatively benign, and the treatment outcomes are very good with limited complications experienced. However, selective treatment of PVAs may not be needed for most of them as treatment of the superficial veins connecting with the PVA may be sufficient.