Pulsation, systolic thrill and murmur in femoral veins secondary to severe tricuspid regurgitation

Acute iliac artery thrombosis and pulsatile femoral and popliteal veins in the same extremity: a case report

Systemic venous pressure is elevated in right heart failure, and this elevation may be reflected in pulsatile venous flow when there is significant tricuspid regurgitation. The presence of this systolic reversed flow in the femoral and popliteal veins may result in major difficulties for diagnosis and treatment. We report the case of a patient with signs and symptoms of acute ischemia of the right lower limb with palpable pulse in the groin and popliteal fossa. Tricuspid regurgitation was suspected by clinical examination, and Doppler ultrasonographic examination of the extremity revealed pulsatile flow in the femoral and popliteal veins while the iliac arterial axis was occluded. A preoperative angiogram revealed an underlying iliac artery thrombosis, which was successfully treated.

PULSATING VARICOSE VEINS!! THE DIAGNOSIS LIES IN THE HEART

Right heart failure is associated with increased systemic venous pressure, which can be diagnosed clinically with the findings of elevated jugular venous pressure, pulsatile liver and distinctive cardiac murmurs (precordial systolic). Severe tricuspid regurgitation (TR) has occasionally been known to lead to marked pulsation of varicose veins. We report three cases that were referred to the vascular clinic of Royal Perth Hospital in which the patients involved had unilateral (right leg) varicose veins and chronic venous ulcers. On clinical examination all three patients had pulsations along the course of the varicose long saphenous vein up to the mid calf. The main differential diagnosis was arterio-venous malformation, which was excluded by compression of the sapheno-femoral junction and demonstrating absence of pulsation in the long saphenous vein. A venous duplex scan showed a grossly incompetent sapheno-femoral junction with abnormal wave forms. Two of the cases were managed conservatively with compression dressing. The option of sapheno-femoral junction ligation was reserved in one patient who had unsettling cellulitis and oedema of the lower limb in spite of compression dressing and optimal conservative management. All three patients had improvement in ulcer size at 3-month follow up with compression therapy. This article highlights that in cases of right heart failure the venous pressures can be felt as low as the mid calf level and that can be a cause of the venous ulcers. There should be a high suspicion of right heart failure in patients with late onset venous insufficiency.

Sonographic Evaluation of Chronic Venous Insufficiency in Right Heart Failure

Clinical and sonographic findings of three octogenarian patients with recent-onset venous insufficiency with venous ulcer were evaluated with clinical examination and venous duplex scanning. The venous duplex findings in the affected lower limb of patients with right heart failure showed phasic flow in the long saphenous vein. The phasic flow was traced back up to the inferior vena cava and the hepatic veins. Echocardiogram confirmed marked tricuspid regurgitation. Clinically, a simple compression of the sapheno-femoral junction showed an absence of pulsation in the long saphenous veins, giving clinical confirmation that venous backflow caused the pulsation in the limb veins. Right heart failure in patients with late-onset venous insufficiency and venous ulcer should be suspected. Sonography complemented with clinical examination is the key to the proper evaluation and management of chronic venous insufficiency with right heart failure.