Primary varicose vein of upper limb: A rare entity

Abstract

Received 04/10/06; Review Completed 29/10/06; Accepted 08/11/06. A healthy 6-years-old male child reported to us with complaint of soft compressible swellings (four years duration) of right forearm and arm, which were progressively increasing in size. This was not associated with pain and discomfort. Patient did not give history of antecedent trauma or weight lifting. On examination, there were multiple soft, cystic, compressible swellings of approximately 2 x 2 cms. on the medial aspect of right forearm and arm along basilic vein distribution. These swellings disappeared on raising the arm above the head and reappeared on applying the pressure. These varicosities were starting form little finger base and extending upto right axilla (Fig. 1). Surrounding skin was normal. No bruit was audible and both arms were of equal size. Bilateral pulses were normal. Opposite upper limb and bilateral lower limbs were normal. There was no family history of lower limb varicosities. On Duplex examination, there was no evidence of venous reflux or proximal dilation. Ascending phlebography (Varicography) also documented basilic vein varicosities with saccular enlargements. There were no signs suggestive of arterioverious fistula and haemangimatous malformations on both the studies. The patient underwent successful treatment of these varicose veins by sclerotherapy. A varicose vein may be defined as a vein that becomes elongated, dilated, tortuous and thickened due to continuous dilatation under pressure. Primary varicose veins are a common affliction of the lower extremities whereas the upper extremities are rarely affected. The literature has little reference as regards the number of cases, causes and management of upper limb varicose veins1,2. Congenital arteriovenous fistulae or iatrogenic arterioverious fistulae for haemodilaysis causes upper extremity varicose veins. Congenital vascular anomalies, the Klippel Trenaunay Syndrome and the Parkes Weber syndrome are other rare causes of arm varicose veins. Venous outflow obstruction caused by subclavian vein thrombosis can be another uncommon cause2,3. The diagnosis of upper extremity varicose veins can be made by means of a good history and physical examination, besides these, non invasive Doppler Ultrasound or duplex allows visualization and quantification of incompetence or obstruction. Invasive investigations are generally unnecessary but may be required in unusual situations like congenital and anatomical variants, to further define the pathology. Arteriovenous fistulae and congenital vascular anomalies are recognized by these investigations1,2,3. Treatment of upper limb varicosities is similar to that of varicose veins in the legs. The treatment of varicosities due to upper limb arterioverious fistulae is usually surgical and entails either ligation of distal venous limb of a side to side fistula or division of the fistula itself and provides excellent cosmetic and functional outcomes2,3. Sclerotherapy with agents like Sodium tetradecyl sulphate and Polidocanal are useful alternatives to surgery4.