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I.E. Katsoulis S. Jader H.A. Bradpiece
Princess Alexandra Hospital, Harlow, Essex, U.K.
Correspondence to: I.E. Katsoulis, 42 Abbots Park, St Albans, Hertfordshire, AL1 1TW, U.K. Email: hrkats@yahoo.co.uk

Introduction

Case report

Keywords: Venous aneurysm, soft tissue mass
Surg J R Coll Surg Edinb Irel., 1 October 2003, 299-301

This is a report of a 71-year-old woman who presented with a superficial soft tissue mass in the antecubital fossa. Excision was undertaken under local anaesthesia. The lesion proved to be a primary aneurysm of the basilic vein. Reviewing the literature we found only a few previous reports of primary venous aneurysms in the upper extremities

INTRODUCTION
Aneurysms of the venous system are considered to be rare malformations that may develop in any part of the venous system.^1-6 Venous aneurysms may be primary, congenital in origin or secondary to trauma.^1-2 Degenerative changes in the venous wall resulting from a connective tissue disorder or a local inflammatory process may also be a causative factor.² Only a few cases involving the upper extremity veins have been reported.^3-21 We recently treated a female patient with a primary aneurysm of the basilic vein. Description of the case and review of the literature form the basis of this report.

CASE REPORT
A 71-year-old woman presented with a mobile lump in the medial aspect of the left antecubital fossa. The lump was first noticed two years ago and since then it had increased in size. The lesion clinically was a painless and mobile, soft, subcutaneous mass that caused only cosmetic concern and the clinical impression was that of a lipoma. The patient was referred for day surgery. She had a two-year history of hypertension (under treatment with Atenolol and Felodipine) and an operation for spontaneous subarachnoid haemorrhage 20 years ago. There was no history of trauma in the left antecubital fossa. The excision of the lump was undertaken under local anaesthesia with plain 0.5% buvipacaine. After a transverse incision of the skin and the subcutaneous tissues a cystic venous lesion was revealed. The lesion was an aneurismal dilatation of a branch of the basilic vein in continuity with the lumen of the basilic vein itself and was filled with thrombus. Adherent to its medial wall was a branch of the medial antebrachial nerve, which was separated and protected. The lesion was totally dissected from the surrounding tissues and excised. The distal venous stump was ligated and the basilic vein wall proximally was sutured with a fine prolene stitch. Recovery and follow-up of the patient were uneventful. Macroscopically, the lesion was a large distended vein measuring 3×2.8×1.8cm and containing a thrombus, which showed recanalisation (Figures 1 and 2). Microscopically, within the wall there were irregular masses of smooth muscle set in mature fibrous tissue. In focal areas there was associated inflammation. The pattern of the smooth muscle within the wall was rather unusual. Features were consistent with a primary aneurysm (Figures 2 and 3).

Figure 4: Microphotograph of the whole lesion (haematoxylin and eosin stain)

DISCUSSION
Aneurysms of the venous system are considered rare venous malformations that occur equally between the sexes and are seen at any age.5 They may develop in any part of the vascular system and their natural history, presentation and treatment varies, depending on their site.^1-6 In the face and neck, jugular veins may most commonly be involved.^1-6 In the thorax, superior vena cava and mediastinal venous aneurysms have been reported.^3-6 Abdominal venous aneurysms have been reported in the portal system, inferior vena cava, and internal iliac vein.^3-6 Lower extremities are the commonest location of vein aneurysms; there have been several reports, mainly of popliteal aneurysms.^3-6

However, only a few cases involving the upper extremity veins have been previously reported.^3-21 To the best of our knowledge, this is the 18th case to be documented in the literature. Only 4.2% of venous aneurysms in the largest reported series (152 cases) occurred in the upper limb.³ They usually present either as a painful or painless subcutaneous mass if they are thrombosed.⁵ They may also first be noticed when the limb is in a dependent position or after exercise.⁵ The case reported here presented with a painless and mobile, soft, subcutaneous mass that caused only cosmetic concern and the clinical impression was that of a lipoma. No serious complications have been reported from upper extremities venous aneurysms even after thrombi formation.^3-21 They have to be differentiated from other subcutaneous masses of the extremity. Venography and ultrasonography commonly reveal the nature of the lesion. Surgical excision is undertaken mainly for cosmetic reasons. They should also be treated if they cause pain or discomfort.

The cause of venous aneurysms remains unknown, although several theories have been proposed. In the absence of any haemodynamic changes, especially in the very low-pressure system of the superior vena cava, and when cardiac pathologies, trauma or arteriovenous fistulae are excluded, these lesions are considered primary and probably congenital.¹ Schatz and Fine (1962) suggested that endophlebohypertrophy is an important factor in the formation of primary venous aneurysms.²² Endophlebohypertrophy, otherwise termed endophlebosclerosis, begins at birth and is associated with areas of stress, which are entries of tributaries and adjacent to an artery.²² Endophlebosclerosis increases with age and occurs immediately adjacent to the artery. It seems that an external force rather than an intraluminal force induces the venous histology of degenerative changes.⁶ Congenital weakness in the vein wall has also been proposed as a possible cause of primary venous aneurysms.² Degenerative changes in the venous wall resulting from a connective tissue disorder or a local inflammatory process may also be a causative factor.² Inflammation, although a prominent finding in some cases, probably results from the mass effect of the aneurysm itself.⁶ Trauma may be another possible cause of the lesion.² Common histological findings in the wall of venous aneurysms include a flattened layer of endothelial cells and a significant diminution in the number and the size of muscle and elastic fibres.⁶ Fragmentation of the internal elastic lamella and its replacement by fibrous connective tissue has been noted as well.¹ All three layers of the normal vein wall are present in venous aneurysms.

Superficial venous aneurysms are commonly asymptomatic and should be included in the differential diagnosis of subcutaneous masses of the neck and face, groin, axilla, upper and lower extremities that are usually referred for day surgery.^3-6 Most venous aneurysms in the superficial venous system are palpable and easily compressed.⁵ This may suggest the diagnosis. However, in several reports the diagnosis was not made until surgical exploration. The basilic vein aneurysm reported here was misdiagnosed as a lipoma. If an aneurysm is suspected, colour duplex ultrasonography and venography are useful studies to demonstrate the lesion.^4,5

We should emphasise here that not all venous aneurysms have a benign behaviour. Popliteal and abdominal aneurysms have caused pulmonary embolisms and require preventative surgical management.^4,5

CONCLUSION
Venous aneurysms are rare vascular malformations. Their natural history depends on their location. Superficial aneurysms should always be included in the differential diagnosis of a subcutaneous mass. Upper extremity is an unusual location of this lesion. Fortunately, this type of venous disease has never caused any damage to the life or to the function of the upper limb of a patient.

ACKNOWLEDGEMENTS
We appreciate the assistance of Dr P. J. Gallagher, Consultant Cardiac Pathologist in the University of Southampton.

REFERENCES
1. Zomboni P, Cossu A, Carpanese L, Simonetti G, Massarelli G, Liboni A.The so-called primary venous aneurysms. Phlebology 1990; 5: 45-50.
2. Pearce WH, Winchester DJ, Yao ST. Venous aneurysms. In: Aneurysms, New Findings and Treatments, ed. by Yao JS, Pearce WH. Norwalk, CT: Appleton and Lange, 1994, pp 379-388.
3. Ritter H, Weber J, Loose DA. Venose aneurysaem. VASA 1993; 22: 105-12.
4. Calligaro KD, Ahmad S, Dandora R, Dougherty MJ, Savarese RP, Doerr KJ, McAffe S, DeLaurentis DA. Venous aneurysms. Surgery 1995; 117:1-6.
5. Gillespie DL, Villavicencio JL, Gallagher C, Chang A, Hamelink JK, Fiala LA, O’Donell SD, Jackson MR, Pikoulis E, Rich M. Presentation and management of venous aneurysms. J Vasc Surg 1997; 26(5): 845-52.
6. Uematsu M, Okada M. Primary venous aneurysm case reports. Angiology 1999; 50(3): 239-44.
7. Buckberg GD, McReynolds DG. Venous aneurysm of upper extremity: a case report. Am Surg 1971; 37(2): 83-86.
8. Sarap MD, Wheeler WE. Venous aneurysms. J Vasc Surg 1988;8(2): 182-3.
9. Perler BA. Venous aneurysm. An unusual upper extremity mass. Arch Surg 1990; 125(1): 124.
10. Friedman SG, Krishnasastry KV, Doscher W, Deckoff SL. Primary venous aneurysms. Surgery 1990; 108(1): 92-5.
11. Nishida K, Miyazawa Y, Matsumoto K, Okinaga K, Imamura T. Primary venous aneurysm of the forearm in a child. Jpn J Surg 1991; 21(2): 241-3.
12. Paes T, Andrews S, Wyatt A. Br J Sports Med 1991; 25(3): 149-150.
13. Ekim H, Gelen T, Karpuzoglu G. Multiple aneurysms of the cephalic vein. Angiology 1995; 46(3): 265-7.
14. Morrison J, Rubin DA, Tomaino MM. Venous aneurysm of the distal forearm MR imaging findings. AJR 1996; 167(6): 1552-4.
15. Goto Y, Sakurada T, Nanjo H, Masuda H. Venous aneurysm of cephalic vein: a case report. Surg Today 1998; 28(9): 964-6.
16. Uematsu M, Okada M. Multiple venous aneurysm of a basilic vein. Ann Vasc Surg 2001; 15(4): 485-7.
17. Wang ED, Li Z, Goldstein RY, Hurst LC. Venous aneurysms of the wrist. J Hand Surg [Am] 2001; 26(5): 951-5.
18. De Waele JJ, Calle PA, Vermassen FE. Thrombosis of an aneurysm of the vasilic vein upper extremity venous aneurysm. Acta Chir Belg 2001; 101(6): 308-9.
19. Acin F, de Benito L, Guilleuma J, Alvarez R. Primary axillary venous aneurysm. Ann Vasc Surg 1999; 13 (5): 539-40.
20. Chakraborty S, McGann G, Coen LD. Embolization of iatrogenic venous pseudoaneurysm. Br J R 1999; 72(855) 311-2.
21. Tahata T, Kusuhara K, Johno H, Okamoto K. Venous aneurysms of the upper extremity- a case report. Angiology 2002; 53 (4): 479-81.
22. Schatz IJ, Fine G. Venous aneurysms. N Eng J Med 1962; 266:1310-1312.

Under the Patronage of His Highness Sheikh Makhtoum Al Makhtoum in association with the Ministry of Health, UAE

(Flying with British Midlands & Gulf Air) Saturday 13th March Depart: Dublin / Dubai Friday 19th/Saturday 20th March Depart: Dubai / Dublin Inclusive of Return Flights economy class 5 nights accommodation based on twin sharing in the 5* Grand Hyatt Hotel/Airport taxes and transfers/Welcome Reception/St. Patrick’s night Dinner & Celebrations/Registration Fee OR Accompanying Persons Fee

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