Venous aneurysms are very rare vascular disorder, consisting of a persistent isolated dilatation of twice the normal vein diameter, excluding the superficial vein system. Clinical manifestations of venous aneurysms of the extremities can vary from asymptomatic or incidental finding to deep vein thrombosis (DVT) and pulmonary embolism (PE). The thrombotic complications are more present in venous aneurysms of the lower limb, being the popliteal vein the most frequent localization. The literature is limited, mainly case reports and small series. Although there is no strong evidence of their management, the surgical approach seems to be the best option. We present two cases of peripheral venous aneurism of the extremities (upper and lower limb) managed both surgically.

Case 1 A 73-year-old man with medical history of chronic pancreatitis, HCV, HBV and nephrectomy was admitted in the hospital due to the finding of bilateral pulmonary thromboembolism in a routine CT scan performed to monitor his chronic pancreatitis. The patient was asymptomatic, without chest pain, shortness of breath nor desaturation. Anticoagulant therapy was started and a few days later after the discharge another CT scan showed that PE was resolved. In an aetiological study of the PE, a 40 mm bilobed right popliteal venous aneurysm without intraluminal thrombus was found in a doppler ultrasonography of the lower limbs. Physical examination revealed few dispersed telangiectasias, no varicose veins and a slight increase of volume in the popliteal fossa, painless and compressible. He didn't refer any trauma nor prior surgery in the right lower limb. A NRM confirmed a 40 mm aneurysm arising from the popliteal vein. Regarding of the risk of thrombosis, the treatment chosen was open surgical repair by tangential aneurysmectomy and lateral venorrhaphy, through a posterior approach and a S-shaped incision. The patient was discharged with systemic anticoagulation and compression therapy with elastic stockings. Case 2 A 19-year-old woman with no medical history is referred to Vascular Surgery due to a painful axillary mass in right upper limb. A NRM previously done in another hospital described a 30 mm axillary venous aneurysm in the right arm. She practiced contact sports although she did not remember any trauma in the area. On physical examination a small compressible and non-pulsatile mass was discovered in the right axillary fossa. The patient underwent open repair through a longitudinal incision in the inner side of her arm and performing a tangential aneurysmectomy and lateral venorrhaphy in the axillary vein. She was discharged in the same day with anticoagulant therapy for a month. The histopathologic examination revealed a venous wall dilation with thrombus adhered to it.

The patient in case 1 presented surgical site infection (Szilagyi I), which progressed favorably with directed antibiotic therapy and dressing. One month after the intervention, no data of DVT was observed in the ultrasonography exam. Eight months later there was a follow-up loss. In case 2 there were no major complications during the postoperative period such as DVT or PE. She returned to her normal routine. The duplex exam after three months demonstrated deep venous system patency without symptoms.

Venous aneurysms are infrequent and, depending on their location, potentially life-threating. In those cases susceptible to treatment, tangential aneurysmectomy and lateral venorrhaphy is the best option according to the actual data. No strong evidence supports endovascular treatment of venous aneurysms, but further studies are needed.

MacDevitt DT, Lohr JM, Martin KD, Welling RE, Sampson MG. Bilateral popliteal vein aneurysms. Ann Vasc Surg 1993;7:282-6. Teter KA, Maldonado TM, Adelman MA. A systematic review of venous aneurysms by anatomic location. J Vasc Surg [Internet]. 2018;6(3):408-413. Available from: DOI: 10.1016/j.jvsv.2017.11.014 Maldonado-Fernandez N, Lopez-Espada C, Martinez-Gamez FJ, Galan-Zafra M, Sanchez-Maestre ML, Herrero-Martinez E, Mata-Campos JE. Popliteal Venous Aneurysms: Results of Surgical Treatment. Ann Vasc Surg [Internet]. 2013;27(4):501-509. Available from: DOI: 10.1016/j.avsg.2012.07.005 Noppeney T, Kopp R, Pfister K, Schierling W, Noppeney J, Cucuruz B. Treatment of popliteal aneurysms. J Vasc Surg [Internet]. 2019;7(4):535-542. Available from: DOI: 10.1016/j.jvsv.2018.12.013 Zybulewski A, Shukla PA, Swintelski C, Kagen A. Rare Popliteal Venous Aneurysm: A Case Report and Review of the Literature. Vasc Endovasc Surg [Internet]. 2017;XX(X):1-2. Available from: DOI: 10.1177/1538574417718444 Bergqvist D, Björck M, Ljungman C. Popliteal Venous Aneurysm—A Systematic Review. World J Surg [Internet]. 2006;30:273-279. Available from: DOI: 10.1007/s00268-005-7982-y Patel R, Hanish S, Baril D, Woo K, Lawrence, P. Contemporary management of lower extremity venous aneurysms. J Vasc Surg: Venous and Lym Dis [Internet]. 2019;6:1-5. Available from: DOI: 10.1016/j.jvsv.2019.06.017 Sessa C, Nicolini P, Perrin M, Farah I, Magne JL, Guidicelli, H. Management of symptomatic and asymptomatic popliteal venous aneurysms: A retrospective analysis of 25 patients and review of the literature. J Vasc Surg [Internet] 2000;32:902-912. Available from: DOI:10.1067/mva.2000.110353