Fatal lower extremity varicose vein rupture

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

Bleeding-Source Exploration in Subdural Hematoma: Observational Study on the Usefulness of Postmortem Computed Tomography Angiography

In a few cases, postmortem computed tomography angiography (PMCTA) is effective in postmortem detection of cortical artery rupture causing subdural hematoma (SDH), which is difficult to detect at autopsy. Here, we explore the usefulness and limitations of PMCTA in detecting the sites of cortical arterial rupture for SDH. In 6 of 10 cases, extravascular leakage of contrast material at nine different places enabled PMCTA to identify cortical arterial rupture. PMCTA did not induce destructive arterial artifacts, which often occur during autopsy. We found that, although not in all cases, PMCTA could show the site of cortical arterial rupture causing subdural hematoma in some cases. This technique is beneficial for cases of SDH autopsy, as it can be performed nondestructively and before destructive artifacts from the autopsy occur.

Vein Ablation is an Effective Treatment for Patients with Bleeding Varicose Veins

BACKGROUND

Bleeding is a rare but potentially life-threatening complication of varicose veins. There is paucity of literature about patients with varicose veins that present with bleeding and the effectiveness of vein ablation as therapy to prevent recurrent bleeding. This study compares patients treated with vein ablation for bleeding varicose veins to patients treated for venous symptoms other than bleeding. We hypothesize that vein ablation is safe and effective in preventing recurrence of bleeding from varicose veins.

METHODS

A retrospective single centre review of consecutive patients undergoing vein ablation using radiofrequency in an outpatient office was performed. Patients presenting with bleeding were identified. A random (3:1) group of patients undergoing vein ablation for other venous symptoms and no bleeding was selected as a comparative group (control). The medical records were reviewed for patient characteristics and outcomes. A telephone survey inquiring about intensity of symptoms on a numeric rating scale (NRS) 0-10 prior and after treatment as well as recurrence of bleeding was also conducted. Patient characteristics and outcomes were compared between the 2 groups.

RESULTS

The incidence of patients with bleeding varicose veins was 3.6% (13/362) of all patients undergoing vein ablation at our center. A total of 26 ablations and 60 ablations were performed in patients with bleeding (N=13) and controls (N=39), respectively. There was no difference in age and race but there was a trend for bleeding to occur more commonly in male patients (61.5% vs 33.3%, P=.073). Patients with bleeding from varicose veins were more likely to have congestive heart failure (P=.013), and present with more advanced venous disease based on CEAP classification (P=.005) compared to the control group. There was no difference between the 2 groups in vein closure (P=.246) or complications (P=.299) after vein ablation. With mean follow up of 2.26 ± 1.17 years, 85% of patients (N=11) remained free from bleeding episodes. One patient with recurrent bleeding required additional vein ablation and the second patient had a concomitant ulcer that was treated with compression therapy.

CONCLUSION

Bleeding from varicose veins is rare and more common in patients with congestive heart failure. Bleeding affects patients with higher CEAP scores. Vein ablation is a safe and effective treatment to prevent recurrence of bleeding.

A case of lethal varicose vein rupture caused by massive leiomyoma

Varicose veins are a common and benign disease, especially affecting the lower limbs of the elderly. This pathology can exhibit several complications, which in the majority of cases do not require medical treatment; life-threatening conditions are possible but extremely rare. We present here a suspected murder case in which a woman was found dead in her home with a large amount of blood soiling the floor and the furniture of her house. Death scene investigation (DSI) with body inspection and bloodstain pattern analysis (BPA) were not exhaustive in excluding a homicide, and the prosecutor asked for a forensic autopsy. During the dissection, a uterine neoplasia, which altered the lower limb venous system, was detected, thus allowing to reconstruct the physio-pathological mechanism of the formation and rupture of the varicose vein.

Fatal hemorrhage from peripheral varicose vein rupture

Varix of the lower extremities is a common entity that eventually presents fatal outcome. Fatal massive bleeding due to rupture of a peripheral varicose vein is rare. The estimated incidence of these cases is 1/1000 autopsies. The case we present is unique among 26,054 autopsies performed in Milan from 1993 to 2020. It describes the investigations carried out in the suspicion of a non-natural event in an elderly woman. She was found dead at home with a large volume of blood near her feet that drained from the right leg. Pathological examination disclosed that the hemorrhage occurred by the rupture of a venous varix of the lower limb. Cases of fatal hemorrhage from peripheral variceal rupture are insidious and require proper characterization. The bloodstain pattern analysis, careful autopsy dissection by layers to demonstrate the rupture, and histologic examination of the lesion are the essential elements to find out the actual cause of death.

A rare suicide case involving fatal bleeding from varicose veins

This case report deals with a sharp force suicide case, which may challenge the experience of many forensic pathologists as well as the studies published to date. An overview of the published cases shows that sharp force suicides account only for 1.6%–3% of all suicides and the self‐inflicted injuries are usually localized on the body parts easily accessible with one's hand including the neck, thorax, or upper extremities, as well as in locations of major vascular bundles or vital organs. Reported, however, is a case in which the victim relied on the knowledge of her medical condition and used a kitchen knife to incise her varicose veins, which resulted in fatal bleeding. The case is rare on a number of grounds: incision of varicose veins is rarely the method of choice in suicide cases, injuries of peripheral veins are rarely fatal, and so are injuries of isolated veins where no damage to arteries is suffered.

The recommended goal in the United Kingdom's National Institute for Health and Care Excellence Clinical Guideline 168 for immediate referral of patients with bleeding varicose veins is not being achieved

OBJECTIVE

Published in July 2013, National Institute for Health and Care Excellence Clinical Guideline 168 (CG168) recommended that people with bleeding varicose veins be referred immediately to a vascular service. We have examined the impact of CG168 on referral practice for patients with bleeding varicose veins from primary to secondary care in a local National Health Service setting.

METHODS

Referrals to a local vascular service in the 6 years before (group 1) and 6 years after (group 2) publication of CG168 were analyzed to assess patients' management after a bleed, with particular reference to a patient's initial presentation and delays in referral to the vascular service. This was done by retrospective electronic database and case note interrogation of patients presenting with bleeding varicose veins. Relevant data were collected onto an Excel spread sheet (Microsoft, Redmond, Wash) in relation to demographic information, comorbidities, clinical presentation, and treatment pathway.

RESULTS

During the period studied, 73 patients presented with bleeding varicose veins. Their mean age was 66 years, and 56% were men. Their mean body mass index was 28 kg/m². Of note, 33 patients (45%) initially self-treated before going to see their general practitioner; another 18 (25%) went to the emergency department. In 51 patients (70%), the underlying superficial disease involved the great saphenous vein, and most patients (73%) were treated with foam sclerotherapy with or without truncal thermal ablation; 45 patients (group 1) were treated in the 6 years before publication of CG168, and 28 patients, allowing 6 months for dissemination, were treated in the 6 years after CG168 publication (group 2). Mean time from index bleed to referral to the vascular service was faster after publication of CG168 (84 days before and 20 days after publication of CG168; P = .00842). Publication of CG168 was also associated with reduced mean bleed to intervention times (194 vs 60 days; P = .00097).

CONCLUSIONS

Publication of UK National Institute for Health and Care Excellence guideline CG168 has been associated with a significant reduction in the delay to referral of patients presenting with bleeding varicose veins; however, the goal of immediate referral to a vascular service is not being met. CG168 is likely to have been a significant component of the factors that have led to the improvements seen thus far.

Fatal bleeding caused by a ruptured varicose vein

Chronic venous insufficiency is generally not lethal, but massive bleeding from ruptured varicose veins can be fatal. A 79-year-old woman was found dead in her apartment in Rome. Pools of blood and contact pattern bloodstains were observed around the body. She lived alone and suffered from vascular dementia. On the medial aspect of the right leg, a circular ulcer communicating with the lumen of a varicose vein was noted. Death was attributed to hypovolemic shock caused by bleeding from the rupture of the varicose vein. Our case confirms that varicose veins rupture is a potentially fatal medical emergency. Conditions such as dementia may lead to failure to understand the gravity of the bleeding and to seek help. Recognition of this issue is important especially when the care of people suffering from mental illness is involved.

Haemorrhage from varicose veins and varicose ulceration: A systematic review

Varicose veins (VVs) and varicose ulceration (VU) are usually considered non-life-threatening conditions, but in some cases they can lead to major complications such as fatal bleeding. The aim of this systematic review is to evidence the most updated information on bleeding from VV and VU. As evidence acquisition, we planned to include all the studies dealing with "Haemorrhage/Bleeding" and "VVs/VU". We excluded all the studies, which did not properly fit our research question, and with insufficient data. As evidence synthesis, of the 172 records found, after removing of duplicates, and after records excluded in title and abstract, 85 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 68 articles because of the following reasons: (1) not responding properly to our research questions; (2) insufficient data; the final set included 17 articles. From literature searching, we identify the following main issues to be discussed in the review: epidemiology and predisposing factors, pathophysiology and forensic aspects, first aid. It has been estimated that deaths for bleeding due to peripheral venous problems account up to 0.01% of autopsy cases. From a pathological point of view, venous bleeding may arise from either acute or chronic perforation of an enlarged vein segment through the weakened skin. From a forensic point of view, in cases of fatal haemorrhage the death scene can even simulate non-natural events, due to crime or suicide. In most cases, incorrect first aid led to fatal complications. Further investigation on epidemiology and prevention measures are needed.

Sudden death by rupture of a varicose vein: Case report and review of literature

Venous disease, including varicose veins and chronic venous insufficiency, is one of the most common chronic medical conditions. Haemorrhage from rupture of varicose veins in the legs is rare and can lead to sudden death. Nevertheless, this condition is not included among the causes of sudden death. In this case, an 88-year-old man was found dead in a large pool of blood at home. Initially, investigators mistakenly assumed that it was a case of homicide. Bloodstain pattern analysis was performed. An external examination of the victim showed an ulcer on the left foot and evident varicose veins untreated on the lower limbs. The aim of this study is to emphasize the role of treatment of varicose veins in the prevention of adverse events such as sudden death from acute haemorrhage.

Essentials of forensic post-mortem MR imaging in adults

Post-mortem MR (PMMR) imaging is a powerful diagnostic tool with a wide scope in forensic radiology. In the past 20 years, PMMR has been used as both an adjunct and an alternative to autopsy. The role of PMMR in forensic death investigations largely depends on the rules and habits of local jurisdictions, availability of experts, financial resources, and individual case circumstances. PMMR images are affected by post-mortem changes, including position-dependent sedimentation, variable body temperature and decomposition. Investigators must be familiar with the appearance of normal findings on PMMR to distinguish them from disease or injury. Coronal whole-body images provide a comprehensive overview. Notably, short tau inversion-recovery (STIR) images enable investigators to screen for pathological fluid accumulation, to which we refer as "forensic sentinel sign". If scan time is short, subsequent PMMR imaging may be focussed on regions with a positive forensic sentinel sign. PMMR offers excellent anatomical detail and is especially useful to visualize pathologies of the brain, heart, subcutaneous fat tissue and abdominal organs. PMMR may also be used to document skeletal injury. Cardiovascular imaging is a core area of PMMR imaging and growing evidence indicates that PMMR is able to detect ischaemic injury at an earlier stage than traditional autopsy and routine histology. The aim of this review is to present an overview of normal findings on forensic PMMR, provide general advice on the application of PMMR and summarise the current literature on PMMR imaging of the head and neck, cardiovascular system, abdomen and musculoskeletal system.

Unusual death due to a bleeding from a varicose vein: a case report

Background

Varicose veins are a common entity presenting a worldwide distribution. Although they are usually benign, sometimes are proved to be a threatening condition. Massive hemorrhage is an unusual complication of this common venous pathology that demands immediate medical intervention.

Case presentation

We present a case of a 66-year-old woman found dead in her house surrounded by a large quantity of blood. Autopsy revealed a 7 mm ulcer on the internal surface of the left lower leg communicating with a varicose vein, signs of exsanguinations and liver cirrhosis. Toxicological analysis was negative.

Conclusion

Massive hemorrhage from a ruptured varicosity is a severe medical emergency. Awareness of the risk of massive hemorrhage may provoke preventive treatment to be undertaken so as terminal loss of consciousness and a subsequent unattended death to be averted.

A Case of Life-threatening Hemorrhagic Shock Due to Spontaneous Rupture of a Leg Varicose Vein

We report a case of massive, life-threatening from a varicose lesion of the right lower extremity. An 81-year-old lady was brought to the emergency room at our hospital because of massive bleeding from her right leg. She had had high ligation of the right saphenous vein at another hospital 2 years ago. After hemostat and transfusion, she recovered from hemorrhagic shock. Three-dimensional enhanced computed tomography angiography revealed a residual right great saphenous vein and recurrent varicose lesion. We performed high ligation of the great saphenous vein and closed all of the residual perforators. The patient was discharged hospital 10 days after the surgery and experienced no bleeding episodes within 8 months after the surgery. Certain high ligation and elimination of perforators of the great saphenous vein in surgery for varicose vein of leg is necessary to prevent lethal bleeding.