Lymph node veins: a little-known cause of varicose veins

REVIEW ARTICLE

Lymph node veins: a little-known cause of varicose veins

André Paciello Romualdo^I; Roberto de Moraes Bastos^I; Alessandro Cappucci^I; Mathias Fatio^I; Andréa Tsunoda^I; Pollyanna Campos^I; Alberto Lobo Machado^I; Eduardo Hideki Tokura^I

^IFleury - Medicina e Saúde, São Paulo, SP, Brazil.

ABSTRACT

Lymph node veins are part of a venous network in Scarpa’s triangle, communicating in many points the superficial venous system and the deep veins, and may either be the cause of incompetence of the superficial venous system, or be involved in recurrent varicose veins after saphenous vein stripping. In the daily routine of venous Doppler examination of the lower extremities, an increasingly frequent association of lymph node veins with primary and/or recurrent varicose veins has been noticed. Appropriate characterization of these veins may help to understand the pathophysiological mechanism of varicose vein appearance and provide a more focused approach to follow-up and treatment. This article sheds some light on the anatomical and physiological aspects of lymph node veins, drawing the attention of professionals involved in the diagnosis of venous disorders of the lower extremities to a little-known cause of varicose veins.

Keywords: Saphenous, Doppler, varicose veins.

RESUMO

As veias linfonodais fazem parte de uma rede venosa no triângulo de Scarpa, que liga em vários pontos o sistema venoso superficial às veias profundas, e podem tanto ser causa de incompetência do sistema venoso superficial quanto estar envolvidas na recorrência pós-safenectomia. Na rotina diária dos exames de Doppler venoso de membros inferiores, temos notado de maneira cada vez mais freqüente a associação das veias linfonodais com varizes primárias e recorrentes. A adequada caracterização dessas veias pode ajudar na compreensão do mecanismo fisiopatológico do aparecimento das varizes e permitir um controle e tratamento mais dirigidos. Este artigo lança luz sobre os aspectos anatômicos e fisiológicos das veias linfonodais, objetivando chamar a atenção dos profissionais envolvidos no diagnóstico de doenças venosas dos membros inferiores para uma causa pouco difundida de varizes.

Palavras-chave: Safena, Doppler, varizes.

Introduction

Color Doppler ultrasound plays a major role in the diagnosis and follow-up of varied vascular diseases, especially in the venous study of the lower limbs.

This article deals with a little-known cause of varicose veins, lymph node veins, which may be related to the primary source or to cases of recurrent varicose veins. Such veins have been increasingly identified by physicians working with vascular diagnoses; hence the importance of knowing it may be an etiological factor of varicose veins.

Lymph node veins: anatomical aspects

The saphenofemoral junction can be defined as the femoral venous segment limited by supra and infra-saphenous valves, as well as by terminal and subterminal valves of the great saphenous vein arch.^1,2 Proximal tributaries that drain between the subterminal and terminal valves are the superficial circumflex iliac vein (lateral pathway), superficial epigastric vein (cranial pathway) and external pudendal vein (medial pathway). Such veins can be single or multiple, can drain alone or at a single trunk, and also end directly in the common femoral vein. These veins have clinical importance because they can be a source of great saphenous vein reflux in cases of competent terminal valves and incompetent subterminal valves (Figures 1 and 2). Distal tributaries are the anterior accessory great saphenous vein (lateral pathway), which meets the great saphenous vein between the terminal and subterminal valves, and the posterior accessory saphenous vein (medial pathway), frequently draining distally to the subterminal valve.^1-3

The lymph node venous network is presented as tortuous veins, commonly between 1 and 3 mm in diameter, subaponeurotic, located between the anterior accessory saphenous and the great saphenous vein. These veins are connected to the great saphenous vein along its 10-15 cm proximal, and their cranial connections are hard to be found by ultrasound due to their small diameter and tortuosity. They frequently have a translymphnodal course, which is well characterized by ultrasound and Doppler examinations (Table 1, Figures 3 and 4).

Lymph nodes are part of a venous network in Scarpa's triangle, which connects the superficial venous system to deep veins in many points. Cranially, they can extend to inguinal abdominal and external pudendal veins, and may also perforate the cribiform fascia connecting to the femoral vein, playing the role of small direct femoral perforating veins.⁴ Such veins were the object of an anatomical study in cadavers, and were characterized in 19% of cases.⁵

Lymph node veins: hemodynamic aspects

In a series of 100 patients who underwent surgery due to great saphenous vein incompetence, Lemasle et al. found lymph node veins as the main cause of reflux in 6% of cases.⁴ Such frequency is likely to be underestimated in studies of causes of great saphenous vein incompetence because a specific investigation should be conducted for its proper characterization (Figures 5 and 6).

Its role in recurrent varicose veins after saphenous vein stripping is well defined. Some authors have tried to associate characterization of ectatic lymph node veins with neovascularization. Postoperative histological study showed dysplastic lymph node veins that enter the lymph nodes and penetrate the lymphatic tissue.^6-9 However, based on the current anatomical knowledge, it is clear that it is a case of hypertrophy of preexisting vessels under the effect of angiogenic factors (Figures 7, 8 and 9).

In the daily routine of venous Doppler exams of the lower limbs, association between lymph node veins and primary and recurrent varicose veins are increasingly more frequent.

Therapeutic consequences

Recurrent varicose veins are common after surgery involving the great saphenous vein. Rates above 40% in 5 years have been described, and about 20% of varicose vein surgeries are performed to repair recurrent veins.^8,10 According to the prevailing opinion, lower recurrent rate can be expected with great saphenous vein stripping, ligation of the saphenofemoral junction at the common femoral vein, and interruption of proximal tributary veins.⁷

Among the main sources of reflux commonly associated with recurrence are persistence of incompetent residual stump, neovascularization, untreated incompetent perforating veins, and residual tributary veins of the arch resulting from incorrect surgical treatment. Such findings justify extended resection of saphenofemoral junction tributaries, in addition to their own primary tributaries, aiming at a more effective disconnection and preventing neoformed vessels from connecting the deep and superficial systems.^6,11-14

Surgical approach of lymph nodes is technically complicated and even unadvisable, as they have small diameter, are friable and hemorrhagic, in addition to a likely deleterious effect on the regional lymphatic system. When lymph node veins are the main source of trunk reflux of the great saphenous vein and the terminal valve is competent, there is a tendency of not performing crossectomy, as it is useless to disconnect a competent arch from the hemodynamic perspective. In addition, from the evolutionary perspective, surgical aggression could trigger an angiogenic process on preexisting immature veins. Recommended treatment is the destruction of the underlying varicosed tissue by phlebectomy or sclerotherapy until the junction of lymph node veins and the great saphenous vein.

Conclusion

Lymph node veins have well defined anatomical and physiological aspects. However, their true role as cause of varicose veins and a more appropriate approach still need to be established, as there is a lack of studies on this issue. It is believed that this article may draw attention to professionals, collaborating with discussion and explanation of the real importance of lymph node veins.

References

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Correspondence

Publication Dates

• Publication in this collection
  20 Feb 2009
• Date of issue
  Dec 2008

History

• Received
  24 June 2008
• Accepted
  14 Oct 2008