Tricuspid insufficiency results in elevated central venous pressure, and various clinical signs, such as enlarged liver, peripheral edema, and ascites are observed. According to past case reports, in cases of tricuspid insufficiency, pulsatile veins have been observed in the neck, forearm, and forehead [6, 7]. In our case, computed tomography revealed congestive liver, pleural effusion, and ascites; however, there were no obvious subjective symptoms other than pulsating bleeding from the superficial varicose veins of the left foot.
Our patient had a history of high ligation and stripping of the right GSV. The right GSV was pulsating according to the surgical record. Significant hematoma occurred as a complication after the operation. It seems that TVR was already present; however, no further examination was performed. Right ventricular cardiomyopathy caused by arrhythmia was the main pathology of the disease and the main cause of right ventricular enlargement and decreased right ventricular contractility, which led to TVR. Therefore, it was highly possible that even if tricuspid valve replacement surgery had been performed, it would not have contributed to the reduction in the venous pressure. Drug therapy with diuretics (torsemide, 8 mg, daily) and cardiac stimulants (pimobendane, 5 mg, daily) was introduced after the bleeding event involving the varicose veins.
In previous studies, some cases of pulsatile varicose veins secondary to TVR were treated by approaches, such as EVLA alone and saphenofemoral ligation with foam sclerotherapy; however, other cases were treated conservatively by compression therapy with elastic stockings, in consideration of the bleeding due to venous hypertension and cardiac risk during the operation [1, 8,9,10,11]. Our case has a history of both stripping and EVLA of the GSV; however, EVLA seems to be associated with a lower risk of bleeding, considering the complication of hematoma after stripping of the GSV. In addition, since the course of this case was favorable during the 1-year follow-up period, it was considered that EVLA showed satisfactory venous sealing efficiency, even in the presence of high venous pressure.
Deep vein regurgitation was also observed in our case, so even after EVLA of the GSV, regurgitation through the incompetent perforating vein and rebleeding from varicose veins may occur. Therefore, it was considered that ligation of the incompetent perforating veins and foam sclerotherapy for the superficial varicose veins were effective. Since there is not enough evidence concerning the long-term outcomes of EVLA for varicose veins caused by TVR, further follow-up will be necessary.