© 2002 by the American Institute of Ultrasound in Medicine
J Ultrasound Med 21:807-809 • 0278-4297
An Unuual Cause of Lower Extremity Edema
Portal Hypertension With a Patent Paraumbilical Vein Connection to the Leg
James J. Sivo, BS, RDMS, RVT
Salinas Valley Radiologists, Salinas, California.
Address correspondence to James J. Sivo, BS, RDMS, RVT, Salinas Valley Radiologists, 1063 Riker St, Suite 3, Salinas, CA 93901.
Abbreviations: CFV, common femoral vein • DVT, deep venous thrombosis
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Introduction
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The differential diagnosis of lower extremity edema includes a varied list of entities. Because of the potentially lethal sequelae of pulmonary emboli, deep venous thrombosis (DVT) is often at the top of that list. It is well known that it is difficult be certain of the presence of a thrombus by the clinical examination alone.1,2 Thus Doppler sonography is routinely used to confirm the presence or absence of DVT. During the sonographic procedure, nonthrombotic causes of leg swelling may be discovered. This report describes an unusual case of portal hypertension as a source of leg edema.
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Case Report
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A 64-year-old woman with right leg swelling was referred to our facility for a venous Doppler examination. The patient had a history of biopsy-confirmed cirrhosis secondary to alcohol abuse. There was no history of DVT, lower extremity surgery, trauma, or carcinoma.
All veins of the right leg had normal compressibility, showed spontaneous, phasic flow patterns, and had an appropriate response to distal augmentation maneuvers. With conventional color Doppler settings showing venous flow in blue, a "band" of red, representing retrograde flow, appeared in one section of the common femoral vein (CFV; Fig. 1 ). Pulsed wave interrogation revealed a high-velocity jet of 138 cm/s with turbulence (Fig. 2). This component of reversed flow disappeared (i.e., returned to antegrade flow) with augmentation of the distal thigh. However, the retrograde flow quickly returned on release of the thigh (Fig. 3). The external iliac and common iliac veins and inferior vena cava showed normal venous flow patterns.
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Figure 1. Color Doppler image of the CFV in the longitudinal plane. Normal venous flow is blue. A red band, indicating a retrograde component of flow, appears within the vein.
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Figure 2. Pulsed wave Doppler image from the CFV at the point of retrograde flow (shown here above the baseline) showing a high-velocity jet with turbulence.
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Figure 3. Pulsed-wave Doppler image from the CFV at the same point as in Figure 2 showing antegrade flow and the loss of turbulence on augmentation (AUG) of the distal thigh. (Antegrade flow is shown below the baseline.) The retrograde flow resumes on release of the thigh.
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Further investigation with color flow imaging revealed the source of the reversed flow jet to be a collateral vessel joining the CFV approximately 2 cm superior to its junction with the greater saphenous vein. Spectral analysis revealed an even higher velocity at this point (166 cm/s). When the course of the collateral vein was followed, it was discovered that this vessel took a tortuous path superiorly along the right side of the pelvis and abdomen. It continued superiorly and joined with a patent paraumbilical vein. Spectral analysis confirmed that flow in the paraumbilical and collateral veins was hepatofugal. Thus, the leg swelling was caused by the portal venous flow that was being diverted into the groin via a patent paraumbilical vein to the inferior epigastric vein and to the CFV connection (Fig. 4).
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Figure 4. Longitudinal image in the right groin showing the collateral inferior epigastric (COLLAT) vein joining the CFV.
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Many attempts by the referring physician to contact this patient, including registered letter, went unanswered. Thus, it was impossible to obtain any follow-up information in this case.
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Discussion
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The differential diagnosis of leg edema includes DVT, a Baker cyst, cellulitis, heart failure, a muscle tear, and complications of venous insufficiency.3 Doppler sonography has proved itself to be a highly accurate and reliable procedure for examining the lower extremity when swelling is present.4 Because most pulmonary emboli originate in the lower extremities,5 the purpose of the sonogram is to discover venous thrombosis and to initiate anticoagulant therapy. However, thrombi are present in only half of the patients with symptoms of DVT.6 Thus, the Doppler procedure will often reveal a nonthrombotic cause of edema. In this case, the leg swelling was caused by decompression of the portal system through a patent paraumbilical vein connecting to the leg via the inferior epigastric vein.
Many sources have discussed the etiology of the patent paraumbilical vein.7–10 In the classic appearance of Cruveilhier-Baumgarten syndrome, there is hepatofugal flow leaving the liver in a paraumbilical vein to join veins of the anterior abdominal wall.7 These venous pathways occur in an attempt by the body to relieve the increased portal venous pressure that accompanies portal hypertension. Secondary to splenorenal varices, a patent paraumbilical vein is the most common spontaneous collateral pathway established and is seen in 10% to 20% of patients with shunts.9,10 This pathway usually takes a course along the midline close to the anterior abdominal wall, ending at the umbilicus. Here it joins a network of collateral veins, known as the caput medusae, and drains into the inferior vena cava. In this case, the paraumbilical vein took an oblique course from the liver toward the right groin. It communicated with the CFV via the inferior epigastric vein.11 Thus, this patient's leg swelling was the result of the increased pressure and flow introduced into the CFV due to the unusual venous pathways that had been established.
Presumably, if necessary, this patient's leg swelling could have been relieved by installation of a transjugular intrahepatic portosystemic shunt. However, because this patient never returned to her referring physician, the outcome could not be determined in this case.
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Footnotes
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Received February 4, 2002, from Salinas Valley Radiologists, Salinas, California.
I thank Michael Basse, MD, for assistance.
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References
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- Rose SC, Zwiebel WJ, Nelson BD, et al. Symptomatic lower extremity deep vein thrombosis: accuracy, limitations and role of color duplex flow imaging in diagnosis. Radiology 1990; 175:639– 644.[Abstract/Free Full Text]
- Shane RA, Casarotto S. Utilization of duplex venous ultrasound in deep venous thrombosis. J Vasc Technol 1998; 22:153–155.
- Rumwell C, McPharlin M. Venous testing. In: Vascular Technology: An Illustrated Review for the Registry Exam. Pasadena, CA: Davies Publishing; 1996:167–196.
- Frederick MG, Hertzberg BS, Kliewer MA, et al. Can the US examination for the lower extremity deep venous thrombosis be abbreviated? A prospective study of 755 examinations. Radiology 1996; 199:45–47.[Abstract/Free Full Text]
- Davies SL, Mattos MA, Markwell SJ, et al. Prevalence of acute deep venous thrombosis and the appropriate indications for the use of color-flow duplex scanning in patients with suspected pulmonary embolism. J Vasc Technol 2001; 25:69–76.
- Lewis BD, James EM, Welch TJ, Joyce JW, Hallett JW, Weaver AL. Diagnosis of acute deep venous thrombosis of the lower extremities: prospective evaluation of color Doppler flow imaging versus venography. Radiology 1994; 192:651–655.[Abstract/Free Full Text]
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- Lafortune M, Constantin A, Breton G, Legare AG, Lavoie P. The recanalized umbilical vein in portal hypertension: a myth. AJR Am J Roentgenol 1985; 144:549–553.[Abstract/Free Full Text]
- Subramanyam BR, Balthazar EJ, Madamba MR, Raghavendra BN, Horii SC, Lefleur RS. Sonography of portosystemic venous collaterals in portal hypertension. Radiology 1983; 146:161–166.[Abstract/Free Full Text]
- Andrews A. Portal hypertension: a review. J Diagn Med Sonography 2001; 17:193–200.
- Gray H. Anatomy, Descriptive and Surgical. Philadelphia, PA: Running Press; 1974.
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Introduction
Case Report