Case 91 - Pseudomass from varicose veins

Summary

Imaging description

Varicose veins may be seen as round or oval soft tissue density masses on CT, particularly when they are seen on a plane perpendicular to its course. Typically, varicose veins are easily diagnosed with intravenous contrast material, which helps to detect the continuity between varicose veins and other venous structures, and to determine the true vascular nature of the varicose veins. However, when contrast is not administered or enhancement of the vein is poor due to early arterial phase or thrombosis, it may be confused with lymphadenopathy or another mass (Figure 91.1).

Reformatted coronal or sagittal images along the course of the dilated vein will help to differentiate dilated veins from other pathologies. In patients with venous obstruction, knowledge of collateral pathways in chest, abdomen, and pelvis is essential to avoid misinterpretation.

Importance

Varicose veins are commonly encountered at cross-sectional imaging of the thorax and abdomen. These vessels can be mistaken for adenopathy, which could lead to improper staging of patients with cancer or unnecessary work-up for malignancy. Erroneous biopsy of varicose veins may lead to profound hemorrhage.

Typical clinical scenario

Varicose veins are enlarged and tortuous venous channels, which are commonly caused by retrograde flow due to incompetency of valves or obstruction to flow. Obstruction of the venous flow may be secondary to thrombus, external compression, or congenital.

In patients with occlusion of the superior vena cava and its tributaries, the collateral venous pathways are often categorized into four main pathways: lateral thoracic, internal mammary, azygos, and vertebral pathways (Figure 91.2). In the abdomen, internal mammary pathways form anastomoses with the superficial epigastric veins, which may be seen in the anterior abdominal wall of patients with superior vena cava obstruction (Figure 91.3). When the inferior vena cava is obstructed, the ascending lumbar vein, which drains into the azygos-hemiazygos system, may be dilated. Dilated azygos or hemiazygos veins can be confused with retroperitoneal, retrocrural, or paraspinal mass or adenopathy (Figure 91.4). In patients with portal hypertension, varicose veins may form in the esophagus or upper abdomen, and may simulate a mass or adenopathy (Figures 91.1 and 91.5).