Small Veins, Big Trouble?

Dear Editor:

I read with interest the report by Chen et al¹ describing a phenomenon of fluctuating cutaneous varices as a clue to obstructive shock secondary to a right atrial (RA) mass in an intubated patient. The physiologic explanation behind this physical exam finding involves direct right ventricular (RV) inflow obstruction by the RA mass and indirect RV inflow obstruction secondary to  impairment of RV diastolic filling from positive intrathoracic pressure. The result is retrograde flow of blood into the peripheral venous system.¹ In addition to arteriovenous fistula, and incompetent venous valves due to thrombophlebitis, Chen et al¹ now add obstructive shock secondary to RA mass to the differential diagnosis of small vein pulsations.²

A cardiac cause of small vein pulsations should never be considered a normal finding. In fact, not only should it be regarded as pathologic but also of important prognostic significance.² Our group has previously reported on this ominous sign as a marker of profound right heart failure in the setting of severe tricuspid regurgitation (STR). This is relevant to the interventional cardiology community, where expanded use of percutaneous treatment options for STR exists. When present (Figure 1 and Video), this sign should give pause that beneath the surface lies a severely dysfunctional right ventricle that is beyond salvage and an assessment for cardiac transplantation should be considered.²

Affiliations and Disclosures

From the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.

The author reports that patient consent was provided for publication of the image used herein.

Address for correspondence: Faris G. Araj, MD, Associate Professor of Medicine, Professional Office Bldg 2, Suite 600, 5939 Harry Hines Blvd, Dallas, TX 75390-9252. Email: faris.araj@utsouthwestern.edu

References

1. Chen TY, Hung CL, Lin CJ, Yeh HI, Liu YY. Fluctuating cutaneous varices as a diagnostic clue for a huge right atrial mass in a dialysis patient. J Invasive Cardiol. 2022;34(10):E755.

2. Metzinger MP, Amin AA, Mammen PA , Hardin EA , Araj FG. Small vein pulsations: an overlooked sign of poor prognosis. Am J Med. 2020;133(10):e597-e598. Epub 2020 Apr 8. doi:10.1016/j.amjmed.2020.03.011

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