Medical Treatment of Varicose Veins
The patient originally presented in 1999 with dyspnea and limited cutaneous systemic sclerosis. Echocardiography revealed a tricuspid gradient of 56 mm Hg; the presence of pulmonary hypertension was confirmed with right heart catheterization (pulmonary artery pressure 49/23mm Hg, mean 31 mm Hg; wedge pressure 13 mm Hg). She was treated with warfarin but lost to follow-up.
In July of 2002, she re-presented with dyspnea and was found to have ascites, pulsatile hepatomegaly, JVP +19 cm, and swollen legs with grossly dilated veins (Figure 1A and 1B). She had worsening pulmonary hypertension causing right heart dilatation and tricuspid regurgitation, with the resultant increased venous pressure causing the varicose veins.
She was started on Bosentan (an endothelin antagonist), and her leg edema and varicose veins improved dramatically (Figure 2A and 2B) within weeks of starting treatment. She continues to make good progress with improvements in her 6-minute walk distance, right heart measurements, and symptoms.