Aneurysmal Dilatations of Telangiectasia: Etiology, Treatment and Histology

Introduction, Objectives, and/or Purpose: Telangiectasias are the most common manifestation of venous disease. Common modalities of treatment include chemical and heat. However, there is a subgroup of telangiectasia that manifest a different clinical presentation and present challenges in treatment. Due to their larger size, telangiectasias may be labeled as aneurysmal. The objections of this study were the following:

1. Utilizing doppler ultrasound the etiology of these complexes was determined as well as frequency of occurrence.
2. Determine the histology of these enlarged telangiectasia and establish parameters for diagnosis.
3. Access the best treatment options to provide faster resolution with minimal sequalae.

Methods: Two hundred patients who presented with telangiectasias alone or in association with other manifestations of venous disease were evaluated with doppler ultrasound. Location of enlarged intradermal complexes of veins were noted as well as presenting symptoms. In four patients’ excision of these enlarged complexes were done due to previous thrombosis or inflammatory skin changes. Histological analysis was done using a hematoxylin eosinophil stain at 4 micro cuts. Treatment was a combination of foam sclerotherapy, subdermal phlebectomy, and dermal incision of the intradermal telangiectasias.

Results: Doppler ultrasound of aneurysmal complexes revealed 3 constant findings: 1) Subdermal variceal complex, 2) An entry and exit perforator with separation of the dermal layer, 3) Dilated intradermal veins > 3 mm on ultrasound. Eight percent of patients presented with this pattern. The age range was 38-78 years of age with a median age of 68. All were female. Histology revealed a vessel wall thickness of at least five times the wall thickness of common telangiectasias. There was enlargement of the dermal space in association with these complexes. At least 80% clearance was obtained after the first treatment using mechanical debulking, foam sclerotherapy, and subdermal tumescent infusion.

Conclusion(s): Normal sized telangiectasias are not visible on doppler ultrasound. We define by ultrasound, telangiectasias as aneurysmal when intradermal venous dilatations can be demonstrated; these are usually > 3 mm by ultrasound. There is usually enlargement of the intradermal space and all these complexes are associated with dermal gaps corresponding to the enlarged dermal perforators. The normal dermal layer is 2-3 mm, whereas in the presence of aneurysmal telangiectasia the depth is at least doubled. The two dermal perforators associated with these complexes are responsible for a closed loop pressure phenomenon. The common blue telangiectasias have vessel wall thickness of 25-100 microns whereas aneurysmal veins have at least five times the thickness. On histology, the intradermal space is occupied by numerous dilated vessels. Aneurysmal complexes usually have localized symptoms and all in this study were confined to the lateral thigh (Subdermal reticular plexus) or the medial thigh (Associated with the Greater Saphenous Vein). Treatment is more complicated due to the volume of blood in the subdermal and intradermal layer. Best results are obtained with subdermal tumescent infusion, foam sclerotherapy, subdermal phlebectomy and incision of intradermal telangiectasia.