Cartilaginous metaplasia of superficial veins was found in a 64-year-old woman who underwent surgery for varicose veins. At operation, some varicose veins of the medial thigh were semi-rigid and fibroelastic to the touch. Histology revealed that half the lumen was occupied by chondroid tissue. The other half was obliterated by fibrous tissue, typical of post-thrombotic involution. Possible causes of cartilaginous metaplasia are briefly discussed

CAGGIATI, Alberto

FRANCESCHINI, MARCO

English

 Cartilaginous metaplasia of superficial veins was found in a 64-year-old woman who underwent surgery for varicose veins. At operation, some varicose veins of the medial thigh were semi-rigid and fibroelastic to the touch. Histology revealed that half the lumen was occupied by chondroid tissue. The other half was obliterated by fibrous tissue, typical of post-thrombotic involution. Possible causes of cartilaginous metaplasia are briefly discussed. </jats:p

A Caggiati

M Franceschini

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Phlebology The Journal of Venous Disease

Cartilaginous metaplasia of varicose veins: a case report

Archivio della ricerca- Università di Roma La Sapienza

Short reportCartilaginous metaplasia of varicose veins:a case reportA Caggiati and M FranceschiniDepartment of Anatomy, Sapienza University of Rome, Via Borelli 50, 00161 Rome, ItalyAbstractCartilaginous metaplasia of superficial veins was found in a 64-year-old woman whounderwent surgery for varicose veins. At operation, some varicose veins of the medial thighwere semi-rigid and fibroelastic to the touch. Histology revealed that half the lumen wasoccupied by chondroid tissue. The other half was obliterated by fibrous tissue, typical ofpost-thrombotic involution. Possible causes of cartilaginous metaplasia are briefly discussed.Keywords: varicose veins; thrombosis; varicophlebitis; cartilaginous metaplasiaIntroductionIt is well known that venous thrombi may undergore-canalization or fibrous transformation. Less fre-quently, thrombosis may evolve in mural calcifica-tion and even ossification. In this paper, we reporta case in which cartilaginous metaplasia wasobserved in the great saphenous vein (GSV) andits tributaries as a long-term consequence of super-ficial thrombophlebitis.ReportOn 23 November 2009, SC, a 64-year-old Caucasianwoman, underwent intervention for varicose veinsin the right leg. Her medical history included along-lasting history of primary varicose veins (35years) and an episode of superficial thrombophlebi-tis in the right thigh in 1998 treated with com-pression and heparin.Preoperative duplex ultrasound demonstratedobliteration of the right GSV from the upper leg tothemid-thigh, and of the thigh portion of its anterioraccessory. The lumen was occupied by inhomo-geneous material showing partial re-canalization(Figure 1a). A small artery originating from periad-Figure 1 Anterior accessory great saphenous vein. (a)Preoperatory duplex appearance. (b) Stereomicroscopy of the lumen.The box indicates the area observed by light microscopy in (c). (c)The different tissues occupying the lumen as evidenced by lightmicroscopy (haematoxylin–eosin, original magnification 20)Correspondence: Alberto Caggiati MD PhD, Department ofAnatomy, Sapienza University of Rome, Via Borelli 50, 00161Rome, Italy.Email: alberto.caggiati@uniroma1.itAccepted 26 September 2011DOI: 10.1258/phleb.2011.011078. Phlebology 2012:1–3 Published online on 8 February 2012 Phlebology, doi: 10.1258/phleb.2011.011078 Copyright 2012 by the Royal Society of Medicine Pressventitial vessels (Figure 2a) ran in the middle of thelumen (Figure 2b). No pain was triggered by com-pressive manoeuvres with probes. Clinical and lab-oratory investigations did not reveal active venousinflammation or thrombosis.At operation, the occluded varicose veins weresemi-rigid and elastic to the touch, as if a siliconprobe would lie inside. Therefore, samples from theanterior accessory were avulsed for histological diag-nosis. Due to the hardness of the material that occu-pied the lumen, large scissors were necessary to cutthe vein.A cylindrical biopsy, 4.5 cm in length andabout 10 mm in diameter, underwent laboratoryinvestigation.At stereomicroscopy, the outer surface showedlarge periadventitial tortuous vessels (Figure 2c).About one half of the lumen was occluded by trans-lucent material. The other half was occupied bygreyish fibrous-like tissue. Irregular fissures werein both parts of the lumen (Figure 1b).The biopsy was then cut into smaller specimensto be investigated microscopically. Besides routinehaematoxylin–eosin, alcian blue and toluidineblue stains were applied for the demonstration ofcartilage cells and their specific matrix proteins.One half of the lumen was obliterated by typicalfibrous tissue, rich in fibroblasts (Figure 1c).The other part of the lumen was obliterated bydense connective tissue in which uninuclear chon-drocytes were visible within lacunae, surroundedby a basophilic matrix (Figures 1c and 3). Toluidineblue and alcian blue stains confirmed the presenceof chondroid tissue (Figure 3). Irregularly shapedlumens were lined by endothelium. A small arteryran in the middle of the occluded lumen(Figure 2d). No significant infiltration, calcificationand ossification were observed.Figure 2 Great saphenous vein. The rich net of periadventital vessels demonstrated by duplex (a) andstereomicroscopy (b). A small artery running in the middle of the obstructed vessel as seen by duplex(c) and demonstrated by histology (d)Figure 3 Uninuclear chondrocytes lie into lacunae surrounded by abasophilic matrix and small vessels (alcian blue, originalmagnification 20)Short report A Caggiati and M Franceschini. Cartilaginous metaplasia of varicose veins2 Phlebology 2012:1–3No complications were noted until December2010. Postoperative clinical and laboratory investi-gations were negative for neoplasia, hypercoagul-ability, autoimmune diseases or dysmetabolicdisorders.DiscussionThe fate of venous thrombi is to dissolve or to trans-form in fibrous tissue. Venous calcification mayoccur also, if less frequently. To the best of athorough revision of the literature, this report isthe first to demonstrate a ‘chondroid transform-ation’ of a peripheral vein due to cartilaginousmetaplasia of a thrombus. Chondroid transform-ation of the venous wall has been described inrelation to the presence of a central catheter orrenal dysfunction in humans,1 or to bypass pro-cedures in the dog.2 Cartilaginous metaplasia ismore frequent in arteries where it is associatedwith, but not causative for atherosclerotic vesseldegeneration and calcification.3On the basis of our findings, no hypothesis can bedone on the pathogenesis of the changes observed.Clinical and laboratory investigations were negativefor other diseases possibly determining the changesobserved. As a consequence, chondroid transform-ation should be considered a non-specific responseto tissue injury following thrombophlebitis. As inthe case of arterial calcification, this process couldbe related to the expression of growth factors,matrix proteins and other bone-related proteins.An important role could be played by the cyto-skeletal gene SM22a, which has recently beendemonstrated to intervene in prochondrogenesisof the arterial media in response to injury.4 In par-ticular, cartilaginous metaplasia could be due totransformation of a-smooth muscle cells by theexpression of transforming growth factor b1.5References1 Wali MA, Eid RA, Dewan M, Al-Homrany MA. Pre-existing histopathological changes in the cephalic veinof renal failure patients before arterio-venous fistula(AVF) construction. Ann Thorac Cardiovasc Surg 2006;12:341–82 Shen J, Yang M, Jiang H, et al. Arterial injury promotesmedial chondrogenesis in Sm22 knockout mice. Cardio-vasc Res 2011;90:28–373 Aigner T, Neureiter D, Campean V, Soder S, Amann K.Expression of cartilage-specific markers in calcified andnon-calcified atherosclerotic lesions. Atherosclerosis 2008;196:37–414 Speer MY. Smooth muscle cells in pathogenesis of vascu-lar medial cartilaginous metaplasia. Cardiovasc Res 2011;90:1–25 Mathieu P, Roussel JC, Dagenais F, Anegon I. Cartilagi-nous metaplasia and calcification in aortic allograft isassociated with transforming growth factor beta 1expression. J Thorac Cardiovasc Surg 2003;126:1449–54A Caggiati and M Franceschini. Cartilaginous metaplasia of varicose veins Short reportPhlebology 2012:1–3 3

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Cartilaginous metaplasia of varicose veins: a case report

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