Chronic venous disease (CVD) is a prevalent condition that impairs the patient’s health-related quality of life and requires effective management [1]. Common symptoms include leg heaviness, fatigue, cramping or aching pain, swelling, throbbing, itching, or numbness. Venous hypertension (mechanical) and perivascular inflammatory (biochemical) changes are two cornerstones for understanding disease progression [2].

Femoral vein duplication (FVD) is a relatively common anatomical variant, with a reported prevalence of 31%-55% in the general population. In cases where valvular incompetence affects one of the duplicated veins, a closed-loop reflux circuit can develop, leading to venous hypertension and subsequent CVD symptoms [3]. Although some studies have provided insights into the surgical management of reflux in deep veins, reports on the minimally invasive technique specifically for treating reflux in symptomatic FVD remain scarce [3,4].

We present a rare case of CVD caused by reflux in FVD, which was successfully treated with cyanoacrylate glue ablation under ultrasonographic guidance. Institutional Review Board approval was waived due to the retrospective case report (Exemption Review No. P01-202409-01-008).

A 64-year-old male construction worker presented to our clinic with a history of bilateral leg heaviness, increased susceptibility to fatigue, and nocturnal cramping for several years. Symptoms were more pronounced in the right leg, worsened when standing or sitting for prolonged periods, and improved upon walking or lying down. The patient had a 5-year history of hypertension and hyperlipidemia, managed with medications.

On physical examination, Grade 1 pitting edema was noted in the right pretibial region, which was more likely to be physiological edema resulting from daily activities rather than a direct consequence of CVD. No other remarkable findings were noted in the examination. In the left leg, tortuous varicosity was identified at the mid-calf level. Laboratory tests revealed normal complete blood cell count, electrochemistry, and urine analysis results.

Duplex ultrasonography (DUS) revealed axial reflux (>1 second on DUS) in the left great saphenous vein (GSV), extending from the saphenofemoral junction (SFJ) to the mid-calf. In the right leg, superficial veins showed no reflux, thrombosis, or perforator incompetence. However, the femoral vein predominantly divided and rejoined posterior to the femoral artery, a variant known as bilateral post-arterial duplication [5]. This duplication extended from 5 cm distal to the SFJ to just proximal to the popliteal vein (Fig. 1A). The anteromedial branch demonstrated a normal venous flow pattern. In contrast, the posterolateral branch (6.2 mm diameter) exhibited deep vein reflux (DVR) lasting 2.3 seconds along its entire course (Fig. 1B).

Figure 1. (A) Ultrasonography showed a duplicated femoral vein in the right lower limb. The asterisk (*) indicates the refluxed vein, and the white arrow represents the direction of access. (B) Duplex ultrasonography showed deep vein reflux. The asterisk (*) marks the ablated deep vein at (C) 1 month and (D) 16 months postoperatively. The Doppler waveform in (C) revealed a normal blood flow pattern from the untreated branch of the FVD, with no abnormal findings. Only the faint Doppler signal observed in (D) was noise, as no blood flow was observed during compression of the leg. GSV, great saphenous vein; FA, femoral artery; dFV, duplicated femoral vein; Adductor L., adductor longus muscle; Vastus M., vastus medialis muscle; RT FVD, right femoral vein duplication.

The right leg was classified as symptomatic C0, Ep, Ad, Pr according to the CEAP system, and the patient was informed about the advantages and disadvantages of conservative management, surgical intervention, and endovenous ablation for symptomatic relief. Given the patient’s request for a fundamental treatment of the veins in both legs, percutaneous cyanoacrylate glue ablation of the refluxing right FVD and left GSV under ultrasonographic guidance was scheduled.

For the procedure, the patient was positioned supine with the right hip abducted and the knee flexed at 60° in a frog-leg position. After preparing the VenaSeal^TM Closure System kit (Medtronic), an 18-gauge, 6 cm disposable needle was inserted through the anterolateral thigh and advanced between the sartorius and vastus medialis muscles to access the refluxing vein (Fig. 1A). Under real-time B-mode ultrasonography guidance, a 0.018-inch guidewire was used to introduce a 5-French sheath, followed by the direct insertion of the white catheter into the sheath without requiring the blue catheter for backup. This approach allowed for the use of a smaller sheath than originally recommended, minimizing potential trauma to the surrounding muscle and tissue during vascular access. The patient was then placed in a 30-degree reverse Trendelenburg position, and ultrasonography confirmed the absence of antegrade flow in the target vein, with the catheter tip positioned 4 cm distal to the bifurcation. To prevent unintended glue-induced thrombosis, two assistants applied thumb pressure to the SFJ and popliteal vein in the posterior fossa. Cyanoacrylate glue ablation was performed over the 10-cm segment of the entire refluxing duplicated vein. The procedure lasted 16 minutes, and the patient was discharged without any discomfort.

Follow-up ultrasonography at 1 month and 16 months postoperatively confirmed complete ablation with no evidence of reflux in the duplicated vein (Fig. 1C, D). The patient remained symptom-free, with no complications such as limb edema, endovenous glue-induced hypersensitivity, or unintended extension of glue-induced thrombosis [6].

Femoral vein duplication is a common anatomical variation in the deep venous system, with an incidence ranging from 6% to 38% [7]. Traditionally, FVD has been significant for two reasons. First, the overall increased venous cross-sectional area compared to non-duplicated veins leads to reduced flow velocity, which is hypothesized to contribute to stasis and increase the risk of deep vein thrombosis (DVT) [7]. Second, in case of multiple femoral veins, internal collaterals can prevent complete occlusion by the thrombus, resulting in a higher prevalence of asymptomatic DVT in patients with FVD [8]. This case highlights another clinically relevant aspect of FVD, which is its association with a readily treatable form of symptomatic DVR (sDVR).

Unlike the well-established management protocols for superficial venous reflux, treatment options for sDVR are limited and primarily conservative. While conservative measures such as limb elevation, venoactive medications, exercise, and compression therapy may provide relief, they often fail to resolve symptoms entirely. Moreover, more invasive interventions, such as valvular reconstruction, are typically not considered when the only goal is symptomatic relief [9]. Zamboni and Gianesini [3] described a surgical technique involving selective ligation of the incompetent vein segment while preserving the competent parallel vein, effectively treating DVR in FVD cases.

Since the Food and Drug Administration approved cyanoacrylate glue ablation for truncal saphenous veins in 2015, this non-tumescent, non-thermal technique has gained popularity as a complementary alternative to endothermal ablation for its safety and efficacy [10]. However, its application for treating reflux associated with FVD falls outside the scope of its “Instructions for Use.” Despite this limitation, we performed cyanoacrylate glue ablation for DVR and successfully demonstrated significant improvement in both the patient’s symptoms and DVR. We also found that the anatomy of the FVD might be suitable for percutaneous endovenous glue ablation, offering a promising option for treating DVR with respect to technical safety and feasibility without requiring open surgery. Our patient remained symptom-free with no post-procedural complications and demonstrated stable occlusion at 1 year postoperatively.

To advance the application of cyanoacrylate glue ablation for treating FVD-associated reflux in clinical settings, it is crucial to establish appropriate patient selection criteria. Based on prior research regarding the indications for glue ablation in superficial venous insufficiency and considering the unique context of FVD, the following criteria are proposed. First, documented significant venous reflux in FVD should be confirmed via DUS. Second, the patient should exhibit persistent CVD symptoms refractory to optimized conservative treatments, including compression therapy and venoactive medications. Third, the parallel femoral vein without reflux must demonstrate sufficient patency and flow to ensure effective venous return following ablation of the incompetent segment. Fourth, the affected vein segment should be anatomically accessible for catheter-based intervention, with adequate length and structural integrity for effective glue delivery. Lastly, this technique is particularly suitable for patients preferring minimally invasive approaches or deemed as high-risk candidates for surgical treatment due to underlying comorbidities.

A technical point worth discussing is the optimal catheter tip position to prevent unintended glue-induced thrombosis. Cho and Joh [11] observed a 1.53-fold linear increase in the stump length for every 1-millimeter increment in the preoperative venous diameter. They found that in patients with a venous diameter ≥5 mm, safe glue injection could be achieved by positioning the catheter tip 4 cm distal to the junction to minimize the stump length. In our patient, preoperative DUS revealed a venous diameter of 6.2 mm, and the catheter tip was accordingly placed 4 cm distal to the bifurcation.

Moreover, although DUS is the standard tool for evaluating lower limb venous disease, routine office-based venous examinations using ultrasonography may have some limitations. These could potentially lead to missed diagnoses in patients presenting with CVD symptoms when thorough anatomical and functional examination of the deep vein has not been performed, resulting in false negative results during DUS evaluation compared to venographic studies [12].

In conclusion, we present a successful case of percutaneous endovenous glue ablation for symptomatic DVR in FVD. This case underscores the importance of thorough DUS examination for accurate diagnosis and treatment planning. Cyanoacrylate glue ablation may be a viable option for managing FVD-related reflux.

None.

The authors have nothing to disclose.

Concept and design: KY, EHJ. Analysis and interpretation: KY, ARS. Data collection: EJH, BMK. Writing the article: KY. Critical revision of the article: KY. Final approval of the article: all authors. Statistical analysis: none. Obtained funding: none. Overall responsibility: KY.