Venous aneurysms are rare malformations that may present in different sizes, shapes, and locations. They are most commonly found in the head and neck region7. They tend to remain asymptomatic unless they thrombose or spontaneously rupture10. Their clinical presentation may be similar to other

conditions in the region, but can be differentiated with ultrasound and CT14. This case report presents a 62 year old man with an asymptomatic saccular aneurysm in the internal jugular vein that was corrected with an elective surgical resection.

A 62 year old male presented with a non- pulsatile, nontender soft mass in the right neck discovered while shaving within the last month. Subsequent work up revealed this to be a venous aneurysm of the internal jugular vein. The patient denied any associated symptoms related to the aneurysm but desired an elective resection due to aesthetic reasons. Upon examination, the patient was afebrile, AAOx3, and in no apparent distress, with a slight mass in the right neck that was mildly fluctuant in nature and exhibited venous pulsation. The mass was nontender without any overlying erythema or skin changes. Patient did not have jugular venous distention on the left side nor any cervical lymphadenopathy. There was no history of known trauma, arterial/venous catheterizations or past surgeries in that region of the neck. Neurological examination showed no deficits with CN II – XII grossly intact.

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Saccular Internal Jugular Venous Aneurysm

Laboratory studies were reviewed and were within normal limits. Ultrasound was not performed. TA revealed an area of aneurysmal dilatation of the right internal jugular vein measuring 4.4cm x2cm. It was saccular in appearance. (Figure 1,2,3).

Figure1.

Figure 2.

Figure 3.

The patient proceeded with surgical intervention after being informed of the risks, benefits, and alternatives. The procedure was performed under general endotracheal anesthesia. The internal jugular vein was clamped proximally and distally, the aneurysmal sac was visualized (~3x4cm in size), incised, and resected from the anterior vein wall (Figure 4). The venotomy was closed using a bovine patch angioplasty (Figure 5). Intra-operative Doppler evaluation revealed excellent venous flow signals through the internal jugular vein. The patient tolerated the surgery well and was taken to the post anesthesia care unit in stable condition.

Figure 4: Visualization of the IJV

Figure 5: Venotomy closed using a bovine patch angioplasty

Venous aneurysms are dilatations or bulging of the veins that occur after the venous wall is stretched or weakened1. Unlike this case of an internal jugular vein (IJV) aneurysm, most aneurysms occur in the superior vena cava and in the popliteal veins2.

These aneurysms have no established classification that can be found in the texts of vascular medicine. However, Gerwig Jr. [3], Eifert et al. [4], Abbott and Leigh[5] have proposed distinct classifications; some general terms that exist consist of: primary

(congenital), acquired, saccular, and fusiform. Saccular aneurysms appear like a sack and are ballooning of the wall of the vessels. Fusiform aneurysms have a more elongated appearance. Macroscopically, aneurysms are described as saccular; however phlebectasias, defined as any change in the venous diameter, are described as fusiform6.

While venous malformations of the jugular veins are very rare, the most commonly affected site in the head and neck is the internal jugular vein7. The etiology of venous aneurysms remains unknown, but congenital factors, inflammation, trauma as well as degenerative changes have been proposed in contributing to the formation of the venous aneurysms8. Jugular fusiform phlebectasias are thought to be congenital, slow growing and rarely noticed until puberty. Histologically, phlebectasias have a thinned elastic/muscular layer9. Unlike this reported case, most saccular aneurysms are known to thrombose and are shown to have degenerative histological changes. Most cases are asymptomatic; symptoms present after thromboembolism.

Other complications include spontaneous rupture and thrombophlebitis10. In this particular case, the patient discovered the mass while shaving and had been completely asymptomatic to this point.

An IJV aneurysm’s clinical presentation is similar to cavernous hemangiomas, brachial cysts, laryngoceles, cystic hygroma, lymphangiomas, and carcinomas11. IJV aneurysms can be broadly and clinically differentiated. The aneurysm can be enhanced by performing valsalva maneuver,

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JERAFS

coughing, crying, and compressing the vein12.

Nevertheless, the most common cause of a mass in the neck is a laryngocele13. When diagnosing a cervical mass, the most accurate testing is ultrasonography, combined with doppler flow imaging, CT angiography, or gadolinium-enhanced magnetic angiography. However, ultrasonography still remains the best method of evaluating these aneurysms because it is noninvasive, low cost, and accurate; it provides a rapid imaging technique that can delineate the extent of the aneurysm and its anatomical relationship with the surrounding structures in the neck14. In this case, CT was used to evaluate an area of aneurismal dilation of the right internal jugular vein measuring 4.4cm x 2.0 cm.

Due to the lack of classification, treatment options vary. Most of these aneurysms are benign in nature with no serious complications being reported. Rarely, thromboembolic events have been noted when the venous aneurysms are located in the abdominal region or lower extremities. Even with decreased likelihood of complications, the preferred choice of treatment for saccular aneurysms has still been surgical resection15. Surgical resection performed on this patient was due in large part to the size of the aneurysm and as well as its disfiguring nature. In contrast, jugular phlebectasias are treated more conservatively, and patients are simply followed clinically unless they become symptomatic or disfigured16.

Conclusion

Diagnosis of a venous aneurysm simply based on clinical presentation is difficult as these malformations are rare. The known literature on venous aneurysms reports variable symptomatology. These range from completely asymptomatic instances to severely complicated cases consisting of deep vein thromboses, pulmonary embolism, thrombophlebitis, and death10. Ultrasound and CT are clear diagnostic and confirmatory tests regardless of the shape, size, and location of the aneurysm.

This was a benign case of an internal jugular aneurysm that was found accidentally by the patient. The resection was done to avoid complications as well as for cosmetic reasons. During surgery, a saccular aneurysm measuring ~3x4cm in size was safely resected, and the patient recovered well with no complications. Due to the potential morbidity, surgical resection should be strongly considered in patients with internal jugular aneurysms.

Diagnosis of a venous aneurysm simply based on clinical presentation is difficult as these malformations are rare. The known literature on venous aneurysms reports variable symptomatology. These range from completely asymptomatic instances to severely complicated cases consisting of deep vein thromboses, pulmonary embolism, thrombophlebitis, and death10. Ultrasound and CT are clear diagnostic and confirmatory tests regardless of the shape, size, and location of the aneurysm.

This was a benign case of an internal jugular aneurysm that was found accidentally by the patient. The resection was done to avoid complications as well as for cosmetic reasons. During surgery, a saccular aneurysm measuring ~3x4cm in size was safely resected, and the patient recovered well with no complications. Due to the potential morbidity, surgical resection should be strongly considered in patients with internal jugular aneurysms.

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