Needle trauma as a trigger for clinical manifestation of a pre-existing venous malformation: a case report

Abstract

Vascular anomalies include a broad spectrum of benign congenital lesions with varying clinical presentations. Historically, terms such as ‘cavernous hemangioma’ have been used imprecisely. Recent consensus supports classifying these lesions as vascular malformations rather than tumors. We report a case of a 58-year-old man with a venous malformation of the arm that became clinically evident at the site of venous blood sampling 10 years earlier. Preoperative computed tomography scan showed a well-circumscribed, vascularized mass in the antecubital fossa. Excision was performed for progressive enlargement, recurrent thrombophlebitis. Histopathology confirmed a low-flow venous malformation consistent with current vascular anomaly classifications. Although venous malformations are congenital lesions, the temporal association with venous puncture suggests that local trauma may have induced hemorrhage or thrombosis, acting as a trigger for lesion enlargement and clinical manifestation. This case highlights the possible role of local trauma in triggering the clinical manifestation and progression of a previously silent venous malformation.

Introduction

Vascular anomalies represent a heterogeneous group of congenital lesions characterized by abnormal blood vessel development [1–5]. The International Society for the Study of Vascular Anomalies (ISSVA) classification divides these anomalies into vascular tumors and vascular malformations, with the latter including low-flow lesions such as venous malformations historically misclassified as cavernous hemangiomas [6–8]. Vascular malformations are congenital, they may remain clinically silent for years and can become evident following triggering events such as trauma, thrombosis, or hormonal changes. We present a rare case of a venous malformation of the left arm that became clinically evident more than a decade after venous blood sampling at the same site, highlighting a possible role of local trauma in unmasking a previously asymptomatic lesion.

Case report

A 58-year-old male presented with a slowly enlarging, painless mass on the central-lateral aspect of his left arm (Fig. 1), which became clinically evident 10 years after venous blood sampling at the same site, complicated by hemorrhage. Serial ultrasounds initially demonstrated lesion stability, however, the patient later developed recurrent thrombophlebitis and increasing skin discomfort. Preoperative computed tomography revealed a well-defined, vascularized soft tissue lesion localized in the antecubital fossa (Fig. 2). The lesion appeared circumscribed with imaging features consistent with a low-flow vascular malformation [9]. Surgical excision was performed (Fig. 3), and histopathological analysis confirmed dilated, thin-walled vessels with spongiform architecture typical of venous malformations (Figs 4–6) [1, 8]. The patient’s postoperative course was uneventful with resolution of symptoms.

Discussion

Venous malformations are congenital low-flow vascular anomalies composed of ectatic venous channels with slow blood flow and absent endothelial proliferation, differentiating them from vascular tumors such as infantile hemangiomas [1–9]. The term ‘cavernous hemangioma’ has been criticized and largely abandoned due to the potential for misclassification and inappropriate treatment strategies [6–8]. According to the ISSVA classification, venous malformations are congenital lesions and are unlikely to arise de novo following minor trauma. In this case, it is more plausible that a previously asymptomatic venous malformation was present, and that the venous puncture induced hemorrhage or thrombosis, leading to its subsequent enlargement and clinical manifestation. The pathophysiological response to local trauma may involve hemorrhage, hematoma formation, thrombosis, and subsequent vessel recanalization with abnormal vascular remodeling [10–12]. This cascade can contribute to the expansion of a pre-existing malformation over time. Most literature reports trauma-associated vascular changes in synovial tissues or subcutaneous locations, but this case highlights a possible role of local trauma in triggering the clinical manifestation and progression of a previously silent venous malformation [9, 10]. Imaging modalities such as Doppler ultrasound, computed tomography (CT), and magnetic resonance imaging are critical for lesion characterization and surgical planning [1, 2], while histopathology remains the gold standard for confirming the diagnosis and excluding malignancy [4]. Early diagnosis and intervention are crucial to prevent complications such as thrombophlebitis, hemorrhage, or functional impairment. Surgical excision remains the mainstay of treatment for symptomatic or enlarging lesions [11].

Conclusion

This case underscores the importance of recognizing needle trauma as a potential trigger for the clinical manifestation and reflects evolving understanding of vascular anomaly classification. Updated terminology, thorough imaging, and histopathological evaluation are key to appropriate diagnosis and management. Awareness of such atypical presentations can improve patient outcomes and help prevent misdiagnosis.

Conflicts of interest

None declared.

Funding

None declared.

References