Case Report Fatal lower extremity varicose vein rupture Garyfalia Ampanozi ⇑ , Ulrich Preiss, Gary M. Hatch, Wolf Dieter Zech, Thomas Ketterer, Stephan Bolliger, Michael J. Thali, Thomas D. Ruder Center of Forensic Imaging and Virtopsy, Institute of Forensic Medicine, University of Bern, Buehlstrasse 20, CH 3012 Bern, Switzerland article info Article history: Received 4 October 2010 Received in revised form 2 November 2010 Accepted 11 November 2010 Available online 8 December 2010 Keywords: Fatal hemorrhage Varicose veins Virtopsy Post-mortem CT angiography Post-mortem MRI abstract Varicose vein rupture is a rare cause of death, although varicosities are a common pathology. We present three cases of sudden death due to varicose vein rupture. After a review of the literature, the case circum- stances and the findings of imaging examination, performed in two cases, are presented. One of them had undergone a post-mortem computed tomography angiography (PMCTA), and one a PMCTA as well as a post-mortem magnetic resonance (PMMR) imaging prior to conventional autopsy. One of the cases presented herein is, to our knowledge, the youngest known fatality due to varicose vein rupture. Ó 2010 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Varicose veins are considered a common condition, with a prev- alence from 2% to 56% in men and from 1% to 73% in women. Female gender, older age, family history, obesity, and occupations requiring prolonged standing are risk factors associated with the development of varicose veins [1]. However, they are not generally considered a life threatening condition [1]. In the 37 years since 1973, when Evans first described 23 fatalities due to ruptured varicose veins [2], only 39 more have been reported in the litera- ture [3–11]. Evans describes two types of bleeding dermal ulcers: the acute perforative type and the chronic ulcerative type. The clinical appearance of an acute perforative ulcer is a small, shallow lesion with slight adjacent cutaneous pigmentation or eczema. The chronic ulcerative process produces a large, deeper ulcer [2]. According to Byard and Gilbert [5], the prevalence of ruptured varicose veins (as a cause of death) is less than 1 in 1000 autopsy cases. The age distribution of the victims varies. According to Byard, these events often involve elderly reclusive individuals [5]. The youngest fatality to date was a 43-year-old man, described by Hejna [8]. The cause of death in all cases was severe hemorrhage and subsequent hypovolemic shock. The Virtopsy project introduced by Thali et al. [12] describes post-mortem imaging (computed tomography, CT, and magnetic resonance imaging, MRI) and its relation to autopsy findings. MRI has proven very useful in detecting small soft-tissue abnormalities [12]. Moreover, post-mortem angiography has overcome one of the last ‘‘blind spots’’ of post-mortem imaging: the display of vascular abnormalities [13]. We present three cases of sudden death due to ruptured vari- cose veins, which were autopsied in our institute during a 4 month period. All cases underwent an autopsy. One case (case 3) under- went post-mortem computed tomography (PMCT), post-mortem magnetic resonance (PMMR) imaging and post-mortem computed tomography angiography (PMCTA) prior to the conventional autopsy. A second case (case 1) underwent a PMCT and a PMCTA examination. 2. Case circumstances and findings 2.1. Imaging The bodies were scanned in artifact-free body bags (Rudolph Egli AG, Bern, Switzerland). Imaging was performed using a 6-slice-CT (Somatom Emotion 6, Siemens, Forchheim, Germany) and a 1.5 T MRI unit (Sonata, Magnetom, Siemens). The PMCTA in cases 1 and 3 was performed after an unenhanced CT scan. The femoral artery and vein were exposed and cannulated. The contrast medium used was a solution of polyethylene glycol (PEG 200, Schärer and Schläpfer AG, Rothrist, Switzerland) and iopentol (Imagopaque 300, GE Healthcare, Basel, Switzerland), in a mixture ratio of 10:1. Contrast medium was injected into the femoral artery first, and then into the femoral vein. After each contrast medium injection, a CT scan was performed (arterial and venous phase CT scan) [13,14]. 1344-6223/$ - see front matter Ó 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.legalmed.2010.11.002 ⇑ Corresponding author. Tel.: +41 31 631 84 11; fax: +41 31 631 38 33. E-mail addresses: garyfalia.ampanozi@irm.unibe.ch, ampanozi@hotmail.com (G. Ampanozi). Legal Medicine 13 (2011) 87–90 Contents lists available at ScienceDirect Legal Medicine journal homepage: www.elsevier.com/locate/legalmed