bleeding from ulceration of varicose lesions of the leg is not rare and is sometimes lethal . case reports illustrate the importance of first aid and 
 surgical intervention in preventing rupture . 
 here we report a case of massive bleeding from a varicose leg lesion in spite of surgical 
 intervention ; we found no such case previously reported . an 
 initial approach of high ligation of the great saphenous vein with complete ligation of 
 branches and closure of perforators can prevent bleeding . an 81-year - old japanese woman in hemorrhagic shock was transported by ambulance to our 
 hospital s emergency room . soon after her leg was elevated and fluid was infused , she recovered from shock and regained 
 consciousness . there were 2 old surgical scars at the groin and medial side of the knee . she 
 had had high ligation of the right saphenous vein at another hospital 2 years ago . her 
 sudden onset of bleeding occurred while she was washing her body in a hotel s public bath . she informed us that she was taking clopidogrel for cerebral artery stenosis and that she 
 had had high ligation of the right saphenous vein at another hospital 2 years ago . her 
 hemoglobin was 6.2 g / dl , and she was given a transfusion . one hour of pressure hemostasis , however , did not control the bleeding , which originated 
 from a pinhole in an anterior tibial varicose vein . we ligated the bleeding vessel by 
 inserting 2 u - stay sutures of 2 - 0 nylon through the skin at the proximal and distal site of 
 the pinhole , and the bleeding stopped . a three - dimensional enhanced computed tomography angiography done the next day showed the 
 entire residual great saphenous vein of the thigh ( figure 
 1figure 1three - dimensional enhanced computed tomography angiography of the right leg . arrow a 
 indicates the residual great saphenous vein , arrow b indicates the part of the vein 
 ligated during the initial surgery , and arrow c indicates the recurrent varicose lesion 
 that ruptured . the great saphenous vein had been ligated at the knee level in a 
 previous surgery ( figure 1 , arrow b ) , but the 
 distal portion of the vein remained . the blood supply was from the perforator of the 
 anterior tibial vein , which showed a varicose lesion ( figure 1 , arrow c ) up to the spontaneous rupture . arrow a 
 indicates the residual great saphenous vein , arrow b indicates the part of the vein 
 ligated during the initial surgery , and arrow c indicates the recurrent varicose lesion 
 that ruptured . a magnetic resonance angiogram of the carotid and cerebral arteries revealed no significant 
 stenosis , and an enhanced ct scan revealed no stenosis of the leg arteries . one week after admission , we undertook 
 high ligation of the residual saphenous vein and ligated all of the varicose vein and its 
 perforators under tumescent local anesthesia . we did a careful and complete ligation of the 
 branches around the saphenofemoral vein junction . there was an stump at the femoral vein 
 that may have been the saphenous vein ligated in the initial surgery . hemorrhaging after high ligation of varicose veins has not been previously reported , and we 
 can think of 2 possibilities to account for the case we describe here : the surgeon who did 
 the first procedure may have ligated the wrong branch , or the patient may have a double 
 great saphenous vein system . either way , the current high ligation ( complete ligation of 
 branches around the saphenofemoral junction ) should prevent recurrence of a varicose lesion 
 and an ensuing bleeding episode . skin ulcers are commonly associated with bleeding leg varicose vein lesions , but in this case we found only a pinhole skin wound , and the 
 patient did not notice any skin injury prior to admission . it is possible that she scratched 
 her leg in the process of washing in the hotel s public bath and that the clopidogrel she 
 was taking contributed to the massive bleeding that followed . her survival may have been 
 made possible by the hotel guests around her helping her to restrict blood flow near the 
 wound and calling an ambulance . no guidelines exist for treating varicose veins of the leg , and it is especially difficult to determine the 
 appropriate treatment for advanced cases . endovenous laser treatment is becoming 
 common , and while our 
 institute is authorized by the japanese society of phlebology to use that technique , our 
 standard technique consists of high ligation , entire removal of enlarged lesions of the 
 great and minor saphenous vein , and ligation of perforators under tumescent local 
 anesthesia . laser surgery , which has better cosmetic outcomes , may be as effective as high 
 ligation , but it is 
 contraindicated in most of the cases our institute handles . the most common contraindication 
 in our patient population is enlarged vein size and concomitant femoral lesions . one of the 
 reasons we see so many advanced cases is that our hospital serves a rural area where many 
 patients are aged and have worked hard over their lifetime as farmers , fishermen , and 
 foresters . we are in the process of preparing a precise analysis of the outcomes of our 
 cases , which number over five hundred .
we report a case of massive , life - threatening from a varicose lesion of the right lower 
 extremity . 
 an 81-year - old lady was brought to the emergency room at our hospital because 
 of massive bleeding from her right leg . 
 she had had high ligation of the right saphenous 
 vein at another hospital 2 years ago . 
 after hemostat and transfusion , she recovered from 
 hemorrhagic shock . 
 three - dimensional enhanced computed tomography angiography revealed a 
 residual right great saphenous vein and recurrent varicose lesion . 
 we performed high 
 ligation of the great saphenous vein and closed all of the residual perforators . 
 the 
 patient was discharged hospital 10 days after the surgery and experienced no bleeding 
 episodes within 8 months after the surgery . 
 certain high ligation and elimination of 
 perforators of the great saphenous vein in surgery for varicose vein of leg is necessary 
 to prevent lethal bleeding .