High resolution unenhanced computed tomography in patients with swollen legs

PURPOSE: To evaluate the accuracy of computed tomography (CT) scan imaging in distinguishing lymphedema from deep venous thrombosis (DVT) and lipodystrophy (lipedema) in patients with swollen legs. MATERIAL AND METHODS: CT scans of the lower limbs were performed in 55 patients with 76 swollen legs (44 lymphedemas, 12 DVT and 20 lipedemas). Thirty-four normal contralateral legs were also similarly evaluated. Primary lymphedema was verified by lymphography or lymphoscintigraphy, whereas secondary lymphedema was documented by a typical clinical history. DVT was established by ultrasound Doppler imaging. The diagnosis of lipedema was made with bilateral swollen legs where lymphoscintigraphy and Doppler examination were both unremarkable. Qualitative CT analysis was based on skin thickening, subcutaneous edema accumulation with a honeycombed pattern, and muscle compartment enlargement. RESULTS: Sensitivity and specificity of CT scan for the diagnosis of lymphedema was 93 and 100%, respectively; for lipedema it was 95 and 100%, respectively; andfor DVT it was 91 and 99%, respectively. Skin thickening was found in 42 lymphedemas (95%), in 9 DVT (75%), and in 2 lipedemas (16%). Subcutaneous edema accumulation was demonstrated in 42 legs (95%) with lymphedema and in 5 (42%) with DVT but in none with lipedema. A honeycombed pattern was present only in lymphedema (18 legs or 41%); muscle enlargement was present in all patients with DVT, in no patient with lipedema, and in 4 (9%) with lymphedema. CONCLUSION: Edema accumulation is readily demonstrated with plain CT scan and is not present in lipedema. Specific CT features of the subcutaneous fat and muscle compartments allow accurate differentiation between lymphedema and DVT.     

Impaired ambulatory venous function in lymphedema assessed by near-infrared spectroscopy.

AIM: The aim of this study was to investigate venous function in patients with leg lymphedema during exercise using near-infrared spectroscopy (NIRS), compared with that of patients with chronic venous insufficiency (CVI). METHODS: Forty-three legs of 33 patients (5 males, 28 females; mean age: 53 years) with leg lymphedema without varicose veins or deep vein thrombosis underwent a treadmill walking test with simultaneous NIRS. For comparison, 136 legs of 91 patients (35 males, 56 females; mean age: 56 years) with varicose veins as a CVI group and 45 legs of 38 healthy volunteers (23 males, 15 females; mean age: 50 years) were also evaluated in the same method. Deoxygenated hemoglobin (HHb) was continuously measured during exercise, and the ambulatory venous retention index (AVRI) of each leg was obtained from the serial changes in HHb. RESULTS: The mean AVRI of the lymphedema group was significantly higher than that of healthy legs and significantly lower than of legs with moderate or severe CVI. Furthermore, it was similar to that in the mild CVI group. CONCLUSIONS: Venous function is impaired in exercising legs with lymphedema, and corresponds to that in legs with mild venous insufficiency. The treatment of lymphedema should take CVI into consideration.     

Comparative analysis of lymphoscintigraphy between lipedema and lower limb lymphedema

Lipedema is characterized by bilateral enlargement of the legs due to abnormal deposition of fat tissue from pelvis to ankles. It is seen most frequently in obese women. Lipedema appears to be a distinct clinical entity but may be confounded with lymphedema. AIM OF THE STUDY: To analyze and to compare between lipedema and lymphedema the qualitative and quantitative aspects of lymphoscintigraphy. METHODS: Fifteen women with lipedema were recruited. Mean age of onset of lipedema was 31.5 +/- 15 years. Body mass index was 35.1 +/- 7.9 kg/m2, 13 women were obese. Lipedema was compared to 15 cases of primary lymphedema (women: 13, men: 2) of the lower limbs (unilateral: 13, bilateral: 2), with a mean age at onset of 28.7 +/- 12.6 years. Lymphoscintigraphy of the lower limbs with morphologic (visualization of inguinal lymph nodes) and kinetic (half-life, lymphatic speed of the colloid) studies was performed in all cases. RESULTS: Absence of visualization of inguinal lymph nodes was observed in 14/15 cases of lymphedema and in 1/15 cases of lipedema (p<0.001). In the 13 cases of unilateral lymphedema, colloid half-life was higher in the pathologic limb than in the controlateral limb (230 +/- 92 vs 121 +/- 36 minutes, p<0.01) and lymphatic speed of the colloid was slower (6.91 +/- 0.86 vs 8.16 +/- 1.02 cm/min, p<0.001). The two patients with bilateral lymphedema had an increased half-life and decreased lymphatic speed of the colloid. Colloid half-life was significantly higher in lipedema than in controlateral limbs of lymphedema (154 +/- 23 vs 121 +/- 36 minutes, p<0.01) with no difference in lymphatic speed of the colloid. Colloid half-life was significantly higher in lymphedema than in lipedema (230 +/- 92 vs 154 +/- 23 minutes, p<0.01) and the lymphatic speed of the colloid was slower (6.91 +/- 0.86 vs 8.10 +/- 0.45 cm/min, p<0.001). CONCLUSION: Lower limb lymphoscintigraphy showed lymphatic insufficiency in lipedema without morphologic abnormality as seen in lymphedema. Lymphoscintigraphy is not indispensable but is a useful tool when diagnosis is doubtful. Treatment is difficult and may include weight loss and possible surgery.     

Prevalence and risk factors of varicose veins in Japanese women

The prevalence and risk factors of varicose veins in Japan were investigated in 541 Japanese women. Varicose veins were defined as any dilated, tortuous, and elongated veins of the lower extremity and classified into four types. The total prevalence rate was 45%. Saphenous type was observed in 22%, segment type in 35%, reticular type in 28%, and web type in 16%. Varicose veins in Japan seem to be less common than in the United States and Europe but more prevalent than in Africa. Concerning risk factors for varices, age, sex, heredity, and childbirth were related to the incidence of varicosities, as reported by others. However, these risk factors were shown to differ according to type of varicose veins.     

Current Evaluation and Treatment of Lower Extremity Varicose Veins

Historically, treatment for symptomatic lower extremity varicose veins has consisted primarily of surgical stripping of pathologic veins. Over the past 2 decades, therapeutic options for lower extremity varicose veins has greatly expanded and now includes several percutaneous and endovascular techniques. This article will discuss the pathophysiology, clinical significance and current therapy for varicose veins.     

Chronic venous insufficiency in primary varicose veins evaluated by plethysmographic technique

Venous hemodynamics were evaluated by plethysmography in normal subjects and patients with venous disorders of the lower extremity, to clarify the pathophysiology of chronic venous insufficiency (CVI) due to primary varicose veins. Expelled volume during five active dorsiflexions of the feet and venous recovery time were calculated to evaluate muscle pump efficiency and valvular competence. Limbs with CVI due to primary varicose veins showed a higher expelled volume and a more shortened refilling time than limbs with simple varicosities. With application of tourniquets, the refilling time normalized in limbs with CVI, as well as in limbs with simple varicosities. These results indicate that a high degree of venous congestion in the distal part of the calf and valvular incompetence of the superficial vein system might cause CVI due to primary varicose veins.     

Postphlebitic syndrome and general surgery: an epidemiologic investigation

Of a random sample comprising 4581 subjects from The Copenhagen County, 3608 (79%) attended an interview and a general health examination. The subjects were defined as suffering from subjective postphlebitic syndrome if they claimed of lower extremity pain or cramps at rest and from objective postphlebitic syndrome if varicose veins, edema, lower extremity ulcers, or skin changes were present. By means of logistic regression analysis, subjective postphlebitic syndrome was found independently associated with previous thromboembolism, obesity, increasing age, female sex, hormonal therapy, varicose veins, and previous major abdominal surgery. Objective postphlebitic syndrome was associated with previous thromboembolism, obesity, former birthgiving, and high social status. The findings support the view that subclinical deep venous thrombosis in connection with previous surgery may give rise to symptoms in the lower extremities.     

老年人下肢静脉曲张61例微创手术治疗分析

目的总结多种微创手术(腔镜超声刀穿通静脉离断、钬激光灼闭及Trivex动力旋切术)联合治疗老年人下肢静脉曲张的早期疗效,评价微创手术在老年下肢静脉曲张患者中的应用价值。方法回顾性分析71例(104条肢体)行微创手术治疗的老年下肢静脉曲张患者的临床资料,观察手术效果、术后并发症、随访复发率等指标。结果71例均治愈。切口平均愈合时间4.3 d,术后平均住院时间4.8 d,18例(29.5%)术后出现不同程度的并发症,经相应治疗后均痊愈或缓解。术后随访1～6个月,未见复发。结论下肢静脉曲张微创手术具有安全、有效、适应证广、创伤小、恢复快、住院周期短的优点,尤其适合老年患者。     

Lysosomal enzymes and superoxide production in polymorphonuclear leukocytes of patients with primary varicose veins.

In order to clarify the role of reactive oxygen species and lysosomal enzymes in the etiopathogenesis of varicose veins, the investigation of their activities in serum and peripheral neutrophils of 17 patients with primary varicose veins was done. The mean activities of acid phosphatase, beta-D-glucuronidase (BDG) and N-acetyl-beta-D-glucosaminidase were higher in serum of patients with varicose veins than in serum of normal subjects. However, the mean BDG activity was lower in the patients' neutrophils and the activities of elastase and myeloperoxidase were higher than in clinically healthy persons. No changes have been observed in the lysozyme activity. The neutrophils of patients with varicose veins had a greater ability to increase superoxide production after their stimulation with opsonized zymosan or phorbol myristate acetate than the neutrophils of normal subjects, while no differences were found in the total reduction of iodonitrotetrazolium (INT) incubated with these leukocytes. The results may represent another piece of evidence suggesting the activation and involvement of neutrophils in pathogenesis of chronic venous insufficiency of lower limbs.     

Lipedema complicated by lymphedema of the abdominal wall and lower limbs

We describe a 52 year-old woman in whom lymphedema primarily of the abdominal wall was superimposed on lipedema resulting in an abdomen of enormous dimensions with marked impairment of ambulation. Treatment consisted of preoperative compression of the legs by an external pneumatic device (Lympha-Press) followed by excision of the lymphedematous abdominal fat pad in conjunction with "debulking" of the right leg. The patient illustrates the extremes of lipedema complicated by lymphedema and the technical difficulties associated with its management.     

Real-time ultrasound in the diagnosis of acute deep venous thrombosis of the lower extremity

One hundred twenty-six patients with clinically suspected acute deep venous thrombosis of the lower extremity (DVT) were examined comparatively with ultrasound and venography. In total, 174 lower extremity venograms were obtained. Ultrasonic examinations were performed on patients in the supine position. The venous segments were evaluated almost exclusively with transversal scanning. In the thigh, the only criterion for DVT was the reduced or absent compressibility of the venous lumen when gently compressed with the transducer. In the calf, normal unobstructed veins can usually not be viewed in the supine patient, whereas thrombotic veins appear as sonolucent, incompressible channels. Eight-three of the 174 lower extremity venograms were positive for DVT. In the majority of cases (53 of 83) the thrombotic process had involved two or more segments in combination. The sites of involvement of the different venous segments were distributed as follows: 24 occlusions of the common femoral vein, 52 of the superficial femoral vein, 56 of the popliteal vein, and 71 of the calf veins. Ultrasound had a sensitivity of 100% for thrombosis of the common femoral vein, 96% for the superficial femoral veins, 98% for the popliteal vein, and 93% for the calf veins. For the entire lower extremity, in regard to the diagnosis of thrombosis, the overall sensitivity was 95%. In 90% the extension of the occlusion was foreseen correctly. In no cases were false-positive results reported. Thus the overall specificity was 100%. The authors conclude that real-time ultrasound is a highly accurate method for the diagnosis of DVT of the lower extremity. It is the only indirect method capable of evaluating the venous system of the thigh, as well as that of the calf, with high accuracy. It should be the first choice of diagnostic imaging method in the diagnosis of deep venous thrombosis of the lower extremity.     

Venous circulatory resistance in the diagnosis and follow-up of venous thromboses

Using a mercury plethysmograph, the venous resistance (a novel venous parameter) is determined separately for the veins of the thigh and lower leg, using the Brakkee and Kuiper (1982) method. In a retrospective study of acute and subacute thrombosis, the authors detected sensitivity of 91 and 36% respectively in proximal and distal thromboses. Specificity was 100 percent. Although differences from the control grop were detected, it would seem that the presence of a varicose trunk or lymphedema does not affect either sensitivity or specificity.     

Current treatment of varices of the lower extremities in Czechoslovakia

The author gives original information on the situation in Czechoslovakia regarding the treatment of varicose veins. The prevalence of varicose veins is 20%, the incidence is more than 1% in the adult population. Heredity accounts for 75% of these cases. In one year, only 35 to 129 patients are operated for varicose veins in a department of Clinical Surgery. The serious complications were analysed over a period of 10 years: there were 37 cases of pulmonary embolism and 10 deaths out of 95,000 operations for varices. The long-term results, that is from 5 - 15 years, were considered to be satisfactory in more than 90% of the cases operated. In Czechoslovakia, sclerotherapy is still a complementary method. However, the good results of sclerosing varices have been proven by the statistics issued by the phlebological clinics set up by the Czech Dermatological Association.     

Usefulness of triggered non-contrast-enhanced magnetic resonance angiography in assessing lower extremity venous disease

Although venous duplex ultrasonography (USG) is reliable for diagnosing lower extremity venous disease (LEVD), cross-sectional imaging studies were usually required before intervention or surgery. Patients of LEVD with renal insufficiency usually restrict the use of contrast-enhanced imaging modalities. In seeking an alternative imaging solution for these patients, we explore the clinical utility of triggered angiography non-contrast-enhanced magnetic resonance imaging (TRANCE-MRI) in the assessment of LEVD.We collected data from patients presenting to a tertiary wound-care center with symptoms of LEVD from April 2017–November 2019. Each participant underwent baseline USG followed by TRANCE-MRI on a 1.5T MR scanner (Philips Ingenia, Philips Healthcare, Best, The Netherlands). Inter-rater reliability was measured using Cohen''s kappa (κ).All 80 participants (mean age, 61.9 ± 14.8 years; 35 males, 45 females) were assessed and were classified into one of five disease groups, deep vein thrombosis (n = 38), venous static ulcer (n = 16), symptomatic varicose veins (n = 18), recurrent varicose veins (n = 3), and lymphoedema (n = 5). The inter-rater reliability between TRANCE-MRI and doppler USG showed substantial agreement (κ, 0.73). The sensitivity, specificity, and accuracy of TRANCE-MRI were 90.5%, 88.1%, and 88.8%, respectively. In 59 (73.8%) USG-negative patients, we were able to diagnose positive findings (deep venous thrombosis, n = 7; varicose veins, n = 15; lymphedema, n = 10; iliac vein compression with thrombosis, n = 6; external venous compression, n = 5; vena cava anomaly, n = 2; occult peripheral artery disease, n = 5; ccluded bypass graft, n = 1) by using TRANCE-MRI. Of these, 9 (15.3%) patients underwent additional vascular surgery based on positive TRANCE-MRI findings.TRANCE technique provides the limb''s entire venous drainage in clear images without background contamination by associated arterial imaging. Additionally, simultaneous evaluation of bilateral lower extremities can help determine the lesion''s exact site. Although TRANCE-MRI can provide MR arteriography and MR venography, we recommend performing only MR venography in symptomatic LEVD patients because the incidence of occult arterial disease is low.     

腔内射频消融闭合术治疗老年人下肢浅静脉曲张的随访研究

目的 评价腔内射频消融闭合术治疗老年人下肢浅静脉曲张的临床疗效.方法 选择接受过腔内射频消融闭合术治疗的35例(43条患肢)原发性大隐静脉曲张老年患者进行随访、分析,大隐静脉主干均全程射频治疗,其中23条患肢同时行高位结扎大隐静脉,20条患肢未行高位结扎,根据临床症状、体征改善情况及彩色多普勒超声检查结果评价术后1～3年的疗效.结果 腔内射频消融闭合术联合行大隐静脉高位结扎组大隐静脉主干闭塞率明显高于未行高位结扎组,分别为21例(91.3%)和14例(70.0%),二者比较差异有统计学意义(χ2=5.467,P<0.05);且再通率明显降低,分别为2例(8.7%)和8例(30.0%),差异有统计学意义(χ2=4.251,P<0.05);局部浅静脉曲张复发率降低.差异有统计学意义[0例与4例(20.0%),χ2=7.030,P<0.01].结论 腔内射频消融闭合术治疗老年下肢浅静脉曲张微创、安全、美观、疗效可靠,联合行大隐静脉高位结扎术,疗效可能更好,但需要进一步长期随访观察.     

Magnetic resonance venography of the lower limb.

Prior to surgery or endovascular therapy for the lower extremity varicose veins or deep venous thrombosis (DVT), ultrasonography provides useful information. But it depends on the operator's technique, each image is limited to a small field of view and interpretation may be subjective. On the other hand, magnetic resonance (MR) imaging is now available with several postprocessing techniques using workstations to demonstrate the gross and objective morphology of these lesions less invasively than the conventional ascending venography. As non-contrast MR venography, fat suppressed three-dimensional (3D) coronal balanced turbo field echo (bTFE) is mainly applied in the semisupine position. The varicose veins on the muscle fascia are easily recognized on volume rendering and the perforating veins can be identified on maximum intensity projection (MIP) and axial multiplanar reconstructions. Gadolinium-enhanced fluid attenuated inversion recovery-bTFE is added when coexisting joint effusion or edema masks the veins. For DVT, direct thrombus imaging (DTI) using fat suppressed 3D coronal inversion recovery-prepared blood suppressed gradient echo sequence is applied. However, the signal intensity of DVT depends on the clot's age on DTI and is sometimes confusing on bTFE. After gadolinium administration, blood shows higher signal intensity than clots regardless of the age and DVT can be easily depicted as filling defects on the axial reformations and summarized on the soap bubble-MIP.     

Varicography in the management of recurrent varicose veins

Forty lower extremities in 29 patients with recurrent varicose veins have been investigated by varicography. In 29 lower extremities the recurrent varicosities were on the long saphenous venous system and in 11 lower extremities on the short saphenous system. The recurrences consisted of varicose segments or tributaries of the long or short saphenous veins, varicose tributaries at the sites of previous ligations of varicose veins, and varicosities associated with incompetent perforating veins in the midthigh and calf. It is suggested that varicography is a useful method for demonstrating the sites of recurrent varicose veins and for enabling definitive surgery to be performed.     

The importance of anatomical variants of the sapheno-femoral junction in lower-limb varicose vein surgery.

BACKGROUND: In the surgical strategy of lower limb varicose veins, the fundamental objective is to prevent relapses. For this purpose, after having examined the international literature on the most frequent relapse causes, the authors emphasize that erroneous diagnosis, varicose disease natural development and incorrect surgical treatment are very important. METHODS: They report their experience about the sapheno-femoral junction anatomic variants that have been verified at the surgical table on 532 consecutive patients operated on for lower limb varicose veins. Of 532 patients 449 (84.4%) patients were women and 83 (15.6%) were men; all of them were, on average 49+/-26 years old. They were all with derivative from sapheno-femoral junction incontinence varicose veins that can be classified according to CEAP (C2-3-4/Ep/As 2-3/Pr). On these patients, 430 (80.8%) patients have had an operation of internal saphena long stripping; 65 (12.3%) patients have had an operation of saphena short stripping and 37 (6.9%) patients have had an operation of internal simple rossectomy. RESULTS: The authors have inspected all collateral veins of the sapheno-femoral junction and they have noticed 135 variants (25.2%) that are very important for the surgeon and, among these variants, they have discovered some collaterals, that flow under the sapheno-femoral junction (about 4%), are particularly insidious and they are the cause of sure relapse if they are ignored. CONCLUSIONS: The purpose of the work is to emphasize the importance of knowing sapheno-femoral junction changeability that is often the cause of relapse after surgical treatment.     

Lymphedema in the morbidly obese patient: unique challenges in a unique population

The population of morbidly obese patients, along with the incidence of lymphedema and massive localized lymphedema associated with this condition, is increasing. A 5-year retrospective review of data (2000-2005) shows that the percentage of patients >350 lb in the authors' clinic population increased from approximately 7% to 11% and 75% of their morbidly obese patients (body mass index >40) had or have lymphedema. After a differential diagnosis between lipedema and lymphedema (primary or secondary) has been made, lymphedema management options include compression bandaging, manual lymphatic drainage, and localized surgeries. The treatment of morbidly obese lymphedema patients requires additional staff time and specialized equipment to move or position them and may be confounded by other conditions (eg, heart failure and venous insufficiency) that contribute to edema. Lymphedema treatments have been found to be useful, providing patients are able to follow treatment guidelines, especially with regard to weight control. In the authors' experience, massive localized lymphedema will recur unless the primary issue of obesity is addressed. Establishing clear criteria and patient participation guidelines before initiating a comprehensive localized lymphedema program will improve outcomes.     

Assessment of the efficacy of venous support by elastic bandages using transcutaneous measurement of oxygen pressure (TcPO2)

Venous contention with elastic bandages is widely used in the treatment of Venous Insufficiency. We have attempted to number the clinical improvement by measuring TcPO2. Our study includes 16 cases; divided as follows: 6 healthy subjects (reference), 5 patients with severe varicose veins of the lower extremities, without ulcer, and 5 patients with varicose veins with ulcer of the leg. Measurements were carried out before and after 10 hours of venous contention. For each patient we have used a light bandage (x) with stretching to 30 and 50% of its length, and a heavy bandage (x) with stretching of 20 and 40%. Our results show, after contention, a decreased TcPO2 in the reference group, but an improvement of this TcPO2 in patients with varicose veins, with or without ulcer. This improvement is more marked with the use of light bandages.