Diagnosis and treatment of venous lymphedema

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Diagnosis and treatment of venous lymphedema Seshadri Raju, MD, James Brooke Furrh, BS, Peter Neglén, MD, PhD Journal of Vascular Surgery Volume 55, Issue 1, Pages 141-149 (January 2012) DOI: 10.1016/j.jvs.2011.07.078 Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 1 Swelling in the dorsum foot, squaring of toes, and Stemmer sign are widely considered “classic” clinical features of lymphedema. In our experience, these may also be present in long-standing venous swelling and are not exclusive to lymphedema (see text). Left, This patient was diagnosed as having “lymphedema” on clinical grounds and was treated for several decades with compression, which was ineffective. Middle, Isotope lymphangiography was normal. Right, Transfemoral venography showed postthrombotic iliac vein stenosis (left venogram is shown). Journal of Vascular Surgery 2012 55, 141-149DOI: (10.1016/j.jvs.2011.07.078) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 2 This patient had onset of leg swelling from early adolescence. Lymphatic delay was noted on the right side but was normal on the left. Venogram showed bilateral iliac vein stenoses. Right limb venogram is shown with severe diffuse iliac vein stenosis. Note the normal caliber of the femoral vein. Journal of Vascular Surgery 2012 55, 141-149DOI: (10.1016/j.jvs.2011.07.078) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 3 Venography is poorly sensitive to iliac vein obstruction. Left, A venogram appears unremarkable. Right, A tight stenosis is present, as shown by the IVUS image. Measured lumen area by IVUS planimetry was 44.3 mm2. Normal value in adults is ∼175 mm2. A 75% stenosis can therefore be calculated to be present. Journal of Vascular Surgery 2012 55, 141-149DOI: (10.1016/j.jvs.2011.07.078) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 4 In some cases, lymphatic delay (left) with standard technique will normalize if triple dose of the isotope-tagged colloid is injected (right). Journal of Vascular Surgery 2012 55, 141-149DOI: (10.1016/j.jvs.2011.07.078) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 5 Cumulative stent patency in abnormal lymphangiographic group. Assisted primary and secondary patency curves were the same. The error bars show the standard deviation. Journal of Vascular Surgery 2012 55, 141-149DOI: (10.1016/j.jvs.2011.07.078) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 6 Swelling relief (cumulative) is shown after stent placement in lymphedematous limbs. Separate curves are shown for subjective relief, as reported by the patient, and for objective relief by examination. The difference in the curves may partly be due to metrics (see text). The error bars show the standard deviation. Journal of Vascular Surgery 2012 55, 141-149DOI: (10.1016/j.jvs.2011.07.078) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 7 Left, Lymphographic nonvisualization of inguinal nodes in a patient with right-sided lymphedema. Right, After iliac vein stent placement, nodes promptly visualized at 20 minutes. Journal of Vascular Surgery 2012 55, 141-149DOI: (10.1016/j.jvs.2011.07.078) Copyright © 2012 Society for Vascular Surgery Terms and Conditions