1. Clinical case of a swollen limb Emphasis on diagnosis
Nicos Labropoulos Professor of Surgery and Radiology Director, Vascular Laboratory Division of Vascular Surgery Stony Brook Medicine Stony Brook, NY

2. Male 49y morbidly obese presented with
RT LE swelling, pain and skin damage
Right thigh circumference 70cm and the left 54cm.
Diabetes, hypertension and previous RT LE DVT
No history of surgery, trauma, or long distance travel

3. 70cm 54cm Bilateral swelling RT>LT RT Extending to foot and toes
Circumferential skin changes
Healed ulcer

4. 2001 Initial duplex ultrasound showed isolated CFV thrombosis measuring 9.6mm. The patient was treated with anticoagulation.
2003 Pain and worsening of the swelling
DU showed CFV thrombosis measuring 22mm

5. Right LE ultrasound CFV
Duplex ultrasound in 2003 showed persistent CFV occlusion measuring 22mm, which progressed from 9.6mm in 2001.

6. Later, he developed a venous ulcer that was managed with inelastic compression bandages.
DU showed no deep or superficial reflux, with isolated CFV occlusion (diameter of 30 mm).
Suspicion for underlying iliac venous outflow obstruction prompted a CTV showing a mass with cystic characteristics adjacent to CFV measuring 30mm.

7. Right LE ultrasound and CTV
2008 persistent CFV occlusion of the common femoral vein and increase in size to 30mm.
Cystic appearing mass compressing the CFV and displacing the femoral vessels

8. The mass, which was previously thought to be a thrombosed CFV, was compressing the vein and causing venous outflow obstruction.
The patient refused any surgical intervention and was lost to follow-up.
He finally returned with worsening symptoms, and repeat venous DU and a venogram were performed.

9. Right LE ultrasound and venogram
Duplex ultrasound and venography with minimal flow in supine position.
Distal augmentation demonstrates patency of the CFV.
Pressure gradient 15mmHg
across the occlusion.
Differential diagnosis
-Vein wall tumor
-Adventitial cyst

10. An encapsulated mass was identified, which was
compressing the underlying common femoral vein.
An extravascular lipoma was released once the capsule was opened.

11. Underlying common femoral vein following removal of lipoma.
Low power view of lipoma, x40 magnification demonstrated varying sizes of normal adipocytes.

12. Postoperatively, the patient developed superficial fat necrosis, which required wound debridement and
VAC therapy.
At 3-month follow-up, the thigh circumference in
the RT thigh was 58cm, his edema improved, the leg ulcer healed, and DU showed a patent CFV.
Lipoma is a rare cause of venous obstruction with
<10 cases reported and at least half are intravenous.

13. Morbid obesity can explain the bilateral
lower limb swelling.
RT thigh and leg were still bigger than the left
after the treatment.
The right limb due to chronic venous obstruction
may have developed lymphedema.