Lymphoedema (LE) is a disorder characterized by persistent swelling caused by impaired lymphatic drainage because of various aetiologies, including lymphatic injury and congenital functional or anatomical defects.
Literature review and expert opinion about diagnosis and treatment of LE in children.
LE is rare in children, with a prevalence of about 1.15/100,000 persons, 20 years old. The management of LE in children differs considerably from adults in terms of origin, co-morbidity and therapeutic approach. The objective of this presentation is to discuss practical issues related to clinically relevant information on the diagnosis, aetiology, work-up and treatment of LE in children. In contrast to adults, who usually experience secondary LE because of acquired lymphatic failure, most cases in children have a primary origin. The diagnosis can be made mainly on the basis of careful personal and family history, and physical examination. LE in children can be part of a syndrome if there are other concomitant phenotypic abnormalities and if a genetic defect is recognizable. Treatment of LE is mostly conservative utilizing decongestive LE therapy including compression therapy, directed exercises, massage and skincare. In the neonate, initial observation alone may be sufficient, as delayed lymphatic development and maturation can result in spontaneous improvement. The role of parents is crucial in providing the necessary input.
We present a review emphasizing a practical approach to treating a child with LE according to current publications and our own experience.
To investigate the influence of compression bandages, manufactured using materials with different elastic properties, on the impaired venous pumping function in patients with venous insufficiency.
Ejection volume (EV) and ejection fraction (EF) were measured using strain gauge plethysmography distal from the patella without and with elastic and inelastic compression bandages in a total of 30 patients with major venous reflux in the great saphenous vein. The interface pressure of the bandages was measured simultaneously in the medial gaiter area. Normal values of EV and EF were obtained from 15 healthy controls.
Patients with venous insufficiency showed a statistically significant reduction of EV and EF compared to controls. Elastic bandages with an average pressure of 42 mm Hg in the supine position achieved a moderate increase of EV and a significant improvement of EF (p < .01), while inelastic bandages applied with comparable resting pressure (41 mm Hg) raised EV and EF into a normal range (p < .001). The improvement of the ejection fraction correlates well with the pressure differences between standing and lying (Static Stiffness Index) and between muscle systole and diastole during exercise (Pearson r = 0.69 and 0.74 respectively, p < .001). Elastic bandages applied with high stretch in order to achieve standing pressures comparable to those of inelastic bandages (>60 mm Hg) led only to a minor improvement of the venous pumping function.
Ejected volume and ejection fraction, which are severely reduced in venous insufficiency, can be increased by compression therapy. Inelastic compression is much more effective than elastic bandages, and is able to normalize venous pumping function. With elastic bandages EV and EF always remain below the normal range even when applied with high stretch producing a resting pressure that is barely tolerable.
The objective of this study is to review the basics of laser and established tissue response patterns to thermal injury, with specific reference to endovenous laser ablation (EVLA). This study also reviews the current theories and supporting aspects for the mechanism of action of EVLA in the treatment of superficial venous reflux.
The method involves the review of published literature and original investigation of histological effects of 810 nm and 980 nm wavelength EVLA on explanted blood-filled bovine saphenous vein in an in vitro system.
The existing histological reports confirm that EVLA produces a transmural vein wall injury, typically associated with perforations and carbonization. The pattern of injury is eccentrically distributed, with maximum injury occurring along the path of laser contact. Intravenous temperature monitoring studies during EVLA have confirmed that the peak temperatures at the fibre tip exceed 1000°C, and continuous temperatures of at least 300°C are maintained in the firing zone for the majority of the procedure. Steam production during EVLA, which occurs early in the photothermolytic process when temperatures reach 100°C, accounts for only 2% of applied energy dose, and is therefore unlikely to be the primary mechanism of action of thermal injury during the procedure.
EVLA causes permanent vein closure through a high-temperature photothermolytic process at the point of contact between the vein and the laser.
Occasional leg symptoms, like feelings of heaviness and tension, and occupational or evening oedema are considered typical features of a venous disorder but show low specificity in epidemiological and observational studies. We evaluated the prevalence and nature of such symptoms in subjects with no history or signs of venous disease and investigated the optimal strength that medical compression stockings (MCS) should exert in order to alleviate the symptoms and to prevent leg swelling.
Specifically designed questionnaires were used to assess the symptoms of 40 healthy employees of a factory producing MCS. Lower leg volumes were quantified in the morning and evening. Calf size hosiery providing documented ankle pressures of 4–9 (mean 7.3), 12–18 (mean 14.9) and 18–22 (mean 19.5) mmHg, respectively, were tested in a prospective, open-label, randomized trial lasting three weeks. Endpoints were the relief of symptoms, prevention of vesperal oedema and comfort in wearing the stockings.
Sixty-five percent of the participants reported at least occasional leg symptoms and oedema. Somatic-type symptoms (i.e. pain, heaviness, swelling, unattractive legs) were present in two, psychic-type symptoms (i.e. leg- and personality-related unrest and stress) in 17 and both components in seven of the 40 subjects. MCS exerting 15 and 20 mmHg prevented the symptoms and oedema. Stockings providing <10 mmHg were ineffective and those providing >19 mmHg were not well-tolerated. The effect on the somatic-type symptoms was strongly correlated with the amount of lower leg volume which could be reduced by wearing stockings (P = 0.005). No correlation was found between the efficacy of compression and the emotional component of the symptoms.
The cause of occasional pain in the legs of apparently healthy people is unknown. Some features of the syndrome reflect an emotional disorder while others mirror venous insufficiency. MCS of 15 mmHg effectively relieve the symptoms resembling venous insufficiency, prevent oedema and are well-tolerated.
To assess the effect of topically applied nitroglycerin (NTG) ointment (2%) on preoperative targeted venous access site great saphenous vein (GSV) diameter in patients undergoing endovenous laser treatment (ELT).
In this double-blinded randomized study design, 75 patients received either (A) treadmill ambulation only, (B) topically applied NTG ointment only, or (C) topically applied NTG ointment + treadmill ambulation. Targeted venous access vein diameters were measured before therapeutic intervention and then repeated after approximately 30 min following pretreatment intervention. Presence of venospasm and the number of ultrasound-guided venous access attempts during each ELT procedure were assessed during the study.
The mean pretreatment vein diameter was 2.6 mm (range 0.9–4.9 mm). The post-treatment percentage change in vein diameter for group A (treadmill ambulation only) was +2.7% (P = 0.403), whereas group B (NTG only) and group C (NTG + treadmill ambulation) demonstrated significant venodilatation of +69.0% (P < 0.0001) and +51.7% (P < 0.0001), respectively. Statistical analysis of variances and multivariate linear regression model revealed topically applied NTG ointment and ‘C’ classification of clinical, aetiological, anatomical and pathological elements (CEAP) were each significant predictors for venodilatation percentage change (P < 0.001 and = 0.028, respectively).
Pretreatment with topically applied NTG ointment (2%) produced a statistically significant, as well as subjective clinically significant venodilatation change in the targeted venous access site diameter of patients undergoing ELT of the GSV in this study.
To illustrate the use of autologous femoral vein for grafting ilio-caval vein defects following abdomino-pelvic tumour resections.
Case report and literature review.
Durable restoration of ilio-caval patency was achieved, with minimal morbidity from graft harvesting.
Autologous femoral vein presents a viable graft option for the immediate reconstruction of large intra-abdominal vein deficits.
Previous reparative valvular surgical options directed at reconstructing damaged common femoral vein (CFV) valves associated with pathological chronic venous insufficiency (CVI) have not succeeded in reliably managing CVI. In consequence, venous valvuloplasty is rare and most patients are managed conservatively. As a result, monocusp surgery was identified as an optional surgical solution for this large underserved patient group.
Ulcer patients appear at wound clinics and often experience disappointing results. Monocusp valves were constructed utilizing viable vein wall in 14 operations on 11 patients. These patients were observed for four years to see if such an autogenous vein wall valve might control aggressive symptomatic CVI when faced with unusable valves.
Long-term follow-up showed that the monocusp valves remained competent at four years. Symptomatic failures have not appeared at this time. Pain, swelling, ulcers and leg congestion were reliably reversed. VEnous INsufficiency Epidemiologic and Economic Study (VEINES) classification (see Abenhaim L, Krux X, VIENES Study collaborators. Angiology 1997;48:59 and Kurz X, Kahn SR, Abenhaim L, et al. Int Angiol 1999;18:83–102) improved over four years from 2.7 ± 0.9 to 0 (P < 0.001); CEAP classifications (see Kistner RL, Eklof B, Masuda EM. Mayo Clin Proc 1996;71:338–45) improved from grade 4–6 to 0–1 (CEAP is not generally a postoperative grading system, but it can be used to develop some form of qualitative analyses as to intervention effectiveness, i.e. what existed preoperatively no longer exists postoperatively. Its postsurgery use is limited by (C5) classification – history of ulcer, which by definition cannot go below that with a history of ulcer even if the ulcer has been cured). Mean venous reflux scores decreased from 3.8 ± 0.4 to 0.3 ± 0.5 (P < 0.001).
Monocusp implantation reliably resolved patient symptoms when unusable CFV valves were encountered. Postoperative CFV reflux is usually undetectable. The monocusp valve exhibits minimal thrombogenicity related to its viability with attendant antithrombotic hormone production capacity and has markedly improved the patient's quality of life. Full thickness monocusp surgery could become widespread with the difficult dysplastic/aplastic CVI patient subset because of its simplicity, repeatability, durability, low complication rate, effectiveness, persistent availability and viability providing nitric oxide synthase and thymomodulin hormone production capacity. The full thickness of vein wall has distinct advantages over other partial thickness valve creation methods because of its long-term vitality. Postoperative coumadin is recommended for six months to minimize risks of deep vein thrombosis and/or pulmonary embolism.
The aim of this retrospective study is to assess the safety and effectiveness of endovenous laser treatment (EVLT) combined with ambulatory phlebectomy (AP) as a single procedure for treating saphenous vein incompetence.
The study enrolled 148 patients with saphenofemoral or saphenopopliteal junction reflux associated with saphenous vein incompetence and enlarged branch veins. Patients were treated with EVLT (135 great saphenous veins, 41 small saphenous veins) concomitantly with AP as a single procedure. All patients were followed up by clinical assessment and duplex ultrasound at one week and 12 weeks after the procedure.
No postprocedural deep vein thrombosis and pulmonary embolism occurred. Saphenous vein recanalization rate at three months was 5.7%. Residual varicosities were found in 11.4% of the patients at three months after procedure, but only 2.3% of those required subsequent interventions.
Combined EVLT and AP could be a safe and effective treatment modality for the saphenous vein incompetence.
To estimate the usefulness of therapeutic ultrasound for healing of venous leg ulcers.
Eighty-one patients were included in this study. Patients in groups 1 and 2 were treated surgically. Patients in groups 3 and 4 were treated conservatively. Patients in groups 1 and 3 were additionally treated with the ultrasound (1 MHz, 0.5 W/cm2) once daily, six times a week for seven weeks.
Comparison of the number of complete healed wounds indicated statistically significant differences between groups 1 and 4 (P = 0.03), 2 and 4 (P = 0.03), 3 and 4 (P = 0.03) in favour of groups 1, 2 and 3. Comparison of the other parameters also demonstrated more efficient therapy effects in groups 1, 2 and 3 than in group 4. There were no statistical differences in all examined parameters between groups 1, 2 and 3 (P > 0.05).
The ultrasound is an efficient and useful method only in conservatively treated venous leg ulcers. There are no special reasons for application of the ultrasound in surgically treated patients. A well-conducted surgical operation is much more effective for a healing process than conservative pharmacological procedures.
This report describes two complications of severe neurologic alterations (TIA, CVA) after foamed sclerotherapy injection.
Using foam sclerotherapy in accepted concentrations, volume, and in standard ratio of air to sclerosant, two serious neurologic complications occurred.
In both cases described, unknown atrial communications existed resulting in foam emboli. One case involving the vertebral system resolved without treatment. The other involving the cerebral system was treated with hyperbaric oxygen.
Foam sclerotherapy can cause serious neurologic phenomenon even though the incidence is rarely described. Immediate treatment with 100% O2 and possible hyperbaric O2 therapy should be considered.
Venous disease was proposed as a cause of restless legs syndrome (RLS) by Dr Karl A Ekbom in 1944, but has since remained largely unexplored. This study examines the effect of endovenous laser ablation (ELA) in patients with concurrent RLS and duplex-proven superficial venous insufficiency (SVI).
Thirty-five patients with moderate to very severe RLS (as defined by the 2003 National Institute of Health (NIH) RLS criteria) and duplex-proven SVI completed an international RLS rating scale questionnaire (IRLS) and underwent standard duplex examination to objectively measure the baseline severity of their conditions. They were separated into non-operative and operative cohorts. The operative cohort underwent ELA of refluxing superficial axial veins using the CoolTouch CTEV 1320 nm laser and ultrasound-guided sclerotherapy of the associated varicose veins with foamed sodium tetradecyl sulphate (STS). All patients then completed a follow-up IRLS questionnaire. Baseline and follow-up IRLS scores were compared.
Operative correction of the SVI decreased the mean IRLS score by 21.4 points from 26.9 to 5.5, corresponding to an average of 80% improvement in symptoms. A total of 89% of patients enjoyed a decrease in their score of ≥15 points. Fifty-three percent of patients had a follow-up score of ≤5, indicating their symptoms had been largely alleviated and 31% had a follow-up score of zero, indicating a complete relief of RLS symptoms.
ELA of refluxing axial veins with the CTEV 1320 nm laser and foamed STS sclerotherapy of associated varicosities alleviates RLS symptoms in patients with SVI and moderate to very severe RLS.
SVI should be ruled-out in all patients with RLS before initiation or continuation of drug therapy.
Idiopathic cyclic oedema syndrome is a group of clinical conditions that exhibit a vascular capillary hyperpermeability accompanied by oedema caused by the interstitial retention of fluid. The objective of the current study was to evaluate the efficacy of aminaphtone in the treatment of idiopathic cyclic oedema.
A total of 15 female patients with clinical diagnosis of idiopathic cyclic oedema and aged between 22 and 49 years and a mean of 37.7 years were evaluated. After diagnosis, the patients were submitted to lower limb volumetry and asked to record the weight in the morning and evening at fixed times. One tablet of aminaphtone was prescribed every 8 h and on the fifth day the patients were reassessed. Percentages and the paired t-test were utilized for statistical analysis, with an alpha error of 5% considered acceptable (P value <0.05).
A significant reduction in limb size was detected after treatment using aminaphtone (P value <0.0001) with losses between 9 g and 370 g, and an average loss of 116.9 g. Variations in weights in the morning and evening were significant (P value <0.00001) with a maximum difference of 3 kg and a minimum of 120 g. Improvements were reported for 70% of patients.
Aminaphtone is efficacious in the reduction of oedema in patients with idiopathic cyclic oedema.
To correlate venous haemodynamic parameters of lower limbs and amplitude of ankle mobility with the clinical, aetiological, anatomical and pathological classification (CEAP) for venous disease.
Two hundred and eighty-four lower limbs of 142 Caucasian women were evaluated and distributed in six groups according to the CEAP classification: Group I = C0 and C1 (n = 24); Group II = C2 (n = 30); Group III = C3 (n = 27); Group IV = C4 (n = 23); Group V = C5 (n = 20) and Group VI = C6 (n = 18). Goniometric examinations of ankle joints and air plethysmography (APG) were performed. Analysis of variance and the Bonferroni correction, Kruskal-Wallis' non-parametric and Dunn tests were utilized for statistical analysis with the level of significance being set at 5% (P value < 0.05).
There were significant restrictions in ankle mobility seen by goniometry at the C5 stage. In addition, significant changes in the venous-filling index were identified at C2, changes in the ejection fraction at C4 and changes in the residual volume fraction at the C4 stage.
The evolution of the clinical state of ankles affected by venous diseases is correlated to a reduction of joint mobility and haemodynamic alterations identified using APG.
Digital photoplethysmography (D-PPG) is a newly introduced method of optical screening of deep vein thrombosis (DVT) by recording changes in the size of limb due to tissue fluid.
The objective of this study is to assess the effect of high pulmonary artery pressure (PAP) and consequently increased venous system pressure on D-PPG test results.
Forty-five patients with and 45 patients without PAP pressure were enrolled in the study and divided into two groups. All the patients had a history of chronic obstructive pulmonary disease (COPD). D-PPG test was performed for both legs of all the patients and the results of the two groups were compared. Also, all patients underwent duplex sonography for ruling out DVT.
Using venous refilling time (RT) of <22 s as the optimal cut-off point, it was found that 32 (35%) legs of patients with and 39 (43%) legs of patients without high PAP had positive D-PPG test. Although the rate of positive D-PPG test was higher in patients with high PAP, this was not statistically significant (P = 0.28). Moreover, overall correlation between RT and venous pump detected by D-PPG and PAP was r = –0.11 (P = 0.2) and r = –0.01 (P = 0.6), respectively.
Our results showed that the rate of positive D-PPG test results is slightly higher in patients with pulmonary hypertension, but this difference is not statistically significant. Therefore, increased PAP could be excluded as a confounding factor of D-PPG test.
To assess differences in clinical outcomes between patients with traumatic and spontaneous leg ulcers.
Consecutive leg ulcer follow-up patients seen between April 2004 and October 2005 in a specialist leg ulcer clinic were asked about the mechanism of the original ulceration. Twenty-four-week healing and 12-month recurrence rates were calculated using Kaplan-Meier analysis and outcomes were compared between groups with traumatic and spontaneous ulcers.
Of the 300 patients assessed, 38 were excluded (incomplete data). In the remaining 262 patients, cause of ulceration was traumatic in 116/262 (44%) and spontaneous in 146/262 (56%). Age, ankle brachial pressure index <0.85 and venous reflux were equally distributed between groups with traumatic and spontaneous ulcers (P = 0.470, 0.793, 0.965 respectively, Chi-square test). Twenty-four-week healing rates were 81% for traumatic and 67% for spontaneous ulcers (P = 0.015, Log-Rank test). Twelve-month recurrence rates were 32% for traumatic and 33% for spontaneous ulcers (P = 0.970, Log-rank test). Patients with traumatic ulcers suffered a total of 53 ulcer recurrences (median 0, range 0–4) compared with 89 in patients with spontaneous ulcers (median 0, range 0–8) (P < 0.001, Mann-Whitney U test).
Approximately half of all leg ulcer patients recall a traumatic event. When managed in leg ulcer clinic, traumatic ulcers heal faster and recur less frequently than spontaneous ulcers.
Arteriovenous (AV) shunting has been postulated as the underlying cause of varicose veins. The aim of this study was to analyse pressure and oxygen content in primary varicose veins in order to determine evidence of arterial shunting.
Thirty-nine patients with varicose veins underwent cannulation of varicosities. The pressure and the blood oxygen content within varicosities were measured in different positions and during exercise. Similar measurements were made in the long saphenous veins of 10 control subjects without venous disease.
Mean pressure in varicose veins in the supine position was 12.3 mmHg (Standard deviation [SD] 3.6 mmHg). Control subjects had similar pressures measured in the long saphenous vein. No pulsatile pressure tracings were obtained. Varicosity pressures in the erect position averaged 66 mmHg (SD 9 mmHg). In all cases, the pressure correlated with the distance of the varicosity from the heart. Pressure reduction in varicosities after exercise was significantly less than that in control subjects. Recovery time (RT 90) was also significantly shorter than in the control group. Mean venous pO2 in varicosities was 4.5 kPa (SD 1.0) in the supine position dropping to 3.9 kPa (SD 0.9) on standing; these values were not significantly different to samples from control subjects.
AV shunting is unlikely to be a causative factor in the development of primary varicose veins.
The aim of the study was to find out if persons with cardiovascular diseases (CVD) (arterial disease or hypertension) have additional risk of varicose veins (VV) compared with those without arterial disease (AD) or hypertension.
We studied, using a validated questionnaire, the prevalence and incidence of VVs in those with and without CVD in a population of 4903 including 40-, 50- and 60-year-old men and women in Tampere, Finland. During the five years of follow-up, we had a special interest on the appearance of new VVs in those without VVs at entry (n = 3065).
We found a higher prevalence of VVs in persons with CVD than in those without CVD (with sex and age adjusted odds ratio [OR] 1.3 [95% confidence interval, CI 1.1–1.5]). The prevalence of VVs was higher in persons with AD (OR 1.7 [CI 1.4–2.2]), but not in persons with hypertension (OR 1.1 [CI 0.9–1.2]) than in those who were free of AD or hypertension, respectively. Subjects with AD had higher incidence of VVs (incidence odds ratio, IOR 1.4 [CI 0.8–2.7]) than subjects without AD and the effect was statistically significant in women (IOR 2.2 [CI 1.1–4.5]). Also the incidence of VVs was more affected by AD than by hypertension (IOR 1.1 [CI 0.7–1.8]).
There seems to exist a relatively strong additional risk of VVs in persons with AD and practically none in those with hypertension compared to those without.