Lymphedema and concomitant venous comorbidity in the extremity: Comprehensive evaluation, management strategy, and outcomes

Abstract

Backgroud The optimal approaches for concurrent vascular lesions with limb lymphedema are not well established. The purpose of the study was to investigate the outcome of the surgical management of lymphedema with concomitant vascular lesions. Methods Between August 2010 and November 2015, 15 consecutive patients with extremity lymphedema and concomitant vascular lesions treated with vascularized lymph node flaps were reviewed. The patients had vascular interventions discovered during workup for lymphedema surgery. Outcomes were assessed using circumferential difference (CD) and circumferential reduction rate (CRR) at 12‐month and final follow‐up visits. Results Vascular lesions (n = 15) included proximal arterial occlusion ( n = 1), vascular malformation ( n = 2), and proximal venous compression/stenosis ( n = 12). Concomitant vascular lesions had an incidence of 15.8% in patients that underwent vascularized lymph node transfers (VLNTs). We had 100% VLNT survival rate and average number of episodes of cellulitis after VLNTs decreased significantly ( p < 0.05). The CRR for the below knee/elbow measurement at 12‐months follow‐up was significantly higher for patients that underwent vascular intervention for venous lesions before VLNT instead of concurrently or after (23.7% vs 12.2%, P = 0.23). Final mean CRR was 23.7% and 12.2% respectively. Conclusion Preoperative workup of concomitant vascular lesions is important for lymphedema management. We suggest appropriate vascular intervention should be done prior to VLNT to maximize the short‐term and long‐term outcomes.

Intra‐abdominal chylovenous bypass treats retroperitoneal lymphangiomatosis

“…Ultrasound Doppler and computed tomography angiography (CTA) were utilized to rule out any proximal vascular lesions and to evaluate the patency of any VLNT for lower-extremity lymphedema. 13 Lymphoscintigraphy was performed, and Taiwan Lymphoscintigraphy Staging was used to interpret findings of partial or total lymphatic obstruction of the lower extremities. 14 Magnetic resonance imaging (MRI) was performed to confirm extravasation of contrast into the peritoneal cavity and to visualize aberrant lymphatic tracts in the soft tissue.…”

Surgical Treatment for Primary Lymphedema: A Systematic Review of the Literature

“…Qualitatively, most studies reported improved symptoms and QoL. 21,22,57,58,73,74,76 Unsatisfactory results were reported in the patient managed with omentum transposition: the leg swelling initially subsided during the first 6 months postoperatively, but the edema gradually returned as the patient became overweight. The overall complication rate was 13%; these included hematoma formation (n ¼ 1), venous congestion or thrombosis (n ¼ 4), and microsurgical revisions (n ¼ 4).…”

Heparin‐induced thrombocytopenia and thrombosis in primary lymphedema patients who underwent vascularized lymph node transplantations

“…Females are affected approximately 3.5‐fold more often than males 2,3 . Primary lymphedema is related to gene mutations, especially genes correlated with the regulation of vascular endothelial growth factor C 4,5 . At least 20 genes have been recognized to be associated with primary lymphedema, and approximately 30% of patients have these genes 4 .…”

“…At least 20 genes have been recognized to be associated with primary lymphedema, and approximately 30% of patients have these genes 4 . Primary lymphedema individuals, therefore, often have comorbidities with vascular diseases 4,5 . Furthermore, immune imbalance, such as hyperactivation of CD4 T cells, has been proven to induce lymphedema in primary lymphedema patients 6,7 …”