Venous and Lymphatic Disease

Eastern Vascular Society

GOALS

To identify cause of leg swelling, differentiating, venous, lymphatic and cardiac sources.
Initiate appropriate therapy to eliminate long term sequelae.

PERTINENT HISTORY/FINDINGS:

Unilateral or bilateral swelling. Bilaterally suggests a systemic disease (e.g. cardiac, hepatic, renal, thyroid, lipodystrophy).
History of DVT, recurrent leg infection.
Dilated veins, pigment changes.
Significant food edema.
Prior pelvic surgery, history of neoplasia or trauma.
Lymphadenopathy.
GYN, GU or GI history consistent with neoplasia.

DIFFERENTIAL DIAGNOSIS:

DVT
Venous insufficiency
3. Lymphadema
Lymphatic obstruction
Systemic Disease (see above)
Causalgia

DIAGNOSTIC STUDIES:

Venous duplex to include iliac veins.
CT scan of pelvis and abdomen if duplex is negative, especially in patients with suggestion of or history of malignancy.
Lymphoscintography - only in patients with atypical findings where diagnosis is in doubt.
Sympathetic block - where causalgia is suspected.

SWOLLEN LEG ALGORITHM

DIAGNOSIS:

BILATERAL

CARDIAC, LIVER, RENAL FUNCTION STUDIES, LIPODYSTROPHY

UNILATERAL

HISTORY CHRONIC VENOUS INSUFFICIENCY (CVI), DVT, TRAUMA, FRACTURE, VENOUS SURGERY, LYMPHEDEMA (LED), INFECTION, RADIOTHERAPY, ONCOLOGIC SURGERY
PHYSICAL EXAM: EDEMA DISTRIBUTION, DILATED VEINS, PIGMENTATION (CVI), STEMMER'S SIGN, NODE # AND SIZE - LED, SENSITIVITY TO TOUCH,
SWEATING - CAUSALGIA

DUPLEX SCAN OF VEINS - RX AS CVI
CT OF PELVIS & ABDOMEN - R/O NPL - SIZE AND # OF LYMPH NODES
OR
LYMPHOSCINTOGRAM + LED
SYMPATHETIC BLOCKADE
CAUSALGIA

TREATMENT- VENOUS & LYMPHATIC DISEASE
CUSTOM FITTED ELASTIC STOCKINGS, SKIN CARE
CAUSALGIA
SYMPATHECTOMY