Lymph drainage and the development of post-reconstructive leg oedema is not influenced by the type of inguinal incision. A prospective randomised study in patients undergoing femoropopliteal bypass surgery

Compression therapy in peripheral artery disease: a literature review

OBJECTIVE

Our objective is to examine the pathophysiology of oedema in the ischaemic and post-revascularised limb, compare compression stockings to pneumatic compression devices, and summarise compression regimens in patients with severe peripheral artery disease (PAD) without revascularisation, after revascularisation, and in mixed arterial and venous disease.

METHOD

A scoping literature review of the aforementioned topics was carried out using PubMed.

RESULTS

Compression therapy has been shown to increase blood flow and aid in wound healing through a variety of mechanisms. Several studies suggest that intermittent pneumatic compression (IPC) devices can be used to treat critical limb ischaemia in patients without surgical options. Additionally, compression stockings may have a role in preventing oedema after peripheral artery bypass surgery, thereby diminishing pain and reducing the risk of surgical wound dehiscence.

CONCLUSION

Oedema may occur in the ischaemic limb after revascularisation surgery, as well as in combination with venous disease. Clinicians should not fear using compression therapy in PAD.

Transverse versus vertical groin incision for femoral artery approach

BACKGROUND

Access to the femoral vessels is necessary for a wide range of vascular procedures, including treatment of thromboembolic disease, arterial grafts (i.e. bifemoral aortic bypass or infrainguinal bypass), endovascular repair of abdominal aortic aneurysm (EVAR), thoracic endovascular aneurysm repair (TEVAR) and transcatheter aortic valve implantation (TAVI). The surgical technique used to access the femoral artery may be a factor in the occurrence of postoperative complications; this will be the focus of our review. We will compare the transverse surgical technique-a cut made parallel to the groin crease-versus the vertical groin incision surgical technique-classic technique: a surgical cut made across the groin crease-to access the femoral artery, in an attempt to determine which technique has the lower rate of complications, is safer and is more effective.

OBJECTIVES

To evaluate the efficacy and safety of transverse groin incision compared with vertical groin incision for accessing the femoral artery in endovascular surgical procedures and open surgery.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to 17 February 2020. The review authors searched the IBECS database to 26 March 2020 and reference lists of relevant studies/papers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized trials (qRCTs) that compare transverse and vertical groin incision, during either endovascular or open surgery procedures.

DATA COLLECTION AND ANALYSIS

Two review authors (MVCRC, FCN) independently selected the studies, assessed risk of bias, extracted data, performed data analysis and graded the certainty of evidence according to GRADE.

MAIN RESULTS

We included one RCT and one qRCT in this review. These two studies had a combined total of 237 participants (283 groins). Infection of the surgical wound was the only outcome that was similar in both studies, and that could therefore be submitted to a combined analysis. Meta-analysis of the two studies showed low-certainty evidence that transverse groin incision resulted in a lower risk of surgical wound infection in the 10- to 28-day period following surgery (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.08 to 0.76; 2 studies; 283 groin incisions). There was low heterogeneity between the studies. We downgraded the certainty of the evidence for surgical wound infection by one level due to serious limitations in the design (there was a high risk of bias in critical domains). The confidence interval for surgical wound infection is relatively wide, further indicating that the certainty of the effect estimate is low. This is likely due to the small number of studies and participants. We observed no evidence of a difference between the two surgical techniques for the other evaluated primary outcome 'lymphatic complications': lymphocele (RR 0.46, 95% CI 0.20 to 1.02; 1 study; 116 groins); and lymphorrhea (RR 2.77, 95% CI 0.92 to 8.34; 1 study; 116 groins). We downgraded the certainty of evidence for lymphatic complications by one level due to serious limitations in the design (there was a high risk of bias in critical domains); and by two further levels because of imprecision (small number of participants and only one study included). High-quality studies are needed to enable a comparison of the two surgical techniques with respect to other outcomes, such as infection of the vascular graft (endoprosthesis/prosthesis), prolonged hospitalization, reoperative surgery, death, neurological deficit (e.g. paresthesia), amputation, graft patency, and postoperative pain.

AUTHORS' CONCLUSIONS

In this systematic review, we found low-certainty evidence that performing transverse groin incision to access the femoral artery resulted in fewer surgical wound infections compared with performing vertical groin incision. We observed no evidence of a difference between the two surgical techniques for the other evaluated outcomes (lymphocele and lymphorrhea). Other outcomes were not evaluated in these studies. Limitations of this systematic review are, however, the small sample size, short clinical follow-up period and high risk of bias in critical domains. For this reason, the applicability of the results is limited.

Effects of Intermittent Pneumatic Compression on Reduction of Postoperative Lower Extremity Edema and Normalization of Foot Microcirculation Flow in Patients Undergoing Arterial Revascularization

BACKGROUND In patients with chronic leg ischemia, the beneficial effect of arterial revascularization can be significantly decreased due to postoperative leg swelling. The aim of this study was to assess the effects of intermittent pneumatic compression (IPC) on skin flow normalization in patients undergoing revascularization procedures due to chronic leg ischemia. MATERIAL AND METHODS We evaluated 116 patients with chronic leg ischemia. The patients were divided into groups according to the performed treatment (endovascular or surgical) and implementation of IPC postoperatively. The leg edema assessment and microcirculation flow assessment were performed pre- and postoperatively, using percutaneous O2 pressure (TcpO2), cutaneous blood perfusion (CBP) measurements, and skin flow motion assessment. RESULTS In patients who did not receive IPC, a decrease in CBP value was observed in the 1st postoperative assessment. Among patients receiving IPC, the CBD value increased at the 1st and 2nd postoperative measurements, especially in the surgical group. The lowest TcpO2 values were observed in by-pass surgery group without IPC postoperatively. CONCLUSIONS The benefits of the by-pass procedure in patients with leg ischemia can be significantly reduced by postoperative edema. Among patients with postoperative leg edema, local tissue blood perfusion can be improved by the use of IPC, which can result in decreased local leg swelling, as well as improved skin blood perfusion and TcpO2.

The Use of Transcutaneous Electrical Stimulation of the Calf in Patients Undergoing Infrainguinal Bypass Surgery

BACKGROUND

Infrainguinal bypass surgery is frequently associated with postoperative reperfusion edema of the limb. The etiology is thought to be multifactorial, and there is as yet no standardized treatment protocol for this problem. The primary aim of this study was to assess whether the use of intermittent electrical stimulation of the calf muscles after infrainguinal bypass surgery was effective in reducing the incidence of edema, and the secondary aims to determine the effect of calf muscle stimulation on arterial and venous flow in the operated leg.

METHODS

Forty patients due to undergo infrainguinal bypass surgery for critical lower-limb ischemia (Fontaine grading III-IV or Rutherford grading II-III) were recruited prospectively and randomly divided into the control group, who received the current standard of care, and study group, who received electrical calf muscle stimulation for a 1 hour session twice daily for the first postoperative week. Preoperatively and postoperatively, the leg was measured at 3 predetermined points and a duplex ultrasound scan performed.

RESULTS

The groups were well matched for all parameters. At 1 week, the below knee and calf girth were less in the study group (P = 0.025 and P = 0.043, respectively). Venous flow volumes at rest and on stimulation were higher in the study group (P = 0.010 and P = 0.029, respectively). At 6 weeks, the below knee girth and amount of pitting edema were less in the study group (P = 0.011 and P = 0.014, respectively).

CONCLUSIONS

We conclude that transcutaneous electrical stimulation of the calf decreased lower-limb swelling at 1 and 6 weeks, and increased the venous flow volume at rest and on stimulation at 1 week in patients undergoing infrainguinal bypass surgery for critical ischemia regardless of patient factors or the type of bypass surgery performed or graft used.

Proximal direct endarterectomy combined with simultaneous distal endovascular therapy for chronic full-length occlusion of the superficial femoral artery in elderly patients

BACKGROUND AND PURPOSE

The most proximal ostial site of the chronic occlusive superficial femoral artery is not suitable for ballooning or stenting because the deep femoral artery may be occluded by these procedures. Thus, the feasibility of performing an open endarterectomy for the occluded ostium of the superficial femoral arteries combined with an endovascular therapy for the remaining distal site was evaluated.

METHODS

Eleven critically ischemic limbs in 10 elderly patients with poor general health were enrolled. They had full-length occlusion of the superficial femoral artery involving its ostium. The ostial site was managed with an open endarterectomy followed by endovascular therapy for the remaining distal site.

RESULTS

All procedures were successfully performed. All patients experienced pain relief, and the wounds healed. During the follow-up observation period (average: 23.9 ± 14.7 months), nine patients died. None of the patients, including those who had lost patency of the superficial femoral artery, received major amputation.

CONCLUSION

Elderly patients, including those who were in terminal stage, were able to withstand the operation, and their postoperative quality of life was not compromised. Although the patency following the surgery was limited, sparing the deep femoral artery could either prevent or delay the recurrence of critical limb ischemia.

An experimental lymphoscintigraphy study in an acute unilateral deep venous thrombosis model

BACKGROUND

The aim of this study is to investigate the effect of both inguinal exploration and deep venous thrombosis on lymphatic flow in an experimental model of unilateral acute obstruction of the femoral vein.

METHODS AND RESULTS

Eighteen male New Zealand White rabbits were the subjects of this study. The rabbits were divided into three groups; Group 1 (n=6, control), Group 2 (n=6, sham), and Group 3 (n=6, operation). After the lymphoscintigraphy was performed on the Group 1 animals, the rabbits in Group 2 and Group 3 underwent intervention. In Group 3, the femoral vein was clipped and excised. In Group 2, an inguinal incision was performed and the clip materials were placed beneath the femoral vein. After the surgical intervention, lower extremity lymphoscintigraphy by subcutaneous administration of Tc-99m nanocolloid was performed in dynamic and static manner in Groups 2 and 3 on the second, fifteenth and thirtieth days after the operation. Unilateral impairment of the lymphatic flow in the operated extremity was observed in Group 3 in the early and late postoperative period but unilateral lymphatic impairment was observed in Group 2 in only the late postoperative period.

CONCLUSION

The lymphatic impairment in an operated extremity might be the consequence of surgical intervention rather than acute venous obstruction in cases where both situations are observed.

Intraoperative lymph mapping with preoperative vein mapping to prevent postoperative lymphorrhea following paramalleolar bypass surgery in patients with critical limb ischemia

PURPOSE

Paramalleolar bypass surgery requires a long incision to harvest the great saphenous vein (GSV), which is often associated with intractable postoperative lymphorrhea. To prevent this complication, we developed a novel method of intraoperative lymph imaging and preoperative vein mapping for vein harvesting.

METHODS

Thirteen consecutive patients with critical limb ischemia (CLI) underwent both preoperative vein mapping and intraoperative lymph mapping (Group A). Duplex vein mapping was performed to mark the GSV. Lymph mapping was performed with indocyanine green fluorescence lymphography. Paramalleolar bypasses were performed using reversed GSV grafts, with careful ligation of the subcutaneous lymph collector vessels above the GSV. The development of intractable postoperative lymphorrhea and the length of the postoperative hospital stay were compared with those in the previous ten consecutive CLI patients without lymph mapping who underwent paramalleolar bypass (Group B).

RESULTS

The occurrence of intractable wound lymphorrhea by the 30th postoperative day was 3/10 (30 %) in Group B, while it was 0/13 (0 %) in Group A (p < 0.05). The length of the postoperative hospital stay was 31.7 ± 8.8 and 57.5 ± 39.5 days (Group A and Group B, respectively, p < 0.05).

CONCLUSIONS

Intraoperative lymph mapping and preoperative vein mapping are technically feasible and can positively contribute to the prevention of postoperative lymphorrhea after GSV harvesting.

MR lymphography of lymphatic vessels in lower extremity with gynecologic oncology-related lymphedema

Objective

To characterize lymphatic vessel morphology in lower extremity lymphedema using MR lymphography at 3T.

Study Design

Forty females with lower extremity lymphedema secondary to gynecologic carcinoma treatment underwent MR lymphography (MRL) at 3T. Lymphatic vessel morphology in normal and affected limbs was compared.

Results

The median diameter of the lymphatic vessels in swollen calf and thigh were significantly larger than that in the contralateral calf and thigh, respectively (p<0.05). The median number of lymphatic vessels visualized in normal calf was less than that in the lymphedematous calf (p<0.01), while no significant difference was found between the normal thigh and swollen thigh. Lymphatic vessel number in the affected calf was significantly greater than that in affected thigh and the mean diameter of affected calf was also significantly wider than that of affected thigh (p<0.01). Mean diameter of lymphatic vessels in the affected calf was significantly different between stage I and stage III (p<0.05), but not significantly different between stages I and II, and between stages II and III (p>0.05). The median number of lymphatic vessels for affected calf showed significant difference between stage I and stage III, and between stage II and stage III (p<0.05), but no significant difference between stage I and stage II (p>0.05). There was no significant difference in mean diameter or median number of lymphatic vessels in the affected thigh found between different stages (p>0.05).

Conclusion

There are significant differences in the number or diameter of lymphatic vessels between normal and affected limbs and there are significant differences for affected calf between early and late stages of lymphedema; therefore, MR lymphography can be helpful in diagnosis or clinical staging for lower extremity with gynecologic oncology-related lymphedema.

Pathophysiology and treatment of edema following femoropopliteal bypass surgery

Substantial lower-limb edema affects the majority of patients who undergo peripheral bypass surgery. Edema has impairing effects on the microvascular and the macrovascular circulation, causes discomfort and might delay the rehabilitation process of the patient. However, the pathophysiology of this edema is not well understood. The Cochrane Library and Medline were used to retrieve literature on edema following peripheral bypass surgery. Factors other than local wound healing alone are suggested in the literature to play a role, given the severity and duration of this edema. Hyperemia, microvascular permeability, reperfusion-associated inflammation and lymphatic disruptions are likely to facilitate the development of edema. Preventive methods could be lymphatic-sparing surgery, intraoperative antioxidative therapy and postoperative elevation. Successful treatment strategies to reduce postoperative edema are based on lymph massage and external compression. In conclusion, the pathophysiology of edema following peripheral surgery is not fully understood, although reperfusion-associated inflammation and lymphatic disruptions are likely to play a crucial role. When future less-invasive techniques prove to be successful, postoperative edema might be minimized. Until then, a careful lymphatic-sparing dissection should be executed when performing a peripheral bypass reconstruction. Postoperatively, the use of compression stockings and leg elevation are currently the golden standards.

Lymphoscintigraphic findings: delayed oedema after great saphenous vein harvesting

Objective

The aim of this study was to identify lymphoscintigraphic changes associated with lower-extremity oedema after the harvesting of the saphenous vein using a series of short Q2 incisions for coronary bypass.

Method

Forty-four patients (32 males and 12 females) with a mean age of 62.7 ± 7.8 (47–75 years old) were evaluated in a retrospective, quantitative, cross-sectional study from June 2007 to January 2008, three to 188 months (mean: 46 months) after the surgical procedure. Assessment was by water displacement volumetry and lymphoscintigraphy of the lower limbs. Results expressed as means with standard deviations were compared employing the Student's t-test and the chi-square or Fisher's exact tests were used to compare data expressed as frequencies. An alpha error of 5% was considered acceptable ( P ≤ 0.05).

Results

The presence of dermal backflow, as identified by lymphoscintigraphy with an accumulation of radiotracer in the thoracic duct and popliteal lymph nodes was significantly greater on the operated side.

Conclusion

There was a significant association between dermal backflow and delayed oedema.

Prospective randomized controlled trial to analyze the effects of intermittent pneumatic compression on edema following autologous femoropopliteal bypass surgery

Background

Patients who undergo autologous femoropopliteal bypass surgery develop postoperative edema in the revascularized leg. The effects of intermittent pneumatic compression (IPC) to treat and to prevent postreconstructive edema were examined in this study.

Methods

In a prospective randomized trial, patients were assigned to one of two groups. All patients suffered from peripheral arterial disease, and all were subjected to autologous femoropopliteal bypass reconstruction. Patients in group 1 used a compression stocking (CS) above the knee exerting 18 mmHg (class I) on the leg postoperatively for 1 week (day and night). Patients in group 2 used IPC on the foot postoperatively at night for 1 week. The lower leg circumference was measured preoperatively and at five postoperative time points. A multivariate analysis was done using a mixed model analysis of variance.

Results

A total of 57 patients were analyzed (CS 28; IPC 29). Indications for operation were severe claudication (CS 13; IPC 13), rest pain (10/5), or tissue loss (7/11). Revascularization was performed with either a supragenicular (CS 13; IPC10) or an infragenicular (CS 15; IPC 19) autologous bypass. Leg circumference increased on day 1 (CS/IPC): 0.4%/2.7%, day 4 (2.1%/6.1%), day 7 (2.5%/7.9%), day 14 (4.7%/7.3%), and day 90 (1.0%/3.3%) from baseline (preoperative situation). On days 1, 4, and 7 there was a significant difference in leg circumference between the two treatment groups.

Conclusions

Edema following femoropopliteal bypass surgery occurs in all patients. For the prevention and treatment of that edema the use of a class I CS proved superior to treatment with IPC. The use of CS remains the recommended practice following femoropopliteal bypass surgery.

A new negative pressure dressing (PrevenaTM) to prevent wound complications following lower limb distal arterial bypass

Wound complications in patients undergoing distal arterial bypass grafting are common and can lead to loss of limb and life. Vacuum-assisted closure (VAC) has been in use for some time and has proven to expedite the process of wound healing when used in those with open sterile or infected wounds. Recent modifications to the VAC system to make it a topical closed incision dressing have been successful and led to the development of the new PrevenaTM dressing. We present the first application of this purpose-built closed incision site vacuum dressing in a patient with multiple potential risk factors undergoing popliteal-tibial bypass grafting.

Evaluation of A-V impulse technology as a treatment for oedema following polytetrafluoroethylene femoropopliteal surgery in a randomised controlled trial

OBJECTIVE

To investigate the efficacy of A-V impulse technology (A-V) for oedema prevention and treatment following PTFE femoropopliteal surgery.

DESIGN

Prospective randomized clinical trial.

MATERIALS

36 patients undergoing PTFE femoropopliteal bypass reconstructions, either being treated postoperatively with a compression stocking (CS) (Group-1, n = 19) or with A-V (Group-2, n = 17).

METHODS

Patients in treatment group-1 used a CS postoperatively during 1 week day and night, patients in group-2 were treated with A-V postoperatively at night during one week. The lower leg circumference was measured preoperatively and at five postoperative time points.

RESULTS

Limb circumference has increased postoperatively on day 1 (CS 1.5%/A-V 1.4%), on day 4 (5.7%/6.3%), on day 7 (6.6%/6.1%), on day 14 (7.9%/7.7%) and on day 90 (5.8%/5.2%). Differences between treatment groups were not significant. A re-operation gives a significant 3.9% increase in circumference as compared to a first operation (95% CI: 1.5-6.4%; p = 0.002).

CONCLUSION

No significant differences were found in the extent of developed edema between the groups following PTFE femoropopliteal bypass surgery. A redo peripheral bypass operation results in significantly more postoperative oedema than a first-time performed bypass operation.

[Lymphoscintigraphy study of oedema after femoropopliteal segment surgery]

INTRODUCTION

Post-surgical oedema of the femoropopliteal segment is a frequent complication, unrelated to the severity of the previous symptoms or changes in subsequent distal arterial pressure. The aim of the study is to assess whether the oedema present in femoropopliteal bypass patients is of lymphatic origin, and the possible influence of the prosthesis and the type of intervention used.

PATIENTS AND METHODS

An analytical, observational and case-control study of 30 patients who had a femoropopliteal bypass. Isotopic lymphoscintigraphy of the superficial and deep lymphatic system was performed on both limbs in all patients selected for the study.

RESULTS

The saphenous vein was used in 19 patients and PTFE in 11. The patients were divided into controls, 15 without oedema, and cases, 15 with oedema. Surgery technique: 9 reconstructions of the popliteal portion (1st p.p.), 18 third popliteal portion (3rd p.p.), and 3 distal branches. Scintigraphy findings: Asymmetric lymphatic drainage between the 2 limbs was observed in the all 30 examinations, except 1 case (which did not have oedema). There was no lymphatic drainage in 5 cases (one developed oedema). Cases with controls and patients with an autologous or synthetic graft, as well as shunts above and below the knee, were compared. The only statistical difference obtained was that the latter developed oedema more often than those performed close to the knee.

CONCLUSIONS

Therefore, the scintigraphy findings did not point to lymphatic damage as a cause of post-femoropopliteal surgery oedema. The material used did not appear to influence this. The below-knee shunts suffered more oedema than those above the knee.

Influence of groin incision, duration of ischemia, and prostaglandin E1 on ischemia-reperfusion injury of the lower limb

OBJECTIVE

The influences of groin incision, duration of ischemia, and the effects of prostaglandin E1 (PGE1) on ischemia-reperfusion (I/R) injury of the hind limb in rabbits were evaluated.

DESIGN

A prospective study.

SETTING

Laboratory.

PARTICIPANTS

In 64 rabbits, bilateral hind limb ischemia was induced by occlusion of the abdominal aorta. Volume changes, neuromuscular function of the hind limb, and creatine kinase (CK) release were measured as variables of tissue injury.

INTERVENTIONS

Eight rabbits served as untreated controls (CON). In 2 groups (each n = 14), 3 hours of ischemia were followed by 3 hours of reperfusion (I/R). In 2 different groups (each n = 14), 45 minutes of ischemia were followed by 2 hours of reperfusion. To determine effects of PGE1, 1 I/R group of each ischemia duration was treated intravenously with 80 ng/kg/min of PGE1 starting 30 minutes after the onset of ischemia (I/R-PGE1). To determine effects of groin incision on edema formation, volume changes were determined in the "operated" right (CON-R, 3h-R, 3h-PGE1-R and 45 min-R, 45 min-PGE1-R) or in the "nonoperated" left hind limb (CON-L, 3h-L, 3h-PGE1-L and 45 min-L, 45 min-PGE1-L), representing a subgroup analysis.

MEASUREMENTS AND MAIN RESULTS

Volume changes after I/R occurred only in operated legs after ischemia (3h-R: 2.3 +/- 0.3 mL, p < 0.0001 v CON-R and 3h-L; 45 min-R: 0.8 +/- 0.2 mL, p < 0.01 v 45 min-L). PGE1 reduced edema formation in the operated legs (3h-PGE1-R: 1.0 +/- 0.4 mL, p < 0.0001 v 3h-R; 45 min-PGE1-R: 0.5 +/- 0.3 mL, p = 1.0 v 45 min-R). Groin incision without I/R had no effect on edema formation (CON-R: -0.13 +/- 0.17 mL of baseline). The increase of CK release from 616 +/- 584 U/L in controls to 5,921 +/- 2,156 U/L after 3 hours of ischemia (p < 0.001) was attenuated by treatment with PGE1 (3,732 +/- 2,653, p < 0.05 v I/R). Forty-five minutes of ischemia did not lead to cellular damage as measured by CK release (I/R: 606 +/- 364 U/L). Recovery of neuromuscular function was not affected by PGE1.

CONCLUSION

Development of edema during I/R depends on groin incision of the hind limb and on the duration of ischemia. The I/R injury is attenuated by PGE1 treatment, in terms of reduced edema formation and CK release, but not in terms of neuromuscular function.

Is compartment pressure related to plasma colloid osmotic pressure, in patients during and after cardiac surgery?

Haemodilution is always considerable during cardiopulmonary bypass (CPB). If this extra fluid sits in the muscle compartments then a corresponding rise in the compartment pressure (CP) is to be expected. The aim of this study was to measure pressure changes in a body compartment with new equipment, the MTC (Microtransducer). Changes in plasma colloid osmotic pressure (COP) were also measured during and after CPB to find a connection, if any, between CP and plasma COP. Ten elective consecutive CPB patients were studied. A 3-French (3-F) catheter-size electronic MTC was inserted in an anterior tibial compartment before CPB. The CP was monitored for 48 h. Plasma COP was also measured before, during and after CPB. CP increased significantly during and after CPB in all patients (p=0.01). COP decreased significantly in all patients (p=0.005), but no correlation was found between changes in COP and CP values in this study. Most of the patients reached their highest CP just after weaning off bypass. The CP remained elevated for 48 h, even though it then tended to decrease again. None of the patients reached the starting value within 48 h. COP decreased rapidly after going on bypass, but returned towards its starting value approximately 6 h after bypass. It is concluded that CP increases considerably during and after CPB and stays increased for at least 2 days after CPB. COP decreases during CPB, but reaches normal values 6 h after the CPB. No correlation was found between changes in CP and COP The MTC is a safe and easy way to measure intracompartment pressure.

Thigh isosulfan blue injection in the treatment of postoperative lymphatic complications

Postoperative lymphatic complications after infrainguinal revascularization are troublesome and potentially serious complications. Vital dye injection into the web spaces of the foot has been recommended as a simple and reliable method to identify lymphatic channel disruption before groin exploration. Such distal injections, however, are not always successful. We describe a modified technique using a proximal thigh injection with isosulfan blue, which is faster and more useful than the distal web space method.

Lower limb oedema following distal arterial bypass grafting

Lower-limb oedema following arterial bypass surgery for ischemia is a common sequela which can complicate wound healing or delay resumption of mobility. Its exact pathogenesis remains uncertain but many theories have been proposed. Lymphatic disruption during arterial exposure, and endothelial damage from atrophy of the media and oxygen-derived free radical release are currently favoured hypotheses. Infrequently, deep vein thrombosis follows surgery and may exacerbate the condition. Efforts aimed at reducing the oedema, such as the use of lymphatic preserving incisional approaches or the use of antioxidants, have given conflicting results. The use of compression hosiery and leg elevation appear to be the most effective measures in reducing postoperative lower limb oedema.

Lymphedema: classification, diagnosis and therapy

This review presents the diagnostic features, the pathophysiology and the available therapies for lymphedema. This disease is often able to be diagnosed by its characteristic clinical presentation, yet, in some cases, ancillary tests might be necessary to establish the diagnosis, particularly in the early stages of the disease and in edemas of mixed etiology. These diagnostic modalities are also useful in clinical studies. Available modalities include isotopic lymphoscintigraphy, indirect and direct lymphography, magnetic resonance imaging, computed tomography and ultrasonography. Lymphedema may be primary or secondary to the presence of other disease and/or to the consequences of surgery. Primary lymphedema may occur at any phase of life but it most commonly appears at puberty. Secondary lymphedema is encountered more often. The most prevalent worldwide cause of lymphedema is filariasis, which is particularly common in south-east Asia. In the USA, postsurgical lymphedema of the extremity prevails. Complications of chronic limb lymphedema include recurrent cellulitis and lymphangiosarcoma. Most patients are treated conservatively, by means of various forms of compression therapy, including complex physical therapy, pneumatic pumps and compressive garments. Volume reducing surgery is performed rarely. Lymphatic microsurgery is still in an experimental stage, although a few centers consistently report favorable outcomes.

Increased lymphoscintigraphic flow pattern in the lower extremity under evaluation for lymphedema

OBJECTIVE

To analyze the clinical and scintigraphic features in four postoperative patients with lower limb edema.

DESIGN

Four case reports are presented, and causes of increased lymphatic flow are discussed.

MATERIAL AND METHODS

Filtered 99mTc-sulfur colloid (0.1 mL; 20 MBq) was administered by subcutaneous injection into the second web space of each foot. Sequential local (inguinal) and whole-body imaging was performed periodically up to 24 hours after the injections. The patients were three women who were 40, 51, and 86 years of age and an 81-year-old man.

RESULTS

Each patient had unilateral lower extremity swelling and had recently undergone an ipsilateral lower limb operation. One female patient had previously undergone proximal femoral vein ligation, and another female patient had venous insufficiency demonstrated by Doppler ultrasonography. The male patient had a history of severe arterial insufficiency, and the remaining female patient had no venous or arterial abnormalities. On lymphoscintigraphy, all patients showed increased lymphatic flow in the edematous lower limb. Only the male patient also demonstrated abnormal dermal backflow pattern.

CONCLUSION

Increased lymphatic flow most likely is a normal response to lower limb edema in the presence of normal peripheral lymphatic structures. In the four described cases, a recent lower limb surgical procedure may have resulted in disturbance of normal proximal lymphatic channels. The role of sympathetic innervation of the peripheral lymphatic system is a potential factor determining lymphatic response to trauma or surgical intervention. Increased flow on lymphoscintigraphy may not necessarily represent normal flow, especially if other scintigraphic features of abnormal lymphatic function-such as dermal backflow pattern-are present.

The concentration of high molecular weight compounds in interstitial tissue fluid: a study in patients with post-reconstructive leg oedema

OBJECTIVES

To study whether relative changes in the concentration of different proteins of the subcutaneous interstitial tissue fluid in patients with postreconstructive leg oedema could give information on the integrity of the capillary wall following vascular reconstruction.

MATERIALS

Sixteen patients developed ipsilateral leg oedema following femoropopliteal (n = 14) or femorotibial (n = 2) bypass surgery for intermittent claudication (n = 10) or critical lower limb ischaemia (n = 6) caused by obliterating atherosclerosis.

METHODS

The leg volume increase was measured according to the formula of a truncated cone. The blister suction method was used for sampling of subcutaneous interstitial tissue fluid. The concentration of albumin, transferrin, immunoglobulin G and alpha 2-macroglobulin of serum and blister fluid was measured with nephelometry.

RESULTS

Seven days postoperatively the mean leg volume increase was 32% (19.8%) in the operated leg compared to the contralateral side (p < 0.01). In the blister fluid each of the proteins had a significantly higher concentration in the operated leg compared to the control leg. This concentration difference was relatively larger for the proteins with the highest molecular weight, immunoglobulin G (p = 0.006) and alpha 2-macroglobulin (p = 0.002).

CONCLUSIONS

A relatively larger concentration difference of the bigger molecules in the subcutaneous interstitial tissue fluid in patients with post-reconstructive leg ocdema suggests increased capillary permeability to plasma proteins following vascular reconstruction.