The Rane Center, Flowood, MS. USA.
J Vasc Surg. 2012 Jan;55(1):141-9. doi: 10.1016/j.jvs.2011.07.078. Epub 2011 Sep 29.
Chronic venous disease (CVD) is a common cause of secondary lymphedema. Venous lymphedema is sometimes misdiagnosed as primary lymphedema and does not receive optimal treatment. We have routinely used intravascular ultrasound (IVUS) imaging in all cases of limb swelling. The aim of this study is to show that (1) routine use of IVUS can detect venous obstruction missed by traditional venous testing, and (2) iliac-caval venous stenting can yield satisfactory clinical relief and can sometimes reverse abnormal lymphangiographic findings.
The study comprised CVD patients who underwent iliac vein stenting. Lymphangiography was abnormal in 72 of 443 CEAP C(3) limbs, with leg swelling as the primary complaint (abnormal lymphangiography group). Clinical features and stent outcome were compared with a control group of 205 of 443 with normal lymphangiography (normal lymphangiographic group).
Clinical features were a poor guide to the diagnosis of lymphedema. Isotope lymphangiography was not helpful in differentiating primary from secondary lymphedema. Venography had 61% sensitivity to the diagnosis of venous obstruction. IVUS had a sensitivity of 88% for significant (≥50% area stenosis) venous obstruction. At 40 months, cumulative secondary stent patency was similar for the abnormal (100%) and normal lymphangiographic (95%) groups. Swelling improved significantly after stent placement in the abnormal lymphangiographic group (mean [standard deviation] swelling grade improvement 0.8 ± 1.1) but was less (P < .004) than in the control group (1.4 ± 1.3). Complete swelling relief was 16% and 44% (P < .001) and partial improvement (≥1 grade of swelling) was 45% and 66% (P < .01) in the abnormal and normal lymphangiographic groups, respectively. Associated pain was present in 50% and 36% of the swollen limbs in the abnormal and normal lymphangiographic groups. Pain relief (≥3 visual analog scale) at 40 months was 87% and 83%, respectively (P = .3), with 65% and 71%, experiencing complete pain relief. Quality of life criteria improved after stent placement in both groups but to a better extent in the normal lymphangiographic group. Abnormal lymphangiography improved or normalized in 9 of 36 (25%) of those tested after stent correction.
Prevailing practice patterns and diagnostic deficiencies probably result in the misdiagnosis of many cases of venous lymphedema as "primary" lymphedema. IVUS is recommended to rule out venous obstruction as the associated or initiating cause of lymphedema. Iliac venous stenting to correct the obstruction has excellent long-term patency and good clinical outcome, although results are not as good as in those with normal lymphatic function.
慢性静脉疾病（CVD）是继发性淋巴水肿的常见原因。静脉性淋巴水肿有时被误诊为原发性淋巴水肿，得不到最佳治疗。我们在所有肢体肿胀的病例中常规使用血管内超声（IVUS）成像。本研究的目的是表明：（1）常规使用 IVUS 可以检测到传统静脉检查遗漏的静脉阻塞；（2）髂-腔静脉支架置入术可以获得满意的临床缓解，有时可以逆转异常的淋巴造影结果。
该研究纳入了接受髂静脉支架置入术的 CVD 患者。443 例 CEAP C（3）肢体中，72 例淋巴造影异常，以腿部肿胀为主要表现（淋巴造影异常组）。比较了临床特征和支架治疗结果与 205 例淋巴造影正常的对照组（淋巴造影正常组）。
临床特征不能很好地指导淋巴水肿的诊断。同位素淋巴造影术无助于区分原发性和继发性淋巴水肿。静脉造影术对静脉阻塞的诊断有 61%的敏感性。IVUS 对明显（≥50%面积狭窄）静脉阻塞的敏感性为 88%。40 个月时，异常（100%）和淋巴造影正常（95%）组的继发性支架通畅率相似。在淋巴造影异常组，支架置入后肿胀明显改善（平均[标准差]肿胀分级改善 0.8±1.1），但低于对照组（P<.004，1.4±1.3）。完全肿胀缓解率分别为 16%和 44%（P<.001），部分缓解（肿胀分级改善≥1 级）率分别为 45%和 66%（P<.01）。在淋巴造影异常和正常组中，分别有 50%和 36%的肿胀肢体存在相关疼痛。40 个月时，缓解疼痛（≥3 分视觉模拟量表）的比例分别为 87%和 83%（P=.3），完全缓解疼痛的比例分别为 65%和 71%。两组支架置入后生活质量标准均有所改善，但淋巴造影正常组改善更明显。在支架矫正后，36 例（25%）接受检查的患者中，9 例（25%）异常淋巴造影得到改善或正常化。
目前的治疗模式和诊断缺陷可能导致许多静脉性淋巴水肿病例被误诊为“原发性”淋巴水肿。建议使用 IVUS 排除静脉阻塞作为淋巴水肿的相关或起始原因。纠正阻塞的髂静脉支架置入术具有极好的长期通畅率和良好的临床效果，尽管其效果不如淋巴功能正常者。
