Vascular
CASE 55: inveStigation oF a SWollen limb
history
A 43-year-old Caucasian woman presents to the surgical outpatients with right leg swelling. This first appeared 3 weeks ago and has gradually increased such that she now finds it difficult to put on her shoe. She is otherwise symptomless. There is no history of trauma to the limb. Apart from a tonsillectomy as a child, there is no past history of note. She is on an oral contraceptive pill.
examination
There is unilateral swelling of the right lower leg from the foot to just above the knee (Figure 55.1). There is no associated erythema and no stigmata of venous disease. The oedema pits when the skin is pressed. All pulses in the leg are palpable. The general examination is otherwise unremarkable.
Figure 55.1 unilateral right leg swelling.
Questions
•What is the differential diagnosis of leg swelling?
•What investigations are required?
•What are the two most likely diagnoses in this patient?
•What are the treatment options?
125
100 Cases in Surgery
ANSWER 55
The common causes of unilateral limb swelling are:
•Long-standing venous disease (e.g. post-thrombotic syndrome)
•Acute deep vein thrombosis
•Lymphoedema
•Extrinsic pressure (e.g. pregnancy, tumour, retroperitoneal fibrosis)
•Klippel–Trénaunay syndrome
•Lipoedema
•Disuse/hysterical oedema
Bilateral symmetrical limb swelling is usually caused by systemic factors such as:
•Heart failure
•Renal failure
•Liver cirrhosis
•Hypoproteinaemia
•Hereditary angioedema
Useful investigations include:
•Blood tests: full blood count, urea and electrolytes, liver function test, albumin
•Electrocardiogram/echocardiography
•Abdominal ultrasound
•Duplex scanning of deep and superficial veins if a venous cause is suspected
•Isotope lymphography
•Contrast lymphography, if diagnosis of lymphoedema equivocal
The most likely diagnoses are either deep vein thrombosis or lymphoedema. Lymphoedema is either primary or secondary. Secondary causes include:
•Surgical excision of local lymph nodes
•Radiotherapy to local lymph nodes
•Tumour infiltrating the lymphatics
•Trauma
•Filiriasis
•Lymphoedema artifacta: patient tying a tourniquet around the limb
In lymphoedema, the vast majority of patients (>90 per cent) are treated conservatively. Interstitial fluid is driven from the limb using intermittent pneumatic compression devices. Compression is maintained using elastic stockings. Massage of the leg may also be beneficial. Patients are advised to elevate the leg when possible and to be vigilant for signs of cellulitis, which should be treated promptly. Diuretics are not useful.
Debulking operations (e.g. Charles and Homan’s reduction) are only considered for a selected few patients where the function of the limb is impaired or those with recurrent attacks of severe cellulitis.
KEY POINT
• the majority of patients with lymphoedema are managed conservatively.
126
Vascular
CASE 56: variCoSe veinS
history
You are asked to see a 47-year-old hairdresser in the vascular clinic. She has been complaining of pain in the right leg on prolonged standing and has noticed unsightly, distended veins in that leg for the past 2 years. For the past 3 months she has also had itching of the skin just below the knee with a red patch in that area. She is currently on treatment for hypertension with no other past history of note. She has two children.
examination
A distended vein can be felt in the medial aspect of the mid-thigh running down to the knee. There are numerous varicosities around and below the knee. There is an erythematous patch of skin approximately 3cm in diameter overlying one of the below-knee varicosities. A thrill is palpable at the sapheno-femoral junction when the patient coughs. Foot pulses are strongly palpable.
Questions
•What is the most likely diagnosis?
•What information would the Trendelenburg test provide?
•What is the significance of the erythematous patch of skin?
•What imaging studies would you consider?
•What are the possible complications if left untreated?
127
100 Cases in Surgery
ANSWER 56
This patient has varicose veins in the distribution of the long saphenous vein, a common condition that is more common in women. Working as a hairdresser involves prolonged standing, which increases venous hydrostatic pressure leading to distension of the veins and secondary valve incompetence within the superficial venous system.
The Trendelenburg test can confirm superficial as opposed to deep-vein incompetence and identify the point of incompetence along the superficial system. The leg is elevated to collapse all the veins and pressure is applied on the long saphenous vein just below the saphenofemoral junction. The patient then stands up, and if the distal varicosities remain empty, the point of reflux from the deep to the superficial system has been identified. If the varicosities fill, then the procedure is repeated, this time applying the pressure at a lower point until the point of reflux is identified.
The itching erythematous patch represents varicose eczema and is an indication for operative intervention.
Imaging identifies all areas of reflux and obstruction within the superficial and deep-venous system. Duplex ultrasound is now the standard diagnostic modality for this purpose. Alternatives include contrast varicography/venography and magnetic resonance imaging.
!Sequelae of varicose veins
•pain
•leg swelling
•bleeding
•eczema
•Skin ulceration
KEY POINTS
•Further skin changes may be prevented with surgical correction of the superficial venous reflux disease.
•Surgery on the superficial venous system should be avoided in patients with an incompetent deep venous system.
128