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VS10 Vascular Surgery
Lymphedema Toronto Notes 2019 Lymphedema
Definition
• impairedlymphaticdrainageresultinginaccumulationofinterstitialfluidandfibroadiposetissue
Etiology
• primary
■ congenital lymphedema (e.g. Milroy disease): presents <2 yr old
■ lymphedema praecox (75% of primary cases): presents in adolescence at onset of puberty ■ lymphedema tarda: presents >35 yr old
• secondary
■ infection (filariasis): #1 cause worldwide
■ malignant infiltration: axillary, groin or intrapelvic
■ radiation/surgery (axillary, groin lymphadenectomy): #1 cause in North America
Clinical Features
• classicallynon-pittingedemaandhyperkeratoticcutaneous/subcutaneouschangeswithprogressive disease
• impairedlimbmobility,discomfort/pain,psychologicaldistress
• positiveStemmersign(sensitive)-examinerunabletoliftskinofthickenedskinfoldatthebaseof
second toe or finger
Treatment
• avoidlimbinjury(canprecipitateorworsenlymphedema) • cellulitis:treatearlytoavoidfurtherlymphaticdamage
• skinhygiene
■ daily skin care with moisturizers
■ early medical assessment and treatment for infection (topical for fungal infection; systemic for
bacterial infection)
• externalsupport:intensive(compressionbandages)vs.maintenance(compressiongarments)
• exercise:gentledailyexerciseofaffectedlimb,graduallyincreasingROM(mustwearcompression
garment while exercising)
• massage:manuallymphdrainagetherapy
• surgical:physiological(earlydisease,increaselymphaticdrainage)vs.reductive(advanceddisease,
remove fibroadipose deposits)
References
Peripheral Artery Disease
Aboyans V, Ricco J-B, Bartelink M-LEL, Björck M, Brodmann M, Cohnert T, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39:763–816.
Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e686- 725.
Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26:517-38.
Aortic Disease
Boodhwani M, Andelfinger G, Leipsic J, Lindsay T, McMurtry MS, Therrien J, et al. Canadian Cardiovascular Society position statement on the management of thoracic aortic disease. Can J Cardiol. 2014;30:577-89.
Canadian Task Force on Preventive Health Care. Recommendations on screening for abdominal aortic aneurysm in primary care. Can Med Assoc J. 2017;189:E1137-45.
Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA, Mansour MA, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg [Internet]. 2018 Jan 1 [cited 2018 Apr 5];67:2-77.e2.
Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo R Di, Eggebrecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. Eur Heart J. 2014;35:2873-926.
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. J Am Coll Cardiol. 2010;55:e27-129.
Carotid Stenosis
Brott TG, Howard G, Roubin GS et al. Long-term results of stening versus Endarterectomy for Carotid-Artery Stenosis. NEJM 2016: 374:1021-1031.
Brott TG, Halperin JL, Abbara S et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. JACC 2011; 57:e16-e94.
Ricotta JJ, AbuRahma A, Ascher E et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg 2011;54:e1-e31. Sardar P, Chatterjee S, Aronow H et al. Carotid Artery Stenting versus Endarterectomy for Stroke Prevention. JACC 2018; 69:2266-2275.
Peripheral Venous Disease
Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014;130:333-46.
Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, et al. Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2015;49:678-737.
Lymphedema
International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology. Lymphology. 2013;46:1-11.
Vascular Surgery Textbook
Cronenwett JL, Johnston W (editors). Rutherford’s vascular surgery, 7th ed. Philadelphia: Saunders/Elsevier. 2014.