Abstract
Background: To define the profile of patients presenting with chronic edema (CE) in three centers in Italy (Lymphoedema IMpact and PRevalence INTernational).
Methods and Results: Data were collected in patients referred for CE between September 2016 and July 2017. A total of 1637 were recruited, 86.7% (1419) outpatients and 13.3% (218) inpatients with 80.6% (1319) female and mean age 54 years. Primary lymphedema occurred in 28.2% (461). In the 71.8% (1176) with secondary CE cancer occurred in 72% (846) and 28% (330) due to other causes. Data showed that 84.2% (226) had full upper body mobility, 15.5% (41) had limited mobility and 0.2% (2) had lost all mobility. Lower limb mobility status: 90.4% (1205) complete mobility, 8.4% (112) reduced mobility and 1.2% (21) wheelchair bound. Concurrent leg ulceration occurred in 32.9% (322) with 3.1% (51) having antibiotics. Treatment patterns varied with only 32.4% (530) receiving instructions in skin care, 61.2% (1002) multilayer compression and a further 67.8% (1110) compression garment with 17.6% (288) having sequential pressure therapy. Only 1.4% (23) had received psychological support. Out of the total 481/1637 (29.4%) were not prescribed any
MARINA CESTARI MD Affiliations:Pianeta Linfedema Study Centre, Terni - ItalyCorrespondence:Questo indirizzo email è protetto dagli spambots. È necessario abilitare JavaScript per vederlo.
ABSTRACT
Venous thoracic outlet syndrome is a unilateral, rarely bilateral, form of thoracic outlet syndrome (approximately 4%), due to an extrinsic compression of the subclavian vein which can be divided into thrombotic and no thrombotic clinical entities.In this study, the author underlines the usefulness of Echo-Colour-Doppler diagnostic to evidence an intermittent subclavian vein compression, without intraluminal thrombus, in patients who had undergone breast surgery, with axillary lymphadenectomy, who refer homolateral venous claudication while performing work activities that can be resolved by resting the limb.In this study, the subclavian venous obstacle discharge was due to impaired posture and/or predisposing morphotype (weak muscular support of the shoulder girdle), completely resolved through specific physical therapy, in order to take pressure off the vein in the thoracic outlet, with complete disappearance of symptoms and consequent improvement in the performance of work activities and quality of life.Furthermore, the resolution of not thrombotic venous thoracic outlet, through physical therapy, avoids the possibility of deep vein thrombosis onset due to the intermittent narrowing of the subclavian vein.Keywords: breast surgery, venous thoracic outlet syndrome, colour duplex ultrasound
INTRODUTION
Thoracic outlet is composed of 3 compartments: costoclavicular and interscalene triangles and retro-pectoralis minor space where neurovascular compression is possible.In this study the author decided to focus the attention on eventual subclavian vein compression in the thoracic outlet after breast surgery, following the evaluation of a patient (38 years, housewife, normal weight, no sport, no central venous catheter) who had undergone breast surgery, with axillary lymphadenectomy followed by radiotherapy, sent to the author’s study centre for lymphoedema onset.In the anamnesis, the patient reported homolateral dominant arm heaviness and fatigue after using it, in abduction, resolving with resting position.The patient was not affected with lymphoedema but with homolateral axillary-subclavian vein thrombosis highlighted through Echo-Colour-Doppler examination.Angio-MRI requested resulted negative for bone, muscle or soft tissue abnormalities as well as a research of congenital thrombophilic factors.Furthermore, a physiatrist evaluation highlighted poor posture (drooping of homolateral shoulder).The aim of this in progress study is to determine the incidence of subclavian vein compression in thoracic outlet in patients who had undergone breast surgery.
MATERIAL AND METHODS
The study was carried out on 110 patients who had undergone (1-2 years) breast surgery (quadrantectomy-axillary lymphadenectomy) followed by radiotherapy, without homolateral central venous catheter.Patients have been divided into 3 groups based upon I.S.L. staging (subclinical stage, stage I and II) and their upper limbs have been examined through Echo-Colour-Doppler (Sonoscape device - 7.5 MHz linear high-frequency probe) at rest, to exclude venous disease, and during the dynamic test to research eventual venous compression in thoracic outlet. The correct dynamic test is performed in seated position, with an experienced physical therapist who passively helps patient to perform the manoeuvre, while the angiologist displays the vascular structures through bilateral abduction manoeuvre by transducer, beneath the clavicle, with longitudinal view of subclavian vein and Doppler angle selected at 60°.In cases of venous thoracic outlet compression at the beginning the flow speed increases, then the flow speed decreases or disappears with upper-stream venous diameter increased and the appearance of spontaneous eco-contrast.Patients positive for venous thoracic outlet compression underwent physiatrist assessment to evaluate their posture.
Did the Masters of the past know the future? History and update of Italian Phlebolymphology’ - Articolo pubblicato su Veins and Lymphatics 04.09.2020
Marina Cestari MD
SUMMARY
The diagnosis of lymph-oedema is essentially clinical, however, we must not ignore the accuracy of the high resolution scan when it is performed by experienced operators using high technology instruments.
We evaluated the utility of this methodology using Echo-Colour-Doppler Sonoline Antares apparatus, in lymph-oedematous upper and lower limbs diagnostics because it is provides us with information on structural characteristics of the examined tissue, and in the ambit of personalized therapeutic strategies.
INTRODUCTION
The first evaluation of patients with lymph-oedema, performed in a team ambit, leads to the compilation of a specific clinical report and personalized rehabilitation project.
Among the instrumental exams requested in the specific clinical report, the Echo-Colour-Doppler is always present: a non-invasive diagnostic approach, repeatable and relatively cheap, it has proved to be indispensable both in differential diagnostics with other oedematous pathologies, both in the ambit of rehabilitative projects and in the choice of selected therapeutic strategies thanks to the precise information on the structural characteristics of the examined tissue.
Leggi tutto: Managment of Lymphoedema: Echo-Colour-Doppler indications for strategies