soirée dr vignes lymphoedeme 23mai2013

Lymphœdèmes

S. Vignes, Unité de Lymphologie, Hôpital Cognacq Jay, Paris

Que faire devant l’apparition d’un lymphœdème du MS ?

•  Délai d’apparition variable : post-op. è 20-30 ans après… •  FDR : curage axillaire, RT,

obésité, réduction activité physique, mastectomie •  S’assurer du suivi oncologique

surtout si douleurs, déficit sensitif/moteur •  Echo-Doppler veineux éventuel

Lymphœdèmes primaires

•  Membre inférieur +++ •  Formes sporadiques (1/6000)

–  sex ratio : 8 F / 2 H –  âge < 25 ans (après 35 ans : rare)

•  Atteinte –  unilatérale : tout le membre –  bilatérale distale : sous gonale

•  Maladie de Milroy : formes familiales congénitale, mutation VEGFR-3

Kinmonth JB et al. Br J Surg 1957;45:1

LO secondaires des MI •  Atteinte aires ganglionnaires inguinales

–  biopsie, exérèse –  maladies malignes : mélanome MI, cancer marge anale, verge, vulve,…

–  lymphomes non hodgkiniens ou de Hodgkin: biopsie ou radioT

•  Atteintes aires ganglionnaires pelviennes

–  cancer utérin (col, corps), ovaires

–  cancer de la prostate, vessie, rectum

Lymphœdème : signes cliniques

•  Diagnostic clinique •  Œdème élastique du dos du pied •  Accentuation des plis de flexions •  Signe de Stemmer •  Orteils "carrés", papillomatose des orteils •  Tendance des ongles à être verticalisés

Szuba A & Rockson S. Vasc Med 1997;2:321

Physiopathologie du lymphœdème

Explorations

Eliminer les autres diagnostics

•  Rénaux : protéinurie •  Cardiaques : échographie •  Compressions abdominales ou

pelviennes (sujet > 40 ans) –  échographie –  voire scanner

•  Echo-doppler veineux MI •  Aucun examen n’est

indispensable

Lymphoscintigraphie MI •  Examen

–  simple –  peu invasif –  reproductible

•  Possible chez l'enfant •  Colloïdes résorbés par le système lymphatique (sulfocolloïde de rhénium ou d'albumine) •  Etude morphologique

Erysipèle

•  Et non lymphangite •  Principale complication :

risque × 71 / membre sain •  Clinique

–  signes généraux ++++ (fièvre brutale, frissons, parfois vomissements,…)

–  PUIS signes locaux

Erysipèle

•  Traitement : 10-14 j – amoxicilline, 3 g/j en 3 prises ou – pristinamycine, 3 g/j en 3 prises

(Pyostacine®) •  Interdits : AINS, corticoïdes +++ •  Non indiqués : anticoagulants •  Reprise le plus tôt possible de la compression

Becq-Giraudon B. Ann Dermatol Venereol 2001;128:368

Erysipèle •  Traitements porte entrée si retrouvée

–  intertrigo interdigital : Mycoster®, et Tt chaussures (poudre) –  fissures talon (pédicurie, hydratation)

•  Récidives fréquentes (2-3/an) –  antibioprophylaxie : Extencilline®, 2,4 MUI/2 (3) semaines IM, avec 1 ml de Xylocaïne®, 1 ml à 1% voire Oracilline® (2/j en deux prises) –  si « allergie » : tests cutanés et réintroduction +++ –  tolérance dépendante de l’IDE –  durée prolongée : 18-24 mois voire plus –  effet suspensif ++++

Diagnostic différentiel : lipœdème

Lipœdème •  Terme anglo-saxon "lipedema", décrit en 1940 chez 5 femmes obèses, débutant à partir de la puberté (<1% : homme) •  Définition : accumulation de tissus adipeux du bassin jusqu'aux chevilles •  Touchant presque exclusivement femmes obèses : entité plutôt que maladie

Allen EV et al. Proc Staff Mayo Clin 1940;15:1984 Harwood CA et al. Br J Dermatol 1996;134:1

Lipœdème

•  Terme peu approprié car pas d'œdème vrai sauf après orthostatisme •  Autres dénominations utilisées dans la littérature : "lipodystrophy", "painful fat syndrome" •  Confusion fréquente avec le lymphœdème des MI

Lipœdème : signes cliniques

•  Critères diagnostiques lipœdème •  Début à la puberté, avant 20 ans •  Atteinte familiale fréquente (≈ 50%), (mère, grand-mère, sœur) •  Atteinte MI

–  bilatérale parfois asymétrique : cuisse

–  épargnant le pied (mais atteinte après une longue évolution ?)

Wold LE. Ann Intern Med 1949;34:1243


•  Gêne à la marche si volume important •  Peau

–  souple –  pincement douloureux ("cellulalgies")

–  douleurs superficielles : ↑ avec âge

–  ecchymoses faciles (bleus)


•  Œdème –  absent au repos

–  apparaissant après longue période

orthostatisme, prenant le godet :

modérés, ↑ lourdeurs

•  Signes associés d'insuffisance veineuse

favorisés

•  Evolution vers un lipo-lymphœdème

avec atteinte du pied, érysipèle,…

Traitement du lipœdème •  Mais entité > maladie •  Difficile, non codifié •  Demande importante : caractère inesthétique MI, insistance femmes jeunes •  Perte de poids : peu d'effet sur la morphologie MI, à la ≠ reste corps, reste essentielle pour éviter complications locales de l'obésité (gonarthrose, insuf. veineuse)

Traitement du lipœdème •  Objectif : compression des MI •  Traitement lymphœdème : inefficace •  Compression élastique

–  morphologie : difficulté enfilage, utilisation difficile, ↓ souplesse

–  tolérance ± bonne (plis cheville, pied)

–  principal intérêt : œdème après orthostatisme

•  Hydratation de la peau •  Natation, aquagym ++++ •  Liposuccion possible

Traitements des varices et lymphœdèmes

Positionnement du problème

Intrication de trois questions 1.  Stripping interdit en cas de

lymphœdème ? 2.  Déclenchement d’un

lymphœdème après stripping 3.  Distinction du stripping des

autres traitements de l’IVC

Insuffisance veineuse et lymphœdème

•  Association très rare •  Ne pas confondre avec l’IVC,

stade C3-C6 (œdème), avec le lipœdème •  Lymphœdème secondaires

–  après traitement des cancers

–  femmes > 50 ans

Insuffisance veineuse et lymphœdème

•  Lymphœdème primaire –  femmes jeunes –  atteinte distale bilatérale, ou unilatérale complète

•  Excepté en présence d’une mutation du gène FOXC2

Traitement des lymphœdèmes MI

Compression élastique •  Pression élevée : classe 3

(20-36 mmHg), 4 (>36 mmHg) •  Superposition de compression

très fréquente : 3+3, 3+4, 4+4…

è Quelle place reste-t-il au

traitement de l’IVC ?

Traitement de l’IVC

•  Risque : aggraver le lymphœdème •  Thérapeutiques et non

esthétiques •  Indications rares car compression

fortes •  Une méthode est-elle préférable à

une autre: stripping, traitement endoveineux, scléroses ?

•  261 patients de 1989 à 1997 –  lymphœdème : 68 –  lipo-lymphœdème : 103 –  lipœdème : 90

•  Stripping, ligatures saphènes, phlébectomies •  Lymphœdème (appréciation subjective)

–  aggravation : 71% –  stabilité : 28% –  amélioration : 1%

Risque de lymphœdème après stripping

•  4,5% des lymphœdèmes: après stripping ou phlébectomies (Brunner U. Phlebol u Protokol 1975;4:266)

•  63% : anomalies lymphatiques scintigraphiques après stripping (Timi JR et al. Revista Panamerica de Flebologia y Linfologia 1988;31:17) •  Risque de complications non pré-

existantes: érysipèles (Fischer R & Frü G.

Phlebol 1991;20;9)

Original article

Lymphatic complications after varicose veins surgery:risk factors and how to avoid them

P Pittaluga*† and S Chastanet*†

*Riviera Vein Institut, Nice, France; †Riviera Vein Institut, Monte Carlo, Monaco

AbstractIntroduction: Lymphatic complication (LC) after varicose veins (VVs) surgery is an annoyingevent with a variable frequency in the literature.Method: Retrospective study reviewing all surgeries carried out for VVs from January 2000 toOctober 2010. Postoperative LC we reported: lymphatic fistula, lymphocele including theminor ones and lymphoedema.Results: During the period studied, 5407 surgical procedures for VVs were performed in 3407patients (74.7% women) with a mean age of 53.4 years. A postoperative LC occurred in 118cases (2.2%): lymphocele on limb in 1.3%, inguinal LC (fistula or lymphocele) in 0.7% and alymphoedema in 0.2%. The population with a LC was older (59.6 vs. 53.3 years, P , 0.05),had a higher frequency of C4–C6 (22.0% vs. 6.5%, P , 0.05), a higher incidence of obesity(31.4% vs. 5.4%, P , 0.05) and was more often treated by a redo surgery or a crossectomystripping (48.3% vs. 13.4% and 38.1% vs. 21.8%, respectively, P , 0.05). We have observeda dramatic decrease in incidence of LC after January 2004 (1.3% vs. 5.3%, P , 0.05)corresponding to a new surgical practice for the treatment of VVs: stripping, crossectomyand redo surgery at the groin were less frequent (74.6% vs. 7.7%, 74.6% vs. 0.2% and11.3% vs. 0.1%, respectively, P , 0.05), while isolated phlebectomy was more oftenperformed during this period (78.4% vs. 8.4%, P , 0.05).Conclusion: LC after VVs surgery is not rare but frequently limited to lymphocele on limbs.Older age, more advanced clinical stage and obesity were associated with a higher frequencyof LC. A mini-invasive and selective surgery has significantly reduced the occurrence of LC.

Keywords: varicose vein; varicose vein surgery; lymphatic complication; lymphocele;lymphodema; lymphatic fistula; risk factors

Background

The lymphatic complications (LC) such as lympho-cele, lymphatic fistula or lymphoedema are some ofthe most frequent complications after surgery forvaricose veins (VVs).1 However, its frequency isvariable in the literature and the risk of long-lastingcomplication is rather low (,0.5%) after primaryVVs surgery.1 Some risk factors for LC are clearlyidentified: lymphatic insufficiency,1 redo surgery

for VVs especially at the groin2 – 4 and speciallocations such as the dorsal part of the foot or thefront of the shin.1,5 Other risk factors includingobesity have not been reported so far.

To evaluate the presence and the frequency of riskfactors for LC after surgery of VVs and therefore totry to avoid it, we reviewed our experience over 10years.

Method

We conducted a retrospective study on all surgeriescarried out for VVs in our centre from January 2000to October 2010. We reviewed the traditional preo-perative data (demographics, signs, symptoms,body mass index [BMI]), the preoperative venoushaemodynamics (presence and location of venous

Correspondence: P Pittaluga, Riviera Vein Institute, 6 RueGounod 06000, Nice, France.Emails: [email protected]; [email protected]

Accepted 5 January 2012

DOI: 10.1258/phleb.2012.012S12. Phlebology 2012;27 Suppl 1:139–142

Original article






Background




Method





reflux), the surgical technique performed andthe postoperative LC reported (lymphatic fistula,lymphocele including the minor ones andlymphoedema).

Results

During the period studied 5407 surgical proceduresfor VVs were performed on 5050 lower limbs (LLs)in 3407 patients (74.7% women). The mean age ofthe population was 53.4 years. The preoperative fre-quency of CEAP (clinical, aetiological, anatomicaland pathological elements) class C classificationwas the following: 0% C0–C1, 83.4% C2, 7.9% C3and 7.3% C4–C6. Symptoms such as pain, heavi-ness, a swelling sensation, pruritus, night cramps,restlessness, tingling and heat were present in63.8% of the cases. The average BMI was 24.02.All patients had a preoperative ultrasound duplexassessment which showed a reflux on the greatsaphenous vein in 56.7%, on the short saphenousvein in 6.4% and a competent saphenous vein (SV)in 30.1% and it was a recurrent reflux after strippingin 13.9%. The surgical procedure carried out was astripping of the SV in 22% of the cases, an isolatedphlebectomy in 63.8% and a redo surgery afterstripping in 14.2%.

A LC was reported during the postoperativecourse in 118 cases (2.2%). The analysis of these118 events showed that in more than the half ofthe cases (60 cases, 56.7%) the LC was a lymphocelelocated at the LLs (Table 1), while a lymphatic ingu-inal complication or a lymphoedema was rare.Among the 13 patients that had a postoperativelymphoedema, five had a worsening of a preopera-tive primary lymphoedema and for eight of themthe lymphoedema appeared after the surgery. TheLC on the LLs was mostly located below the kneeand on the foot (Table 2).

To evaluate the possible preoperative risk factorsfor the appearance of LC after surgery we com-pared the data of the patients with LC (118 cases)with those without LC complications (5289 cases)(Table 3). For the group in which an LC occurredafter the surgery the mean age was older (59.6%vs. 53.3%, P , 0.05), the frequency of C4–C6 washigher (22.0% vs. 6.5%, P , 0.05), the average BMI

was higher (28.7 vs. 23.9, P , 0.05) and the fre-quency of obesity (BMI . 30) was more frequent(31.4% vs. 5.4%, P , 0.05). All types of LC weremore frequent for obese patients, especiallyinguinal complications which were 14 timesmore frequent in obese patients with a BMI . 30(Table 4).

The type of surgical procedure had an influenceas well: high ligation plus stripping and redosurgery was more frequently followed by an LCduring the postoperative course (Table 5).

We also observed that the period during whichthe surgery was carried out had an influence onoutcomes regarding LC: the frequency of LC wasat 5.3% before January 2004 and 1.3% after thisdate, which corresponded to a radical change ofthe techniques performed in our centre for the treat-ment of VVs (Table 6). The traditional high ligationplus stripping dropped from 74.6% to 0.2% of theprocedures while endovenous or mini-invasivesaphenous ablation reached 7.7% and isolated phle-bectomy (ASVAL) 92.3%. In addition, for the treat-ment of recurrent VVs a redo surgery at the groinwas practically abandoned.

At last, a preoperative skin marking guided byultrasounds was performed in 82.4% after January2004 and only in 20.9% before.

Discussion

Our study showed that an LC after surgery for VVswas not rare, occurring in 2.2% after the surgical

Table 2 Location of lymphatic complication on the lower limbs

Lymphatic complications %

Lymphocele on lower limbs 68Above knee 6 8.8Below knee 50 73.5Foot 12 17.6

Table 3 Comparison of population with and without a lymphaticcomplication after varicose veins surgery

Lymphaticcomplication

No lymph.complication

P

118 5289Age (average

years)59.6 53.3 ,0.0001

Female 75.4% 74.9% NSC4–C6 22.0% 6.5% ,0.05Preop

symptomatic70.3% 70.1% NS

Average BMI 28.7 23.9 ,0.05BMI . 30 31.4% 5.4% ,0.05

BMI, body mass index; NS, non-significant

Table 1 Lymphatic complications after varicose veins surgery


Total 118 2.2Lymphocele on lower limbs 68 1.3Inguinal lymphocele or fistula 37 0.7Lymphoedema 13 0.2

Original article P Pittaluga and S Chastanet. Lymphatic complications after varicose veins surgery

140 Phlebology 2012;27 Suppl 1:139–142

1.  Etude rétrospective de janvier 2000 à octobre 2010

2.  5407 patients

reflux), the surgical technique performed andthe postoperative LC reported (lymphatic fistula,lymphocele including the minor ones andlymphoedema).

Results

During the period studied 5407 surgical proceduresfor VVs were performed on 5050 lower limbs (LLs)in 3407 patients (74.7% women). The mean age ofthe population was 53.4 years. The preoperative fre-quency of CEAP (clinical, aetiological, anatomicaland pathological elements) class C classificationwas the following: 0% C0–C1, 83.4% C2, 7.9% C3and 7.3% C4–C6. Symptoms such as pain, heavi-ness, a swelling sensation, pruritus, night cramps,restlessness, tingling and heat were present in63.8% of the cases. The average BMI was 24.02.All patients had a preoperative ultrasound duplexassessment which showed a reflux on the greatsaphenous vein in 56.7%, on the short saphenousvein in 6.4% and a competent saphenous vein (SV)in 30.1% and it was a recurrent reflux after strippingin 13.9%. The surgical procedure carried out was astripping of the SV in 22% of the cases, an isolatedphlebectomy in 63.8% and a redo surgery afterstripping in 14.2%.

A LC was reported during the postoperativecourse in 118 cases (2.2%). The analysis of these118 events showed that in more than the half ofthe cases (60 cases, 56.7%) the LC was a lymphocelelocated at the LLs (Table 1), while a lymphatic ingu-inal complication or a lymphoedema was rare.Among the 13 patients that had a postoperativelymphoedema, five had a worsening of a preopera-tive primary lymphoedema and for eight of themthe lymphoedema appeared after the surgery. TheLC on the LLs was mostly located below the kneeand on the foot (Table 2).

To evaluate the possible preoperative risk factorsfor the appearance of LC after surgery we com-pared the data of the patients with LC (118 cases)with those without LC complications (5289 cases)(Table 3). For the group in which an LC occurredafter the surgery the mean age was older (59.6%vs. 53.3%, P , 0.05), the frequency of C4–C6 washigher (22.0% vs. 6.5%, P , 0.05), the average BMI

was higher (28.7 vs. 23.9, P , 0.05) and the fre-quency of obesity (BMI . 30) was more frequent(31.4% vs. 5.4%, P , 0.05). All types of LC weremore frequent for obese patients, especiallyinguinal complications which were 14 timesmore frequent in obese patients with a BMI . 30(Table 4).

The type of surgical procedure had an influenceas well: high ligation plus stripping and redosurgery was more frequently followed by an LCduring the postoperative course (Table 5).

We also observed that the period during whichthe surgery was carried out had an influence onoutcomes regarding LC: the frequency of LC wasat 5.3% before January 2004 and 1.3% after thisdate, which corresponded to a radical change ofthe techniques performed in our centre for the treat-ment of VVs (Table 6). The traditional high ligationplus stripping dropped from 74.6% to 0.2% of theprocedures while endovenous or mini-invasivesaphenous ablation reached 7.7% and isolated phle-bectomy (ASVAL) 92.3%. In addition, for the treat-ment of recurrent VVs a redo surgery at the groinwas practically abandoned.

At last, a preoperative skin marking guided byultrasounds was performed in 82.4% after January2004 and only in 20.9% before.

Discussion

Our study showed that an LC after surgery for VVswas not rare, occurring in 2.2% after the surgical

Table 2 Location of lymphatic complication on the lower limbs


Lymphocele on lower limbs 68Above knee 6 8.8Below knee 50 73.5Foot 12 17.6

Table 3 Comparison of population with and without a lymphaticcomplication after varicose veins surgery

Lymphaticcomplication

No lymph.complication

P

118 5289Age (average

years)59.6 53.3 ,0.0001

Female 75.4% 74.9% NSC4–C6 22.0% 6.5% ,0.05Preop

symptomatic70.3% 70.1% NS

Average BMI 28.7 23.9 ,0.05BMI . 30 31.4% 5.4% ,0.05

BMI, body mass index; NS, non-significant

Table 1 Lymphatic complications after varicose veins surgery


Total 118 2.2Lymphocele on lower limbs 68 1.3Inguinal lymphocele or fistula 37 0.7Lymphoedema 13 0.2

Original article P Pittaluga and S Chastanet. Lymphatic complications after varicose veins surgery

140 Phlebology 2012;27 Suppl 1:139–142

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Background




Method





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Background




Method





procedures. Nevertheless, in the wide majority ofthe cases the LC was minor, represented by alymphocele located at the LLs, while more seriouscomplications such as lymphatic fistula or lym-phoedema were infrequent (0.7% and 0.2%, respect-ively), in accordance with the literature.1 Weobserved that the redo surgery for recurrent VVshad a much higher frequency of LC (7.5% vs.2.2%) as it has been reported by other authors.2 – 4

In accordance with the literature, we observedthat a lymphatic insufficiency was a risk factor foran LC since five out of 13 patients with a post-operative lymphoedema have had a preoperativeprimary lymphoedema. We also found in thisstudy other risk factors increasing the incidence ofpostoperative LC, such as older age and presenceof chronic venous disease with skin damage (C4–C6). Above all, obesity was found in this study tobe a strong risk factor for LC: the presence of aBMI . 30 increased the frequency of lymphoceleon LLs by 1.6, the frequency of lymphatic inguinalcomplication by 7.5 and the frequency of lymphoe-dema by 14.7.

We observed a significant difference for the rateof LC according to the period studied: 5.3% beforeJanuary 2004 while it dramatically decreased to1.3% after January 2004. Actually we accomplisheda major evolution in our surgical approach after2004 towards a less invasive technique, especiallyfor the treatment of VVs recurrence with the near-abandonment of redo surgery at the groin (0.1%vs. 11.4%), but also for the treatment of primaryVVs. Indeed after January 2004, the traditionalhigh ligation and stripping was quasi-replaced byisolated phlebectomy (ASVAL) and mini-invasive

saphenous ablation. The interest of avoiding asurgery at the groin is cited,6,7 as well as thebenefit of the preservation of the saphenous junc-tion during stripping8,9 for the reduction of post-operative complications after surgery, with goodresults in terms of signs and symptoms. The endo-venous treatments by laser and radiofrequency, aswell as foam sclerotherapy, are in the same trendof mini-invasiveness for the treatment of VVs,leading to a reduction of complications, includingLC.10 – 13

This evolution of our surgical technique wasaccompanied with a more frequent preoperativeskin marking guided by ultrasounds (82.4% vs.20.9%), and therefore a more precise surgicalgesture. The importance of a precise preoperativeduplex ultrasounds assessment for the safety ofthe procedure and quality of the result is clearlyreported in the literature.5,14,15

Therefore, as older age, presence of skin damageand obesity are identified as risks for an LCafter surgery for VVs, it is mandatory to use lessaggressive approaches by mini-invasive surgery,thermo-ablation or foam sclerotherapy, guided bypre- and/or perioperative guidance by ultrasoundespecially for these patients.

Conclusion

LC after VVs surgery are not rare but are frequentlylimited to lymphocele on limbs. Our study con-firmed that redo surgery, especially at the groin, isa risk factor for LC especially at the groin. Olderage, chronic venous disease with skin changes andobesity were also found to be risk factors for LCafter VVs surgery. In our experience, a mini-invasive surgical approach avoiding redo surgeryat the groin or high ligation, and guided by preo-perative skin marking, has reduced the frequencyof postoperative LC.

Table 4 Comparison of the frequency of different types of lym-phatic complication in obese (BMI . 30) and non-obese patients(BMI,30)

Obese Non-obese P Ratio

N 324 5083Lymphocele on limb 4.0% 1.1% ,0.05 3.6Inguinal complication 5.9% 0.4% ,0.05 14.7Lymphoedema 1.5% 0.2% ,0.05 7.5

BMI, body mass index

Table 6 Comparison of postoperative lymphatic complications andprocedures carried out before and after 2004 for the treatment ofvaricose veins

BeforeJanuary2004 (%)

After January2004 (%)

P

Lymphatic complications 5.3 1.3 ,0.05Stripping!crossectomy 74.6 0.2 ,0.05Redo surgery at the groin 11.3 0.1 ,0.05Endovascular or mini-

invasive ablation0.0 7.7 ,0.05

Isolated phlebectomy 8.4 92.3 ,0.05Preoperative skin marking 20.9 82.4 ,0.05

Table 5 Incidence of postoperative lymphatic complicationdepending on the type of surgical procedure

Lymphatic complication % P

All surgeries 118 2.2High ligation and stripping 45 3.8 ,0.05Redo surgery 57 7.5 ,0.05Isolated phlebectomy 16 0.5 ,0.05

P Pittaluga and S Chastanet. Lymphatic complications after varicose veins surgery Original article

Phlebology 2012;27 Suppl 1:139–142 141

A systematic review and meta-analysis of thetreatments of varicose veinsM. Hassan Murad, MD, MPH,a,b,c Fernando Coto-Yglesias, MD,a,d Magaly Zumaeta-Garcia, MD,a

Mohamed B. Elamin, MBBS,a Murali K. Duggirala, MD,a,c Patricia J. Erwin, MLS,a

Victor M. Montori, MD, MSc,a,c,e and Peter Gloviczki, MD,f Rochester, Minn; and San José, Costa Rica

Objectives: Several treatment options exist for varicose veins. In this review we summarize the available evidence derivedfrom comparative studies about the relative safety and efficacy of these treatments.Methods: We searched MEDLINE, Embase, Current Contents, Cochrane Central Register of Controlled Trials(CENTRAL) expert files, and the reference section of included articles. Eligible studies compared two or more of theavailable treatments (surgery, liquid or foam sclerotherapy, laser, radiofrequency ablations, or conservative therapywith compression stockings). Two independent reviewers determined study eligibility and extracted descriptive,methodologic, and outcome data. We used random-effects meta-analysis to pool relative risks (RR) and 95%confidence intervals (CI) across studies.Results: We found 39 eligible studies (30 were randomized trials) enrolling 8285 participants. Surgery was associated witha nonsignificant reduction in the risk of varicose vein recurrence compared with liquid sclerotherapy (RR, 0.56; 95% CI,0.29-1.06) and all endoluminal interventions (RR, 0.63; 95% CI, 0.37-1.07). Studies of laser and radiofrequencyablation and foam sclerotherapy demonstrated short-term effectiveness and safety. The quality of evidence presented inthis review was limited by imprecision (small number of events), short-term follow-up, and indirectness (use of surrogateoutcomes).Conclusion: Low-quality evidence supports long-term safety and efficacy of surgery for the treatment of varicose veins.Short-term studies support the efficacy of less invasive treatments, which are associated with less periprocedural disabilityand pain. (J Vasc Surg 2011;53:49S-65S.)

Approximately one-third of men and women aged 18to 64 years have varicose veins.1 The high prevalence leadsto significant health care expenditure on treatments ofvaricose veins.2 Surgical treatment of varicose veins in-cludes high ligation and saphenous vein stripping, with orwithout phlebectomy; until the past few years, this proce-dure had been used most commonly by surgeons world-wide.3-5 However, several other less invasive treatmentmodalities that are claimed to be as effective as surgery arecurrently available, including radiofrequency or laser abla-tion of the great (GSV) or small saphenous veins (SSV), orboth, combined with or without phlebectomy, liquid scle-rotherapy,2,6 and foam sclerotherapy.7-9 Numerous ran-domized controlled trials (RCTs) and observational studieshave compared the efficacy of these procedures, but to our

knowledge, no contemporary systematic synthesis is avail-able to compare all available treatments.

The Society for Vascular Surgery (SVS) partnered withthe American Venous Forum (AVF) to develop clinicalpractice guidelines to improve the care of patients withvenous disease. To assist in venous guideline development,the SVS and the AVF commissioned us to conduct thissystematic review and meta-analysis to summarize the best-available evidence about the benefits and harms of thedifferent treatments of varicose veins.

METHODS

The report of this protocol-driven systematic reviewwas approved by the Venous Disease Committee of the SVSand the AVF and adheres to the Quality of Reporting ofMeta-analyses (QUOROM) standards for reporting sys-tematic reviews of RCTs and reporting Meta-analyses ofObservational Studies in Epidemiology (MOOSE).10,11

The quality if evidence was rated using the Grading ofRecommendations Assessment, Development, and Evalu-ation (GRADE) framework.12

Eligibility criteria. Eligible studies were RCTs andcohort studies that enrolled participants with primary vari-cose veins who were treated with surgery, sclerotherapy,foam sclerotherapy, percutaneous endovenous thermal in-terventions (ablation with radiofrequency or laser), or con-servative management with compression stockings. We in-cluded studies that measured any of the outcomes ofvaricose veins recurrence, patient satisfaction, esthetics,time to return to work, pain, and procedurally related

From the Knowledge and Evaluation Research Unit,a the Division ofPreventive Medicine,b the Department of Medicine,c the Division ofEndocrinology, Diabetes, Metabolism and Nutrition,e and the Divisionof Vascular and Endovascular Surgery, Mayo Clinic, Rochesterf; and theHospital Nacional de Geriatria y Gerontologia, Caja Costarricense SeguroSocial, San José.d

Competition of interest: none.The editors and reviewers of this article have no relevant financial relation-

ships to disclose per the JVS policy that requires reviewers to declinereview of any manuscript for which they may have a competition ofinterest.

Reprint requests: M. Hassan Murad, MD, MPH, Associate Professor, MayoClinic Program Director, Preventive Medicine Fellowship Investigator,Knowledge and Evaluation Research Unit, 200 First St SW, Rochester,MN 55905 (e-mail: [email protected]).

0741-5214/$36.00Copyright © 2011 by the Society for Vascular Surgery.doi:10.1016/j.jvs.2011.02.031

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A systematic review and meta-analysis of thetreatments of varicose veinsM. Hassan Murad, MD, MPH,a,b,c Fernando Coto-Yglesias, MD,a,d Magaly Zumaeta-Garcia, MD,a

Mohamed B. Elamin, MBBS,a Murali K. Duggirala, MD,a,c Patricia J. Erwin, MLS,a

Victor M. Montori, MD, MSc,a,c,e and Peter Gloviczki, MD,f Rochester, Minn; and San José, Costa Rica

Objectives: Several treatment options exist for varicose veins. In this review we summarize the available evidence derivedfrom comparative studies about the relative safety and efficacy of these treatments.Methods: We searched MEDLINE, Embase, Current Contents, Cochrane Central Register of Controlled Trials(CENTRAL) expert files, and the reference section of included articles. Eligible studies compared two or more of theavailable treatments (surgery, liquid or foam sclerotherapy, laser, radiofrequency ablations, or conservative therapywith compression stockings). Two independent reviewers determined study eligibility and extracted descriptive,methodologic, and outcome data. We used random-effects meta-analysis to pool relative risks (RR) and 95%confidence intervals (CI) across studies.Results: We found 39 eligible studies (30 were randomized trials) enrolling 8285 participants. Surgery was associated witha nonsignificant reduction in the risk of varicose vein recurrence compared with liquid sclerotherapy (RR, 0.56; 95% CI,0.29-1.06) and all endoluminal interventions (RR, 0.63; 95% CI, 0.37-1.07). Studies of laser and radiofrequencyablation and foam sclerotherapy demonstrated short-term effectiveness and safety. The quality of evidence presented inthis review was limited by imprecision (small number of events), short-term follow-up, and indirectness (use of surrogateoutcomes).Conclusion: Low-quality evidence supports long-term safety and efficacy of surgery for the treatment of varicose veins.Short-term studies support the efficacy of less invasive treatments, which are associated with less periprocedural disabilityand pain. (J Vasc Surg 2011;53:49S-65S.)

Approximately one-third of men and women aged 18to 64 years have varicose veins.1 The high prevalence leadsto significant health care expenditure on treatments ofvaricose veins.2 Surgical treatment of varicose veins in-cludes high ligation and saphenous vein stripping, with orwithout phlebectomy; until the past few years, this proce-dure had been used most commonly by surgeons world-wide.3-5 However, several other less invasive treatmentmodalities that are claimed to be as effective as surgery arecurrently available, including radiofrequency or laser abla-tion of the great (GSV) or small saphenous veins (SSV), orboth, combined with or without phlebectomy, liquid scle-rotherapy,2,6 and foam sclerotherapy.7-9 Numerous ran-domized controlled trials (RCTs) and observational studieshave compared the efficacy of these procedures, but to our

knowledge, no contemporary systematic synthesis is avail-able to compare all available treatments.

The Society for Vascular Surgery (SVS) partnered withthe American Venous Forum (AVF) to develop clinicalpractice guidelines to improve the care of patients withvenous disease. To assist in venous guideline development,the SVS and the AVF commissioned us to conduct thissystematic review and meta-analysis to summarize the best-available evidence about the benefits and harms of thedifferent treatments of varicose veins.

METHODS

The report of this protocol-driven systematic reviewwas approved by the Venous Disease Committee of the SVSand the AVF and adheres to the Quality of Reporting ofMeta-analyses (QUOROM) standards for reporting sys-tematic reviews of RCTs and reporting Meta-analyses ofObservational Studies in Epidemiology (MOOSE).10,11

The quality if evidence was rated using the Grading ofRecommendations Assessment, Development, and Evalu-ation (GRADE) framework.12

Eligibility criteria. Eligible studies were RCTs andcohort studies that enrolled participants with primary vari-cose veins who were treated with surgery, sclerotherapy,foam sclerotherapy, percutaneous endovenous thermal in-terventions (ablation with radiofrequency or laser), or con-servative management with compression stockings. We in-cluded studies that measured any of the outcomes ofvaricose veins recurrence, patient satisfaction, esthetics,time to return to work, pain, and procedurally related

From the Knowledge and Evaluation Research Unit,a the Division ofPreventive Medicine,b the Department of Medicine,c the Division ofEndocrinology, Diabetes, Metabolism and Nutrition,e and the Divisionof Vascular and Endovascular Surgery, Mayo Clinic, Rochesterf; and theHospital Nacional de Geriatria y Gerontologia, Caja Costarricense SeguroSocial, San José.d

Competition of interest: none.The editors and reviewers of this article have no relevant financial relation-

ships to disclose per the JVS policy that requires reviewers to declinereview of any manuscript for which they may have a competition ofinterest.

Reprint requests: M. Hassan Murad, MD, MPH, Associate Professor, MayoClinic Program Director, Preventive Medicine Fellowship Investigator,Knowledge and Evaluation Research Unit, 200 First St SW, Rochester,MN 55905 (e-mail: [email protected]).

0741-5214/$36.00Copyright © 2011 by the Society for Vascular Surgery.doi:10.1016/j.jvs.2011.02.031

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Bountouroglou et al32 randomized patients to SFJligation and GSV stripping and phlebectomies, or to SFJligation under local anesthetics and foam sclerotherapy tothe GSV. At 3 months, both groups had similar reductionin the median CEAP class from preoperative value of C4 toa value of C1. Sclerotherapy however, was associated withfaster return to normal activities (2 vs 8 days), betterreduction of VCSS (sclerotherapy group median VCSSdropped from 5 to 1 and surgery median dropped from 7 to3; P ! .001), and reduced overall cost by almost 50%.32

Allocation was concealed in both of these RCTs; how-ever, the short duration of follow-up renders the assess-ment of outcomes of interest less valid and the quality ofevidence is low. These studies were sponsored by commer-cial funding sources (foam manufacturers). The quality ofevidence supporting equivalence is considered low.

Other surgical studies. Jakobsen42 compared radicalsurgery, including saphenofemoral and/or saphenopopli-teal ligation, GSV and/or SSV stripping, ligation of incom-petent perforating veins located by clinical examination,and avulsion of tributaries, with minimally-invasive surgery(ligation under local anesthesia) and sclerotherapy. At 3years, radical surgery was associated with better esthetic andsymptomatic results.

Rutgers et al49 compared stripping and local avulsionsof varicose veins vs high ligation of the saphenofemoraljunction and sclerotherapy. Cosmetic results, judged byboth the patient and the surgeon, and clinical and Dopplerultrasound results, were significantly better after the strip-ping operation.

Dwerryhouse et al37,61 compared flush ligation of thesaphenofemoral junction with subsequent diathermy avul-sion of all the visible varicose tributaries vs a combination ofligation and GSV stripping to the knee. After 5 years offollow-up, they found that stripping had significantly de-creased the need for reoperation (RR, 0.28; 95% CI,0.13-0.59).

When surgery is compared with all endoluminal abla-tion therapies (laser, radiofrequency, and foam), meta-analysis shows that surgery led to a nonsignificant reductionin the risk of varicose vein recurrence (RR, 0.63; 95% CI,0.37-1.07; I 2 " 90%; 16 studies).

Adverse effects

In general, all treatments for varicose veins were welltolerated, without significant periprocedural adverse ef-fects; particularly, DVT and PE in these studies were veryinfrequently reported. Local complications were commonbut were generally minor. Table II summarizes the re-ported frequency of local complications associated withsurgery, liquid sclerotherapy, laser ablation, radiofrequencyablation, and foam therapy. Laser and radiofrequency ab-lation studies reported more side effects than sclerotherapyand surgery studies, which could be attributed to differen-tial reporting of minor side effects.

DISCUSSION

Our findings. In the systematic review, we searchedthe literature for studies that compared different treatmentmodalities for varicose veins. We found 38 studies that meteligibility criteria and compared different permutations ofthe available approaches to treating varicose veins and theincompetent saphenous veins. In general, invasive treat-ments (surgical and endoluminal) were superior to conser-vative management in elimination of varicose veins anddecreasing ulcer recurrence rates. Studies of liquid sclero-therapy, foam, and endoluminal thermal ablation therapieshad short follow-up time, making them unsuitable to assesslong-term outcomes.

Surgery appears to have low- to moderate-quality evi-dence demonstrating less recurrence and better long-termresults. Compared with surgery, however, liquid or foamsclerotherapy and endoluminal thermal ablation therapies(laser and radiofrequency) were associated with faster re-

Table II. Commonly reported adverse events

Surgery Sclerotherapy Laser ablation Radiofrequency ablation Foam therapy

! Wound infection,3%-6%

! Skin staining ornecrosis, 3%

! Purpura/bruising,11%-23%

! Saphenous nerveparesthesia, 13%

! Contusion,bruising,hematoma, 61%

! Sural or saphenousnerve injury, 10%-23%

! Superficial phlebitis,22%-27%

! Erythema, 33% ! Superficial phlebitis,0%-20%

! Skin pigmentation,51%

! Hematoma, 31% ! Hyperpigmentation,57%

! Hematoma, 7% ! Headache, 11%

! Superficial phlebitis,0%-12%

! Hypopigmentation, 2% ! Thermal skin injury, 7%

! Blistering/sloughing,7%

! Paresthesia, !1%

! Scaring, 13% ! Leg edema, !1%! Telangiectatic matting,

28%! Edema, 15%! Paresthesia, 1%-2%! Superficial phlebitis, 6%

JOURNAL OF VASCULAR SURGERYMay Supplement 201162S Murad et al

Conclusions

•  Informer par écrit les patients du risque d’aggravation du lymphœdème (May R. Angio 1981;5:265) •  Facteurs favorisants : obésité,

âge, C4-C6 •  Indications formelles d’un

traitement de l’IVC (avec la compression) •  Si doute persistant avant un

geste : lymphoscintigraphie

Traitement des lymphœdèmes

Traitements des lymphœdèmes

•  Bandages peu élastiques (contention) •  Compression élastique •  Drainages lymphatiques manuels •  Exercices sous bandages •  Auto-apprentissage des bandages •  Education •  Soins cutanés locaux

Buts du traitement des lymphœdèmes

1.  Réduction de volume : phase "intensive" –  hospitalière ou ambulatoire –  bandages peu élastiques

2.  Maintien du volume réduit : phase "d'entretien" en ambulatoire –  compression élastique et –  bandages (fréquence plus faible)

http://www.has-sante.fr/portail/jcms

Réduction de volume : bandages monotypes peu élastiques

•  Bandes à allongement court < 100% (Partsch H, et al. Dermatol Surg 2006;32:224)

•  Bandages multicouches (2-4) MAIS

monotypes (≠ pathologies vasculaires)

•  Intérêt : pression de repos faible mais

forte en mvt (gymnastique, marche, vélo)

•  Effet contensif >>> compressif Harris SR et al. Lymphology 2001;34:84 Cohen SR et al. Cancer 2001;92:980 Lymphoedema Framework. Best practice for the management of lymphoedema. International consensus. London: MEP Ltd, 2006

Drainages lymphatiques manuels

•  Nombreuses techniques : Vodder, Foldi, Leduc, Ferrandez, Schiltz†, de Micas (www.afpdlm.org) •  Qu’en attendre ?

–  court terme : ü  sensation d’allègement, ü  ↓ tension cutanée ü  effet relaxant

–  long terme : effet ≈ 0 sur volume si utilisés seuls

Badger C et al. Cochrane Database Syst Rev 2004 MacNeely M et al. Breast Cancer Res Treat 2004 Vignes S et al. Breast Cancer Breast Treat 2007

Drainages lymphatiques manuels

•  Drainages lymphatiques manuels – petite synergie avec les bandages peu élastiques

– utiles dans les LO proximaux (sein, thorax)

– utile phase intensive, facultatif phase d'entretien

Badger C et al. Cochrane Database Syst Rev 2004;3:CD003141 Harris SR et al. Lymphology 2001;34:84 Lymphoedema Framework. Best practice for the management of lymphoedema. International consensus. London: MEP Ltd, 2006

Compression élastique

Compression et lymphœdèmes

Classes élevées: 3, 4 Bas cuisse > chaussettes

Pieds fermés Sur-mesure

Superposition MI

soirée dr vignes lymphoedeme 23mai2013

Travel