ABSTRACT
Arjun Jayaraj, MD
Vascular Surgeon
RANE Center for Venous and Lymphatic Disease at St. Dominic Hospital
Jackson, Mississippi, United States
Recent studies have emphasized the important role lymphatics play in the drainage of interstitial fluid and edema prevention. While infra inguinal lymphatics have been studied in some depth and patterns of pathology identified, such data above the groin is sparse, particularly in patients with phlebolymphedema. This study attempts to evaluate the status of lymphatic flow above the inguinal ligament in patients undergoing stenting for symptomatic chronic iliofemoral venous obstruction (CIVO).
Methods:
Thirty-one lower limbs that underwent pedal lymphoscintigraphy (LSG) for leg edema and subsequent stenting for symptomatic CIVO formed the study cohort. Each limb underwent intranodal lymphangiogram (INL) of an ipsilateral inferior inguinal group lymph node (10cc of lipiodol) at the time of stenting. Fluoroscopic visualization of lipiodol transit was done (20min/40 min/3 hours post-injection). Enumeration of lymph nodes and lymphatic channels from above the inguinal ligament to L1; visualization of the thoracic duct; time delay to visualization of lymph nodes, lymphatic channels, thoracic duct; and pathologic changes to thoracic duct when present were all evaluated. These anomalies were independently scored (normal [0], mild [1], moderate [2], and severe [3] disease) and subsequently combined to generate a total suprainguinal score (0-3). This score was then compared to the limb’s lymphoscintigraphy derived infrainguinal score (total infrainguinal score 0-3), using t-test and Spearman correlation. Clinical outcomes (grade of swelling/VCSS) post stenting were appraised.
Results:
Of the 31 limbs (30 patients), 18 were women, with left laterality noted in 23 limbs. MTS/PTS occurred in 9/22 limbs. Twenty-four limbs (77%) had suprainguinal lymphatic disease (SLD). At baseline, limbs with severe suprainguinal lymphatic disease had same degree of leg swelling and VCSS as limbs with mild-moderate suprainguinal lymphatic disease (p >0.1) with similar improvement post stenting (p >0.4). 7 limbs underwent complex decongestive therapy (all with severe suprainguinal lymphatic disease/concomitant severe infrainguinal disease in 1) for residual leg edema with improvement. When suprainguinal lymphatic disease was compared to infrainguinal lymphatic disease, 6 limbs (19%) had the same degree of involvement both above and below the groin (1 normal and 5 severe disease). 17 limbs (55%) had more severe suprainguinal lymphatic, while 8 limbs (26%) had more severe infrainguinal lymphatic disease. Three limbs with normal pedal lymphoscintigram had severe suprainguinal lymphatic disease. The mean total score for suprainguinal lymphatic disease was 2.19, while for infrainguinal lymphatic disease it was 1.55 (p=0.03). Spearman correlation coefficient was 0.1 (p= 0.69).
Conclusions:
Suprainguinal lymphatic disease appears to be common in patients undergoing stenting for symptomatic CIVO. This may have a role to play in persistent/residual leg swelling post stenting and complex decongestive therapy. Further study is warranted.