Swelling of the legs
Yu.T. Tsukanov, A.Yu. Tsukanov
Department of Surgical Diseases of Postgraduate Studies (Head of Department - Prof. Yu.T. Tsukanov) of the Omsk State Medical Academy. Medical clinic "Angio Center" Russia, Omsk.
A total of 135 patients were examined, including 47 menand 88 women aged 17 to 88 years (mean age 43 years) who turned to an angiologist and associated lower extremity edema with their existing varicose veins.
With a comprehensive survey,the following variants of lesions causing an increase in the limb volume alone or in combination: secondary lymphedema in varicose veins, primary lymphedema, flat feet, arthrosis of the ankles in combination with and without flat feet.
It was found that the edema of the distal sections of the lowerlimbs - uncharacteristic for uncomplicated varicose disease syndrome. The presence of such edema with varicose veins, with the exclusion of primary lymphedema, lesions of the foot and ankle joints, including in cases of trophic changes in the subcutaneous tissue of the tibia, including open and healed ulcers, should be used as an argument for the search for previously suffered deep vein thrombosis.
Traditionally, for many years the edema of the lowerlimbs is considered a typical manifestation of varicose veins. At the same time, an increase in the volume of the lower limbs can have different causes of vascular and non-vascular nature [1-3].
In this study,conditions leading to an increase in the volume of the lower extremities of the legs in patients who, in the medical field or without it, turned to the angiologist for an adherence of the lower extremities with the existing varicose veins.
The purpose of the study: elucidation of the causes causing an increase in the volume of the lower limbs in patients with varicose veins.
The study group included 135 patients, inincluding 47 men and 88 women aged 17 to 88 years (mean age 43 years) who applied from 2009 to June 2010 to an angiologist at the Angio Center medical clinic.
Patient inclusion criteria: an increase in the perimeter of the distal part of the lower limb is more than 1.0 cm in comparison with the other limb or the difference in comparing morning and evening measurements in the foot and shin area of more than 1.0 cm in the presence of varicose veins.
Before deciding on inclusion in the studyMeasurement of circumference in the middle of the foot and above the ankle was performed. Comparative measurements were performed in the morning before ascent from bed and in the evening after daytime orthostatic load.
1) the difference in the length of the circumference in the region of the foot and shin on healthy and aching limbs;
2) the difference in circumference of the limb, measured in the morning and evening at the level of the maximum increase in volume.
With a difference in measurement of at least 1.0 cm in the first or second parameter of the patient, with his informed consent, they were included in the study group.
Exclusion criteria: acute thrombosis of deep veins, acute varicothrombophlebitis, previously operated patients and patients who underwent sclerotherapy, lymphedema 2 and 3 stages, combined oral contraceptives, hormone replacement therapy, pregnancy, severe concomitant diseases of the heart, lungs, liver, kidneys accompanied by swelling of the lower extremities.
To clarify the causal relationships of the increase in volumedistal departments of lower extremities with vascular and non-vascular lesions, a detailed clinical and instrumental examination of venous and lymphatic vessels, as well as of the osteoarticular apparatus of the extremities was carried out.
In the work a complex clinicalexamination, measurement of circumference before and after the day's orthostatic load, ultrasonic duplex scanning of the venous system and fiber, radiography of bones. Attention was drawn to the presence of deformations in the ankle and foot area, which were compared with the pain sensations present in them and the results of radiography.
Objectification of lymphatic edema was carried out atultrasonic duplex examination using SonoSite 180 Plus using a linear sensor with an operating frequency of 10-5 MHz at the points: the middle of the rear of the foot, 3-4 cm above the medial malleolus, on the shin in its widest part in the morning and evening.
The thickness of the fiber from the skin to the fascia was evaluated andthe severity of fibrotic sclerotic changes in it, the degree of hydrophilicity of the cellulose, the prevalence and localization of edema . A significant increase in the thickness of the skin layer and deep fascia on the affected limb was considered an increase of 0.1 cm or more in comparison with the symmetrical part of the healthy limb .
Investigation of the venous system of the lower extremitiesperformed with ultrasound duplex scanning with color coding of blood flow in the patient's position while standing on the SonoSite 180 Plus. In the presence of several diseases in the patient, the cause of edema was determined on the basis of a set of information obtained with the priority of detailed clinical data (the type of limb and the characteristics of complaints) revealed in the analysis of complaints and anamnesis.
Statistical analysis was carried out usingof the program Statistica 6.0. Results All patients had an increase in the volume of the distal parts of the lower limb, but the configuration of the edema was different and was determined by the disease that caused it.
The following variants of lesions are registered,causing a distal increase in the limb volume alone or in combination: secondary lymphedema in varicose veins, primary lymphedema, flat feet, arthrosis of the ankles in combination with and without flat feet.
Total vascular causes occurred in 95of patients (70.4%). In 19 (14.1%) of them, swelling was manifested by a predominant lesion of the foot in the form of a pillow-like deformation of its back region. In 7 patients of this group, edema spread to the ankle and lower third of the tibia. At the same time, changes in the subcutaneous veins were segmental, and therefore did not significantly affect venous hemodynamics.
In 13 of them, reflux along the trunkssaphenous veins, according to the data of duplex scanning, was absent, while in the remaining 8 people the reflux along the large saphenous vein was limited to its proximal segment within the thigh. The predominantly recorded bilateral, but asymmetric variant with the prevalent lesion of a single limb.
All patients in this group have a symptomStemmer, which is pathognomonic for distal primary lymphedema . The diagnosis of the latter was confirmed by ultrasound. In all patients, increased hydrophilicity of the cellulose, the presence of sclerotic changes. It should be noted that all patients of this group have connective tissue dysplasia.
The most numerous was a group of patientsvaricosity, accompanied by secondary lymphedema - 76 (56.3%) people. At ultrasonic research of a fiber at all patients of the given group the expanded lymphatic ducts shown echo-transparent merging slits against a background of increase of hydrophilicity and skleroticheski changes of a cellulose are revealed.
When duplex scanning of the veins of the lowerlimbs in all patients of this group showed a pronounced varicose transformation of superficial veins with reflux over the large saphenous vein all along with a shortage of perforators on the shin, which was combined in 10 patients with reflux in the small saphenous vein.
All 76 patients had a pronounced chronicvenous insufficiency, manifested by the induction of subcutaneous tissue (class C4), as well as trophic ulcers: in 5 people - with open (class C6), in 11 with scarring (class C5). An important finding was that 42 (55.3%) of 76 patients with a pronounced long-term varicose veins dilatation during duplex scanning showed changes that are characteristic of the previous deep vein thrombosis of the lower leg, most often posterior tibial and fibular, developed in data of anamnesis, after the clinical manifestation of varicose veins .
In 64 (47.4%) patients with varicose veinsof varying severity, there was a local limited increase mainly in the lateral or both surfaces of the ankle joint region. Its cause was chronic bursitis due to arthrosis of the ankle joint. Of these, 51 subjects had a predominant increase in the lateral surface of the pericondylar zone, combined with flat feet.
The latter, causing valgus deformation of the foot withchanges in the axis of the ankle, increases the load on its lateral surface. In this case, the patients recorded a swelling, mainly limited to the lesions of the synovial membranes or the entire joint as a whole. Characteristic was that with arthrosis swelling, as well as tenderness in this area was proportional to the severity of the load on the feet.
Such edema was accompanied by pain along the jointcrevices for palpation, support on the leg and walking. In 14 (10.4%) people, the noted limited edema of the rear of the foot was combined with local soreness of metatarsophalangeal joints, coinciding with the localization of edema, and provoked by walking in shoes with a stiff insole, high or low heel.
Based on the results of the comprehensiveit was found that among the patients examined there were no cases when an increase in the volume of the distal departments of the lower extremities developed in the presence of uncomplicated varicose veins in the absence of primary lymphedema, lesion of the joints of the feet and ankle
We noted that most of the surveyedof patients (83 / 61.5%) were overweight. At the same time, 80 of them (59.3%) had different combinations of reasons for increasing the volume of the lower extremities. Discussion It is known that phase hypertension in peripheral veins can lead to phase hypertension in the capillaries, causing a transient disruption of the Starling force relationship  with the possible diffusion of part of the plasma into the intercellular space .
However, such transient microcirculatorydisorders, as a rule, do not lead to edema . At the same time, it is necessary to understand the actual accumulation of fluid in the intercellular space under the latter . Tissue swelling occurs only when the lymph drainage of the resulting interstitial fluid is disturbed and can develop only with absolute or relative insufficiency of the lymphatic system .
In cases of primary lymphedema that causesan increase in the volume of the distal parts of the limbs, the function of the venous system and capillary ultrafiltration are preserved. In our observations, patients in this group were diagnosed with early lymphedema (limphedema praecox) due to lymphatic hypoplasia, according to Kinmonth J.
The latter implies three variants of lymphedema: congenital, early and late . In this case, the lymphatic system does not cope with the usual volume of fluid transport from the limb and the discharge of interstitial fluid into the cardiovascular system is reduced. Since protein transport is impaired, the edema in these patients is more dense and less labile throughout the day, although the dependence on the orthostatic load remains.
As a result, there is lymphedema - tissue swellingdue to stagnation of lymph . In the development of venous insufficiency, full-fledged lymphatic vessels due to their potential can compensate for the time of stagnation of fluid and prevent swelling for the time being. As the volume of ultrafiltrate increases, the volume of lymph also increases accordingly.
And only in cases where the volume of ultrafiltratebegins to exceed the transport capacity of the lymphatic system, there is lymphatic insufficiency with a high ejection (functional), which is manifested by distal edema .
People, because of their profession or imagelife that conducts the active part of the day mainly while standing or sitting, conditions can be created in the venous section of the capillaries for a transient decrease in liquid reabsorption . However, permanent distal edema occurs only with venous diseases and solely as lymphedema, due to relative lymphatic insufficiency [2,9].
This situation is observed in gross violationsoutflow, primarily associated with the defeat of deep veins of the lower extremities, which is confirmed by this study. The only exceptions are cases of complete immobilization of patients with a forced sitting posture.
At the same time, as the presentthe study, along with functional lymphatic insufficiency in patients with chronic venous insufficiency, may damage lymph vessels directly in the shin of the lower leg with the development of trophic disorders in it.
It should be noted that an increase in the volume of the lowerlimbs in patients with varicose veins may also be due to an increase in the volume of the venous bed and deposited in the finiteness of the blood at the end of the day due to the pathological dilatability of the varicose veins affected by the venous walls. However, this increase in volume predominantly occurs in the muscular parts of the limb .
It is characteristic that in our observations there was neitherone patient with a distal edema with uncomplicated varicose disease. In patients with edema of the distal lower limbs, more often than not (50% of cases), early thrombosis of deep, especially tibia, veins was recorded.
This makes it necessary to excludesuffered deep vein thrombosis in patients with distal edema, especially as with varicose veins there are conditions for the development of deep vein thrombosis due to a sufficiently high frequency of ectasia of the tibia veins . Interest in the theoretical and practical aspects was provided by observations in which several causes of an increase in the limb volume were revealed in patients.
Most patients with C4-C6 were diagnosed withthe next fairly typical set of diseases: vein-lymphatic insufficiency, arthrosis of the ankles, flat feet. It is characteristic that 90% of these patients had obesity 2-4 degrees. The latter seems to be an extremely important circumstance, as it provokes the development and progression of all the listed diseases.
Individual reasons must be differentiatedincreasing the volume of limbs and their priority in a particular patient, remembering that the pathology of the vessels is only one of the reasons causing edema and an increase in the volume of the lower limbs.
The presence of edema of the distal parts of the lowerlimbs with varicose veins, with the exclusion of primary lymphedema, damage to the joints of the foot and ankle, including in cases of trophic changes in the subcutaneous tissue of the tibia, including open and healed ulcers, should be used as an argument for the search for previously transferred deep vein thrombosis, especially the shin.
Obesity promotes the development of the complexdiseases, including arthrosis of the ankles and feet, which along with chronic venous-lymphatic insufficiency cause distal edema of the lower extremities.