1. A retrospective study of 5,407 surgical procedures for varicose veins between 2000-2010 found 118 patients (2.2%) experienced lymphatic complications post-operatively, most commonly lymphoceles on the limbs (1.3%). 2. Risk factors for lymphatic complications included older age, more advanced clinical stage of varicose veins, higher rates of obesity, redo surgeries, and crossectomy stripping procedures. 3. The incidence of lymphatic complications dramatically decreased after 2004, corresponding to a shift to less invasive isolated phlebectomy and avoiding stripping and redo surgeries at the groin, which reduced complications to 1.3%.

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

2. 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

3. 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

4. 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

5. 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

6. Szuba A & Rockson S. Vasc Med 1997;2:321
Physiopathologie du lymphœdème

7. Explorations

8. 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

9. 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

10. Erysipèle
• Et non lymphangite
• Principale complication :
risque × 71 / membre sain
• Clinique
– signes généraux ++++
(fièvre brutale, frissons,
parfois vomissements,…)
– PUIS signes locaux

11. 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

12. 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 ++++

13. Diagnostic différentiel :
lipœdème

14. 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

15. 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

16. 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

17. Lipœdème : signes cliniques
• Gêne à la marche si volume
important
• Peau
– souple
– pincement douloureux
("cellulalgies")
– douleurs superficielles : ↑
avec âge
– ecchymoses faciles (bleus)

18. Lipœdème : signes cliniques
• 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,…

19. 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)

20. 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

21. Traitements des varices et
lymphœdèmes

22. 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

23. 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

24. Insuffisance veineuse et lymphœdème
• Lymphœdème primaire
– femmes jeunes
– atteinte distale bilatérale,
ou unilatérale complète
• Excepté en présence d’une
mutation du gène FOXC2

25. 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 ?

26. 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 ?

27. • 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%

28. 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)

29. 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
Abstract
Introduction: Lymphatic complication (LC) after varicose veins (VVs) surgery is an annoying
event with a variable frequency in the literature.
Method: Retrospective study reviewing all surgeries carried out for VVs from January 2000 to
October 2010. Postoperative LC we reported: lymphatic fistula, lymphocele including the
minor ones and lymphoedema.
Results: During the period studied, 5407 surgical procedures for VVs were performed in 3407
patients (74.7% women) with a mean age of 53.4 years. A postoperative LC occurred in 118
cases (2.2%): lymphocele on limb in 1.3%, inguinal LC (fistula or lymphocele) in 0.7% and a
lymphoedema 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 crossectomy
stripping (48.3% vs. 13.4% and 38.1% vs. 21.8%, respectively, P , 0.05). We have observed
a 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, crossectomy
and redo surgery at the groin were less frequent (74.6% vs. 7.7%, 74.6% vs. 0.2% and
11.3% vs. 0.1%, respectively, P , 0.05), while isolated phlebectomy was more often
performed 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 frequency
of 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
perative data (demographics, signs, symptoms,
body mass index [BMI]), the preoperative venous
haemodynamics (presence and location of venous
om
anuary 2012
DOI: 10.1258/phleb.2012.012S12. Phlebology 2012;27 Suppl 1:139–142
To evaluate the possible preoperative risk factors
for 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 occurred
after the surgery the mean age was older (59.6%
vs. 53.3%, P , 0.05), the frequency of C4–C6 was
higher (22.0% vs. 6.5%, P , 0.05), the average BMI
O
w
Ta
co
A
Fe
C
Pr
A
BM
BM
Table 1 Lymphatic complications after varicose veins surgery
Lymphatic complications %
Total 118 2.2
Lymphocele on lower limbs 68 1.3
Inguinal lymphocele or fistula 37 0.7
Lymphoedema 13 0.2
1. Etude rétrospective de janvier 2000 à octobre
2010
2. 5407 patients

30. At last, a preoperative skin marking guided by
ultrasounds was performed in 82.4% after January
2004 and only in 20.9% before.
Discussion
Our study showed that an LC after surgery for VVs
was not rare, occurring in 2.2% after the surgical
Table 3 Comparison of population with and without a lymphatic
complication after varicose veins surgery
Lymphatic
complication
No lymph.
complication
P
118 5289
Age (average
years)
59.6 53.3 ,0.0001
Female 75.4% 74.9% NS
C4–C6 22.0% 6.5% ,0.05
Preop
symptomatic
70.3% 70.1% NS
Average BMI 28.7 23.9 ,0.05
BMI . 30 31.4% 5.4% ,0.05
BMI, body mass index; NS, non-significant
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
Abstract
Introduction: Lymphatic complication (LC) after varicose veins (VVs) surgery is an annoying
event with a variable frequency in the literature.
Method: Retrospective study reviewing all surgeries carried out for VVs from January 2000 to
October 2010. Postoperative LC we reported: lymphatic fistula, lymphocele including the
minor ones and lymphoedema.
Results: During the period studied, 5407 surgical procedures for VVs were performed in 3407
patients (74.7% women) with a mean age of 53.4 years. A postoperative LC occurred in 118
cases (2.2%): lymphocele on limb in 1.3%, inguinal LC (fistula or lymphocele) in 0.7% and a
lymphoedema 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 crossectomy
stripping (48.3% vs. 13.4% and 38.1% vs. 21.8%, respectively, P , 0.05). We have observed
a 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, crossectomy
and redo surgery at the groin were less frequent (74.6% vs. 7.7%, 74.6% vs. 0.2% and
11.3% vs. 0.1%, respectively, P , 0.05), while isolated phlebectomy was more often
performed 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 frequency
of 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
perative data (demographics, signs, symptoms,
body mass index [BMI]), the preoperative venous
haemodynamics (presence and location of venous
m
nuary 2012
DOI: 10.1258/phleb.2012.012S12. Phlebology 2012;27 Suppl 1:139–142
procedures. Nevertheless, in the wide majority of
he cases the LC was minor, represented by a
able 4 Comparison of the frequency of different types of lym-
hatic complication in obese (BMI . 30) and non-obese patients
BMI,30)
Obese Non-obese P Ratio
N 324 5083
ymphocele on limb 4.0% 1.1% ,0.05 3.6
nguinal complication 5.9% 0.4% ,0.05 14.7
ymphoedema 1.5% 0.2% ,0.05 7.5
MI, body mass index
Table 6 Comparison of postoperative lymphatic complications and
procedures carried out before and after 2004 for the treatment of
varicose veins
Before
January
2004 (%)
After January
2004 (%)
P
Lymphatic complications 5.3 1.3 ,0.05
Strippingþcrossectomy 74.6 0.2 ,0.05
Redo surgery at the groin 11.3 0.1 ,0.05
Endovascular or mini-
invasive ablation
0.0 7.7 ,0.05
Isolated phlebectomy 8.4 92.3 ,0.05
Preoperative skin marking 20.9 82.4 ,0.05
Pittaluga and S Chastanet. Lymphatic complications after varicose veins surgery Original article

31. A systematic review and meta-analysis of the
treatments of varicose veins
M. 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 derived
from 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 the
available treatments (surgery, liquid or foam sclerotherapy, laser, radiofrequency ablations, or conservative therapy
with 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 with
a 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 radiofrequency
ablation and foam sclerotherapy demonstrated short-term effectiveness and safety. The quality of evidence presented in
this review was limited by imprecision (small number of events), short-term follow-up, and indirectness (use of surrogate
outcomes).
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 disability
and pain. (J Vasc Surg 2011;53:49S-65S.)
Approximately one-third of men and women aged 18
to 64 years have varicose veins.1
The high prevalence leads
to significant health care expenditure on treatments of
knowledge, no contemporary systematic synthesis is ava
able to compare all available treatments.
The Society for Vascular Surgery (SVS) partnered wi
fidence intervals (CI) across studies.
ults: We found 39 eligible studies (30 were randomized trials) enrolling 8285 participants. Su
onsignificant reduction in the risk of varicose vein recurrence compared with liquid sclerothe
9-1.06) and all endoluminal interventions (RR, 0.63; 95% CI, 0.37-1.07). Studies of l
ation and foam sclerotherapy demonstrated short-term effectiveness and safety. The quality
s review was limited by imprecision (small number of events), short-term follow-up, and indir
comes).
nclusion: Low-quality evidence supports long-term safety and efficacy of surgery for the tre
ort-term studies support the efficacy of less invasive treatments, which are associated with less
d pain. (J Vasc Surg 2011;53:49S-65S.)
proximately one-third of men and women aged 18
ears have varicose veins.1
The high prevalence leads
ificant health care expenditure on treatments of
e veins.2
Surgical treatment of varicose veins in-
high ligation and saphenous vein stripping, with or
t phlebectomy; until the past few years, this proce-
ad been used most commonly by surgeons world-
5
However, several other less invasive treatment
ties that are claimed to be as effective as surgery are
ly available, including radiofrequency or laser abla-
the great (GSV) or small saphenous veins (SSV), or
knowledge, no contemporary s
able to compare all available tre
The Society for Vascular Su
the American Venous Forum
practice guidelines to improve
venous disease. To assist in ven
the SVS and the AVF commi
systematic review and meta-ana
available evidence about the
different treatments of varicose
Table II. Commonly reported adverse events
Surgery Sclerotherapy Laser ablation Radiofrequency ablation Foam therapy
● Wound infection,
3%-6%
● Skin staining or
necrosis, 3%
● Purpura/bruising,
11%-23%
● Saphenous nerve
paresthesia, 13%
● Contusion,
bruising,
hematoma, 61%
● Sural or saphenous
nerve 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, Ͻ1%
● Scaring, 13% ● Leg edema, Ͻ1%
● Telangiectatic matting,
28%
● Edema, 15%
● Paresthesia, 1%-2%
● Superficial phlebitis, 6%
JOURNAL OF VASCULAR SURGERY
May Supplement 201162S Murad et al

32. 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

33. Traitement des lymphœdèmes

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

35. 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)

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

37. 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

38. 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

39. 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

40. Compression élastique

41. Compression et
lymphœdèmes
Classes élevées: 3, 4
Bas cuisse > chaussettes
Pieds fermés
Sur-mesure
Superposition MI