UNILATERAL LEG

SWELLINGS
Dr. Kishwar Ali
Vascular Surgeon
Assistant Professor of Surgery,
FUMC
 Learning Objectives
• To know;

• About the different causes of leg swellings.

• Differentiate between the causes of unilateral & bilateral leg
swellings.

• How to evaluate the common causes of unilateral leg swellings.

• Management approach to commonest unilateral leg swellings.
Leg Swelling may be:

Unilateral Bilateral

Acute Acute

Chronic Chronic
Acute unilateral swelling:

• Acute DVT
• Ruptured Baker’s cyst
• Compartment syndrome
• Calf Muscle hematoma
• Rupture of the Achilles tendon
• Soft tissue trauma/ bone fracture
• Cellulitis
Chronic Unilateral swellings:

• Chronic Venous insufficiency

• PTS
• VVs
• Klippel Trenaunay’s Syndrome
• Lymphoedema
• Soft tissue tumours
• Bony tumours
• Arteriovenous malformations
• Arterial aneurysms
Acute bilateral swelling

• Acute Bilateral DVT due to IVC thrombosis

• Sudden deterioration of heart failure(CCF)
• Sudden Deterioration of Kidney diseases
or CLD
 Chronic Bilateral Swelling

• CCF
• ESRD
• Obesity
• DCLD
• Pelvic Tumours
• Hypothyroidism
• Dependency edema
• Malnutrition
• Hypoalbuminemia
We will focus on the common
unilateral leg swellings only
• DVT
• Lymphoedema
• CVI
• Cellulitis
• CVM
• Compartment syndrome
• Trauma
• Tumors
• Aneurysms
DEEP VENOUS THROMBOSIS
 Deep vein thrombosis is the
formation of a blood clot in any of
the deep veins of the body, usually in
the leg.
 Virchow's triad

describes

three factors that are thought to contribute to

thrombosis
.

•
VENOUS STASIS
Prolonged bed rest.
A cast on the leg
Limb paralysis from
stroke
Spinal cord injury
Long travel in a
vehicle
 • Thrombophilia Congenital:
Deficiencies of protein-S, protein-C, anti-
thrombin, Factor V Leiden, prothrombin
gene mutation.
HYPERCOAGULABILITY Sticky platelet syndrome
HYPERCOAGULIBILTIY Hyperhomocystinemia
Increased lipoprotein

• Acquired disorders of coagulation

• Anti-phospholipid antibodies
• Malignancy
• Pregnancy
• OCP use
• HIT
• Obesity
 Trauma
Surgery

Invasive procedure Iatrogenic causes

ENDOTHELIAL
ENDOTHELIAL
INJURY
DAMAGE
central venous catheters

Subclavian, IJV central lines causing

upper extremity DVT
The thrombus propagates in the direction of the blood flow.

Inflammation is triggered, causing tenderness, swelling, and erythema.

Pieces of thrombus may break loose and travel through circulation- emboli.

Fibroblasts eventually invade the thrombus, scarring vein wall and destroying
valves. Patency may be restored, valve damage is permanent, affecting directional
flow.
 • Calf pain or tenderness
•
Swelling with pitting oedema
•
Increased skin temperature
Presentation •
Superficial venous dilatation
•
Cyanosis can occur with severe
obstruction
Less frequent manifestations
of venous thrombosis include

Phlegmasia alba dolens,

Phlegmasia cerulea dolens,
and Venous gangrene.

These are clinical spectrum of

the same disorder.
 PHLEGMASIA ALBA DOLENS

• PAINFUL CONGESTION OF
LEG
• LEG BECOMES WHITE
• SOME COLLATERAL VENOUS
CHANNELS ARE PRESERVED
 PHLEGMASIA
CERULIA DOLENS

Painful, swollen cyanosed

leg
No venous collaterals are
preserved
Complete proximal venous
occlusion
VENOUS GANGRENE
 It pre-test probability score
WELLS CLINICAL
PREDICTION GUIDE
Helps in early risk stratification
and appropriate use of
laboratory tests and imaging
modalities.
Wells score

Active cancer (rx within last 6 months or palliative) 1

Calf swelling >3 cm compared to other calf 1

Collateral superficial veins (non-varicose) 1

Pitting edema 1

Swelling of entire leg 1

Localized pain along distribution of deep venous system 1

Paralysis, paresis, or recent cast immobilization of lower extremities 1

Recently bedridden > 3 days, or major surgery requiring regional or general anaesthetic in past 12 weeks
1

Previously documented DVT 1

Alternative diagnosis at least as likely deep vein thrombosis

-2
Interpretation

• Score less than 2: Low risk of DVT

• Score more than 2: High risk for DVT

 D-DIMERS
It should be noted that since D-dimer assays
present a low specificity for DVT, the value of this
test should be limited to ruling out rather than
confirming the diagnosis of a DVT.
ALGORITHM FOR DIAGNOSTIC IMAGING
 Color-flow Duplex scanning is the imaging test of choice
for patients with suspected DVT
ULTRASONOGRAPHY

Inexpensive,

Non-invasive,

Widely available

Ultrasound can also distinguish other causes of leg

swelling, such as tumour, popliteal cyst, abscess,
aneurysm, or hematoma.
 MAGNETIC RESONANCE IMAGING
It detects leg, pelvis, and pulmonary thrombi
and is 97% sensitive and 95% specific for DVT.
It distinguishes a mature from an immature
clot.
MRI is safe in all stages of pregnancy.
Test may not be appropriate for patients with
pacemakers or other metallic implants, it can
be an effective diagnostic option for some
patients.
 Cellulitis

Thrombophlebitis

DIFFERENTIALS Ruptured baker’s cyst

Arthritis
Asymmetric peripheral edema secondary to CHF, liver
disease, renal failure, or nephrotic syndrome

lymphangitis
Extrinsic compression of iliac vein secondary to tumor,
hematoma, or abscess Hematoma
Lymphedema
 The primary objectives of the
treatment of DVT are to -
EMERGENCY
Prevent pulmonary embolism,
DEPARTMANT
CARE Reduce morbidity, and

Prevent or minimize the risk of

developing the postphlebitic syndrome
 Encourage mobilization.

Appropriate analgesia
GENERAL
THERAPEUTIC Limb elevation
MEASURES Increase fluid intake

Compression stocking .
SPECIFIC
• Anticoagulation
TREATMENT • Thrombolytic therapy
• Surgery for DVT
• Filters for DVT
 • Initial treatment of DVT is with low-
molecular-weight heparin or
unfractionated heparin for at least 5
days along with oral anticoagulants
Anticoagulation like warfarin till the target INR(2-3) is
achieved.

• Followed by warfarin (target INR,

2.0–3.0) for at least 3 months.
 CATHETER DIRECTED THROMBOLYSIS/ SURGICAL
THROMBECTOMY

SURGERY FOR
Venous gangrene
DVTPhlegmasia alba/cerulia dolens
Proximal iliofemoral DVT

The major surgical procedures for DVT are clot removal and
partial interruption of the inferior vena cava to prevent
pulmonary embolism.
Indications OF IVC FILTERS

Contraindication to anticoagulation.

Significant bleeding complication of anticoagulation therapy.

Pulmonary embolism with contraindication to

anticoagulation.

Recurrent thrombo-embolic complication despite adequate

anticoagulation therapy.
LYMPHOEDEMA
“Accumulation of abnormal amount of protein rich fluid in
the interstitium due to compromised lymphatic system ”

It’s a progressive, chronic and debilitating swelling that can

affect any part of the body, mostly the limbs leading to
distortion in shape, size, reduction in mobility and impaired
function
 Sub dermal
fibrosis
Collagen Dermal
deposition thickening

Pathophysiology
LYMPH- Valvular
lymphostasis
EDEMA incompetence

Hypocon-
Obstruction
tractility
Aplasia
hypoplasia
 LYMPHEDEMA

Primary lymphedema Secondary lymphedema

Congenital Praecox Tarda

 Secondary Lymphedema
Most common lymphedema having well
recognized causes
Causes of Secondary Lymphedema
Breast surgery with radiotherapy

Primary malignancy
Prostate, cervical cancer, malignant melanoma
Trauma to lymphatics
Surgical excision of lymph nodes
Filariasis
Presentation of lymphedema
Characteristically foot involvement
Ankle contours are lost with infilling of the
submalleolar depressions
Buffalo hump on foot dorsum
Square shaped toes
Stemmer’s sign
 Skin changes
Chronic eczema
Dermatophytosis
Fissuring
Ulcerations
 Brunner Classification

0 Histological abnormalities
Not clinical evident

I Pitting edema,
Subsides with elevation

II Non pitting edema

Not relieved with elevation

III Irreversible skin changes,

fibrosis, papillae
Treatment
 Investigations
• Diagnosis is mostly clinical
• Duplex
• Isotope lymphangioscintigraphy
• CT
• MRI
• Contrast lymphangiography
 TREATMENT

Conservative Surgical
 Conservative

Physical Medication
❖ Complex Lymphedema Therapy (CLT)

➢ Manual lymphatic drainage (MLD)*

(massage to make the flow to normal lymphatics)
➢ Low stretch bandaging
(to prevent re-accumulation)
CLT
Intermittent pneumatic pump compression
therapy
Effectively milking the lymph
from the extremity

Compression garment
To help prevent return of fluid
 Skin care
(Examine, dry,
moisturizers)
Exercises
Psychological
support
& occupational
therapy
Medications
Antibiotics
Antifungal
antiparasitics
 Surgical

Ablative/reduction Bypass surgeries

 Debulking Operation

• Sistrunk procedure
• Homan procedure

• Thompson procedure

• Charles procedure
Bypass surgeries

Lymph node anastamosis with veins

Lymphovenous anastamosis
 Chronic Venous insufficiency

• Venous return is impaired over a

number of years, by reflux, obstruction
or calf muscle pump failure.
• This leads to venous hypertension, and
clinically complications like edema,
eczema, lipodermatosclerosis and
ulceration • Primary Varicose veins
• Post thrombotic syndrome
• Congenital Varicose veins
• (Klippel Trenaunay's Syndrome)
Cellulitis
• Sudden swelling of the extremity with redness, pain and increased
warmth
• Nausea, vomiting, fever
• May be Erysipelas or cellulitis
• Treatment is
• Leg elevation
• Antibiotics
• Incision and drainage if abscess develops
Congenital Vascular
malformations
• Venous malformations
• Lymphatic malformations
• Capillary malformations
• Combined
• Low flow
• High flow
Compartment syndrome
• After trauma
• After revascularization
• Pain out of proportion to the physical findings
• Tense compartment
• Leg is commonly involved
• Treatment is fasciotomy
 Trauma
• Musculotendin
ous rupture
• Bleeding into
the muscle
compartment
• Soft tissue
trauma
• Fractures
 Tumours
• Soft tissue
tumours(Sarcoma)
• Bony tumours
Arterial Aneurysms

• Femoral arterial aneurysm

• Popliteal aneurysms