Did the Masters of the past know the future? History and update of Italian Phlebolymphology’ -  Articolo pubblicato su Veins and Lymphatics 04.09.2020


MARINA CESTARI MD Affiliations:Pianeta Linfedema Study Centre, Terni - ItalyCorrespondence:Questo indirizzo email è protetto dagli spambots. È necessario abilitare JavaScript per vederlo.


Venous thoracic outlet syndrome is a unilateral, rarely bilateral, form of thoracic outlet syndrome (approximately 4%), due to an extrinsic compression of the subclavian vein which can be divided into thrombotic and no thrombotic clinical entities.In this study, the author underlines the usefulness of Echo-Colour-Doppler diagnostic to evidence an intermittent subclavian vein compression, without intraluminal thrombus, in patients who had undergone breast surgery, with axillary lymphadenectomy, who refer homolateral venous claudication while performing work activities that can be resolved by resting the limb.In this study, the subclavian venous obstacle discharge was due to impaired posture and/or predisposing morphotype (weak muscular support of the shoulder girdle), completely resolved through specific physical therapy, in order to take pressure off the vein in the thoracic outlet, with complete disappearance of symptoms and consequent improvement in the performance of work activities and quality of life.Furthermore, the resolution of not thrombotic venous thoracic outlet, through physical therapy, avoids the possibility of deep vein thrombosis onset due to the intermittent narrowing of the subclavian vein.Keywords: breast surgery, venous thoracic outlet syndrome, colour duplex ultrasound


Thoracic outlet is composed of 3 compartments: costoclavicular and interscalene triangles and retro-pectoralis minor space where neurovascular compression is possible.In this study the author decided to focus the attention on eventual subclavian vein compression in the thoracic outlet after breast surgery, following the evaluation of a patient (38 years, housewife, normal weight, no sport, no central venous catheter) who had undergone breast surgery, with axillary lymphadenectomy followed by radiotherapy, sent to the author’s study centre for lymphoedema onset.In the anamnesis, the patient reported homolateral dominant arm heaviness and fatigue after using it, in abduction, resolving with resting position.The patient was not affected with lymphoedema but with homolateral axillary-subclavian vein thrombosis highlighted through Echo-Colour-Doppler examination.Angio-MRI requested resulted negative for bone, muscle or soft tissue abnormalities as well as a research of congenital thrombophilic factors.Furthermore, a physiatrist evaluation highlighted poor posture (drooping of homolateral shoulder).The aim of this in progress study is to determine the incidence of subclavian vein compression in thoracic outlet in patients who had undergone breast surgery.


The study was carried out on 110 patients who had undergone (1-2 years) breast surgery (quadrantectomy-axillary lymphadenectomy) followed by radiotherapy, without homolateral central venous catheter.Patients have been divided into 3 groups based upon I.S.L. staging (subclinical stage, stage I and II) and their upper limbs have been examined through Echo-Colour-Doppler (Sonoscape device - 7.5 MHz linear high-frequency probe) at rest, to exclude venous disease, and during the dynamic test to research eventual venous compression in thoracic outlet. The correct dynamic test is performed in seated position, with an experienced physical therapist who passively helps patient to perform the manoeuvre, while the angiologist displays the vascular structures through bilateral abduction manoeuvre by transducer, beneath the clavicle, with longitudinal view of subclavian vein and Doppler angle selected at 60°.In cases of venous thoracic outlet compression at the beginning the flow speed increases, then the flow speed decreases or disappears with upper-stream venous diameter increased and the appearance of spontaneous eco-contrast.Patients positive for venous thoracic outlet compression underwent physiatrist assessment to evaluate their posture.

Lymphedema in many countries is still considered an "aesthetic" problem, even though a chronic, degenerative, and debilitating disease. After a long period of study with internal and external experts, the Italian Ministry of Health has implemented National Care guidelines for lymphedema and other related disorders. This Document represents a fundamental element with regards to diagnostic and therapeutic regulation procedures that satisfy the health needs of these patients. In this paper the description of the main constituents of the document that has revolutionized the possibility of access the best specialized care facilities situated in the country.


S. Michelini (1), M. Cestari (2), M. Ricci (3), A. Leone (4), A. Galluccio (1), M. Cardone (1)

(1) San Giovanni Battista Hospital, Rome, Italy
(2) Vascular Public Consulting Room, Terni, Italy
(3) Rehabilitative Department Torrette Hospital, Ancona, Italy
(4) Carmide Hospital, Catania, Italy


The problem of classifying treatment of primary and secondary lymphedema in both the public and private sectors, derives from a series of considerations. First of all the fact that the same global guidelines of the principal scientific societies that are experts in the subject (i.d. Consensus Document of the International Society of Lymphology) 1,2,3 illustrate the opinions of the leading world experts of the field: some consider lymphedema as an alteration of the lymph transport linked to intrinsic or extrinsic dysfunction of the lymphatic system itself; others consider it a disease. In fact the World Health Organization in the International Classification of Diseases (version number 9-ICD9) recognizes the various forms of lymphedema as diseases and not as symptoms or clinical manifestations. They were also assigned specific codification for the disease: 457.0 Breast cancer related lymphedema and 457.1 for all the other forms of primary and secondary lymphedema.

Marina Cestari  MD



The diagnosis of lymph-oedema is essentially clinical, however, we must not ignore the accuracy of the high resolution scan when it is performed by experienced operators using high technology instruments.
We evaluated the utility of this methodology using Echo-Colour-Doppler  Sonoline Antares apparatus, in lymph-oedematous upper and lower limbs diagnostics because it is provides us with information on structural characteristics of the examined tissue, and in the ambit of personalized therapeutic strategies.


The first evaluation of patients with lymph-oedema, performed in a team ambit, leads to the compilation of a specific clinical report and personalized rehabilitation  project.
Among the instrumental exams requested in the specific clinical report, the Echo-Colour-Doppler is always present: a non-invasive diagnostic approach, repeatable and relatively cheap, it has proved to be indispensable both in differential diagnostics with other oedematous pathologies, both in the ambit of rehabilitative projects and in the choice of  selected  therapeutic  strategies thanks to the precise information on the structural  characteristics of the examined tissue.

La valutazione dell’edema è essenzialmente clinica basata sull’ispezione e soprattutto della palpazione che si esprime attraverso la valutazione di due parametri fondamentali quali la consistenza e la comprimibilità.
Dunque la valutazione clinica dell’edema è soggettiva e qualitativa, ma è possibile renderla oggettiva e quantitativa attraverso l’uso del tonometro, uno strumento meccanico realizzato in Australia dalla Flinders Biomedical Engineering.
Metodica precisa e ripetibile, è utile per valutare la tonicità tissutale attraverso la misurazione della resistenza tissutale alla compressione e la sua variazione nel tempo.
Lo strumento consiste di una base d’appoggio, di un cilindro metallico, al di sopra del quale si pone un peso di 200 gr. che induce l’approfondimento nel tessuto di un perno che fuoriesce dalla base e di due quadranti di misurazione. (Foto1)
Per quanto riguardo la modalità di applicazione, il tonometro viene  poggiato sulla superficie cutanea dell’arto e sorretto in posizione verticale, senza indurre pressione, e vengono effettuate rilevazioni su punti markers costanti. La lettura dei quadranti viene effettuata dopo 5” dall’applicazione.
L'utilita della metodica si basa:
- sul confronto della resistenza alla compressione tra i due arti,
- sulla verifica dell’efficacia del trattamento effettuato (farmacologico o fisico)
- sulla possibilità di effettuare misurazioni nel tempo per monitorare cambiamenti tissutali nel tempo.
Il limite della metodica è dato dall’impossibilità di effettuare misurazioni in zone, che richiamano la nostra attenzionella palpazione, ma dove non è possibile posizionare in modo stabile lo strumento.

Foto 1