Hyperstomy
syndrome
(Portuguese
PDF version)
Rubens
Carlos Mayall, Antônio Carlos Dias Garcia Mayall, José
Carlos Mayall, Josias de Freitas, Monique Ferreira Almeida, Fernando
Vidinha Fontes, Walter Ferreira de Azevedo Júnior, Wellinton
Draxler Pereira de Souza
Correspondence:
Hospital da Gamboa
Caixa Postal: 1822
CEP 20001-970 - Rio de Janeiro - RJ
ABSTRACT
Hyperstomy
syndrome is defined as a dysfunction of microcirculatory arteriolo-venular
flow which stimulates ischemic diseases without arterial occlusion
and causes precocious venous backflow. This paper presents a review
of hyperstomy syndrome since this entity was first described. It
also presents six cases of patients with hyperstomy syndrome who
were successfully treated.
Key
words: ischemia, lymphedema, microcirculation.
Palavras-chave: isquemia, linfedema, microcirculação.
J
Vasc Br 2003;2(3):186-96
Hyperstomy
syndrome is defined as a dysfunction of microcirculatory arteriolo-venular
flow which stimulates ischemic diseases without arterial occlusion and
causes precocious venous backflow. Currently, it is considered that
intense lymphatic repercussion is possible in some cases, turning malignant
some ulcers of the lower leg.
Pratesi and Malan1-4 were the first to describe
this syndrome, which was called hemometakinesis by De Bakey.5
In 1968, Amir-Jahed6,7 presented as angiodyskinesia
a similar syndrome associated mainly with venous problems and affecting
young females after the use of contraceptive pills. Based on these findings,
Dramez et al.8,9 have successfully treated
the syndrome by intraarterial injection of procaine. At the same time,
Haimovici10,11 observed similar findings
in angiographic studies of arteriovenous communication. In 1976, Mayall12-15
devoted an entire monograph to the treatment of this entity, and called
attention to the syndrome by describing lymphedemas with dysregulated
arteriolo-venular flow on angiography and angiographic findings in 56
patients, in addition to some cases of malignant Marjolin ulcers by
cancer invasion.
ETIOPATHOGENESIS
AND PATHOPHYSIOLOGY
Microcirculation
(Zweifach-Neleman) is responsible for maintaining the blood flow through
the capillaries, both at rest and during muscle work. Using electronic
microscopy, Redish & Tangco16 have
shown this arteriolo-venular microcirculation. It is controlled by the
neurovegetative system, which regulates the closure and opening of the
channels responsible for venular and lymphatic hypertension. Arteriolo-venular
microcirculation can be observed using high speed arteriography, vein
oxymetry , or by observing the venous pressure on clinostatism, which
can be measured by Doppler up to 30 mmHg. In addition, microcirculation
can also be observed by the increase in skin temperature due to the
arterialization of the veins warmed to evaluate increased oxygen tension
and reduced CO2 tension.
Using arteriography, after injecting 60 ml of dye in the inguinal artery
one must wait 6 seconds for the warm venous backflow to fill the femoral
vein, 7 to 8 seconds for the knee, and 10 to 12 seconds for the leg
all the way to the feet; to clearly see the arteries of the legs, it
is fundamental to have the leg on internal and external rotation, so
as to see the three arteries clearly separated from the two bones. In
addition, to be able to observe the venous backflow on the radiograph
plates, it is important to see the abnormal branching of the main arteries,
the femoral artery and the three arteries running along the leg up to
the foot. It is also important to observe the direction, if it is horizontal
or vertical, instead of following the acute angle that is normal in
most cases, and to observe if the flow is delayed or not, especially
when hyperstomy is due to the effect of closure or opening of the preferential
microvessel channels and/or of the glomus by the neurovegetative sphincter
effect on alpha- adrenergic control.
ETIOLOGIC
FACTORS
The most
important are: trauma of the soft tissues in the extremities; bone fractures;
postphlebitic syndromes; venous insufficiency; arterial occlusion; reduction
of arterial pressure in muscle arterioles; vasomotor syndromes without
arterial lesion; arterial syndromes following Raynaud's phenomenon;
and also obstruction of lymph nodes closer to the proximal roots.
SYMPTOMS
The symptoms
of hyperstomy syndrome depend on several factors and on the intensity
of each case.
Pain: pain is manifested only as paresthesia or light pain, distension
of the skin, and intermittent claudication not quickly improved by rest,
as in venous or arterial insufficiency.
A slight increase in local temperature. If left without treatment, hyperstomy
syndrome may develop into elephantiasis, as occurs in venous or lymphatic
diseases; hyperstomy syndrome can be the reason or the effect of thrombosis
in arteries. Cold may be felt below the extremity, and warmth on the
hyperstomy area, according to newly formed veins.
Sex: In Iran, where contraception is official, hyperstomy syndrome has
been observed to be more frequent in young females using contraceptive
pills. Our experience shows that males are more frequently affected,
at a 2:1 rate.
There seems to be no association between the intensity of subjective
symptoms and objective findings; recidivation of venous ulcers is easily
cured after hyperstomy treatment.
Oscillometric readings: normally increased in the absence of edema.
Oxymetry: shows arterialization of venous blood near the location of
the arteriolo-venular dysfunction, not as intense as in arterio-venous
(AV) fistulas.
Distal pulses: can be expanded with decreased intensity according to
the number of hyperstomies.
Local signs and symptoms of venous insufficiency are more evident depending
on the size of the hyperstomy.
There is also an increase in venous pressure, although not as intense
as in AV fistulas.
Tissue O2 consumption is increased in hyperstomy. Fontaine
et al.17, using Xenon 133, have observed
increased depuration of blood flow on the calf volume.
Arteriography: Should be performed if possible, on fast serial and with
a chronometer over the radiograph plates, to register exactly how many
seconds were required for the image to appear on the plate after the
beginning of the dye injection. This should be done instead of using
the automatic radiography changer, which fails to register the time
lost when there is the need for a bigger interval to see the late backflow,
which is well-registered on the plates by the chronometer. In addition,
this allows a change in position to see from the aorta down to the foot;
for that, an additional 6 seconds are lost.
The most typical findings in the inguinal femoral artery, commonly by
handmade pressure injection of 60 ml of contrast are:
a) Simultaneous filling of the superficial and deep femoral arteries
and veins in the thigh within 3 to 6 seconds. This is important in patients
with large-sized artery occlusions, when more than 15 seconds of interval
may be necessary for the leg to be seen. This time is not registered,
for example, on the automatic changer of Schonänder, but the hand
chronometer shows that exactly on the plate.
b) A blurry or smudgy appearance of the muscle mass around the arteriolar
branches during the second (or arteriolar-capillar) phase, in the places
corresponding to 7 to 9 seconds, is an unusual symptom of hyperstomy,
as well as high temperature and oscillometric increase.
c) Abnormal artery size, number, extension and direction, often going
up instead of making an acute angle with the exit of artery branches.
d) Incomplete or delayed filling by the contrast dye of the distal branches
of the arterioles of the leg due to the derivation of the blood flow
through the short circuits, commonly in the thigh and calf, in the posterior
tibial branches and in the superficial femoral artery. For an accurate
mapping of these abnormal branchings, it is advisable to place the X-ray
plates so as to allow internal and external rotation of the foot to
clearly show the position of the tibia and fibula bones, and to avoid
superposition with the tibial and fibular arteries. It is important
to remember that the normal X-ray plate shows only vessels larger than
0.10 mm. Therefore, a normal X-ray will never accurately show the newly
formed hyperstomic arteriolar-venular shunts, whose terminal size is
30 to 60 micra.
DIFFERENTIAL
DIAGNOSIS
Congenital
arterio-venous fistulas
Arruda18 wrote that these fistulas are
commonly present since birth, or they may appear around puberty. They
present strawberry marks, angioma and abnormal direction of the large
varicose veins, with increased size of the leg before puberty, as is
very frequent in Klippel-Trénaunay Syndrome,19,20
often with dysgenesia of deep veins. There is also an immediate, fast
and precocious venous-varicose backflow. Some patients present more
atypical arteriolo-venular congenital angiodysplasias with the following
features:
- The fading of the arterial contrast phase is more intense distally
in relation to the fistula. If it is a case of hyperstomy, the distal
filling is more delayed;
- The spotty appearance in the fistula area is much more visible and
intense than the blurry appearence around hyperstomy branches;
- The big dilatation of surrounding veins is absent around hyperstomy
branches. There is only a precocious venous backflow, but the veins
show a normal shape or only small phlebectasy in more advanced cases;
- AV fistulas are commonly diffuse around the limbs. In hyperstomy,
branches are more localized. Bone lesions are common in AV fistulas.
If AV fistulas are hypoactive, the radiologic signs are very similar
to those of hyperstomy, but in the active and bigger AV fistulas, the
arteries are more convoluted and open directly into the veins of great
size. The communication with the veins is very visible, showing that
the problem is not in the microcirculation. Because of this, bigger
veins and heart insufficiency are especially common in AV fistulas,
where the Nicoladoni-Branham sign of bradycardia after local digital
compression is always present.
Occlusive
arterial diseases
Commonly they are the cause of the appearance of hyperstomy. This is
important for surgeons to remember - it is the reason why a lumbar sympathectomy
can worsen the ischemia in extremities, as frequently observed, producing
paradoxical gangrenes. A ganglioplegic spinal block can be made before
surgery in sympathetic spinal ganglions using chlorpromazin 25 mg, intra
muscular injection, or a spinal block with 20 ml of procaine 1% in saline.
Low body temperature measured by skin thermometry is a contra-indication
for this operation.
Tumors
of soft tissues
The early symptoms of hemangiosarcomas on the thigh or calf are painful.
Arteriography shows a big anarchy, similar to what is observed in more
severe cases of hyperstomy, as a good mapping for biopsies. In Marjolin
ulcers, due to epidermoid carcinomas, arteriography always shows the
abnormal findings of intense hyperstomy, whose radical correction has
helped long term cure after a skeletization of all hyperstomies to kill
the tumor by preventing arterial feeding.
TREATMENTS
Conservative
Since in young people the problem may be functional, it is advisable
to wait for some weeks or use a placebo treatment. According to Dramez
et al.,8 intra-arterial procaine injections
have given goods results in the long term.
In the majority of cases secondary to ischemia we recommend treatment
by intra-arterial injections of hydrogenated alkaloid derivative ergotoxin,
together with injections of procaine and oral intake of ergotoxin derivates21
(100 g capsules three times a day). In patients with hyperstomy secondary
to venous stasis and with lymphedema, mainly with venous problems, we
always recommend the correction of venous insufficiency by elastic compression
of highest pressure possible, day and night.
With larger ulcerations, in addition to the etiological treatment, the
main symptoms must be treated as well, mainly pain, with strong analgesics
administered intravenously, if necessary. When the main problem is to
reduce the excess of exsudation, drug treatment is recommended, with
derivates of bovine peptides of coagulation factor VIII, in pills of
0.125 mg, three times a day, in addition to phlebotonics. Other possible
drugs are micronized pills of diosmin 450 mg with flavonoid titulated
hesperidin 50 mg, two pills each day in the morning, and pills of benzopyrone
15 mg (coumarin) troxerutin 90 mg, six times a day, followed by hand
massages on the trunk, inguinal region and legs, with a 40 ml cream
of benzopyrone 200 mg; 300 or 500 mg pills of heparin 2000 UI, a day
of B-hydroxyethyl-rutosides, six pills a day. To avoid infection, exsudation
is reduced mainly by local bandages, closed with a transparent biological
cellophane sheet. This significantly decreases the number of bandages
required and the speed of scar formation. As the wound becomes anaerobic
and aseptic, it is not necessary to use antibiotics. Before resuming
walking, the patient must wear elastic stockings for a long period.
SURGICAL
TREATMENT
If the
conservative treatment is not enough for the correction of hyperstomy,
we recommend skeletization of the main arteries whose branches are responsible
for the typical symptoms in the legs or arms. This is possible thanks
to the accuracy of diagnosis by selective and fast serial arteriography.
Diagnosis may also be based on phlebography, lymphography, scintilography
or other imaging methods, such as Duplex scanning ecocolor Doppler,
helicoid tomography or magnetic resonance (Figure 1).
 Figure
1 - Magnetic nuclear resonance (August 8, 2001). Atherosclerotic renal
artery. Left iliac artery, femoral artery and early vein filling on
the leg.
Below
we present some cases of patients presenting hyperstomy who were successfully
treated.
Case
1
This is a 46-year-old woman. Following surgery for Brown dermatome for
lymphedema of the leg, she developed a great lymphedema over the entire
thigh after erysipelas and lymphangitis with marked incapacity during
15 years due to excessive weight of the mass (Figure 2).
Figure
2 -Great lymphedema of the thigh, on the right and after 15 days post-op.
A phlebography
of the leg revealed marked compression by excessive weight over the
femoral vein in the thigh. This was corrected by elevation of the entire
mass (Figure 3).
Figure
3 - Phlebography of the left thigh. The arrow shows compression of the
vein.
A femoral
arteriography revealed six new abnormal hyperstomy branches in Hunter's
canal (Figure 4).
Figure
4 - Arteriography of the left thigh, six abnormal hyperstomy branches.
After
ligation of the six abnormal branches, the mass shrank significantly.
It was then easier to resect (lumping operation) the excessive tissue
in the main part of the thigh. The thigh was markedly improved.
In 1993, 19 years after the surgery, and in 1999, without any kind of
treatment, there was a small relapse of the lymphedema of the leg, but
the patient is ambulant and fully active (Figure 5).
Figure
5 - 19-year follow-up.
Case
2
This is a 43-year-old man who had a small intractable lymphedema with
a big ulceration recidivate after a traumatic skin injury to the foot
and ankle when he was 2 years old. Lymphography depicted mild lymphedema;
phlebography showed tortuous phlebectasis (Figure 6). Arteriography
showed intense hyperstomy branching of the anterior tibial artery, just
below the ulceration (Figure 7). A biopsy showed a squamous cells (epidermoid)
carcinoma (Marjolin ulcer).
Figure
6 - Small intractable lymphedema. Large ulceration on March 30, 1987,
present since 4 years of age.
Figure
7 -Arteriography: large hyperstomy. Black arrow shows six abnormal branches.
After
seven days of chemotherapy (methotrexate + cyclophosphamidid + fluoruracil
+ prednisone), all the soft tissue of the ulcer was excised with all
the six branches of the anterior tibial artery through a selective infusion
on the popliteal distal artery (Figure 8).
Figure
8 - Ulcer cured on May 14, 1987 with Thiersch graft.
In May
1997, after 10 years, the patient was cured without relapse or metastasis
of the tumor and edema on the leg. He required no special treatment
except for elastic stockings.
Case
3
This is a 55-year-old woman presenting a big lymphedema of the left
arm after radical mastectomy followed by radiotherapy. After conservative
therapy, a phlebography revealed severe stenosis of the axillary vein.
Contrast injection into the brachial artery showed an abnormal six-branch
arteriolo-venular hyperstomy (Figure 9). Conventional lymphography by
hydrosoluble dye, not oil, showed only two lymphatic branches on the
internal border of the skin flap.
Figure
9 - Arteriography of the left arm, abnormal branches of hyperstomy.
During
a small lumping operation on the arm for resurfacing of the skin all
the arterioles with hyperstomy were resected. Complete debridement was
performed around the axillary vein. Only one lymphatic-vein anastomosis
was done. After surgery, the perimeter of the arm was reduced from 87
to 32 cm (Figure 10).
Figure
10 - Big lymphedema of the left arm, 86 cm in perimeter. Afterwards,
improved lymphedema of the left arm, 32 cm in perimeter following surgery.
Case
4
This is a 70-year-old woman seen at Hospital da Gamboa on July 19, 1997,
presenting serious necrotic ischemic plaques (Figure 11) , infected
and ulcerated, on the left leg's antero lateral border. She also presented
an infected ulcer on the internal ankle of the same leg and a plantar
ulcer resulting from type II diabetes. We observed segmental obliterans
arteriosclerosis on the left internal iliac artery, occlusion of left
kidney artery and a 6-cm atherosclerotic segment in the superficial
femoral artery, as well as segmental occlusion of the three arteries
of the leg with good collateral circulation filling the foot. Arterial
hypertension MX 200 min 110. Initially, the indication was for amputation.
We decided to treat the patient using conservative methods first, and
began intravenous administration of sodium heparin 5,000 units every
four hours, day and night, followed by broad spectrum antibiotics, guided
by repeated antibiograms with selective sensitivity.
Figure
11 - Necrotic ischemic ulceration (July 16, 1997).
The patient was kept in absolute rest, in bed, with slight elevation
of the side of legs, due to the presence of severe superficial and deep
varicose veins, without thrombosis on phlebography. An excellent arteriography
and aortography magnetic nuclear resonance confirmed the arterial lesions
and also the great hyperstomy lesions below the left leg. For this reason,
we treated the patient with 100 mg of oral ergotoxin derivative, diosmin
450 mg pills, and oral benzopirone derivatives as recommended by Casley
Smith.22 When infection was controlled
and a good granulation appeared on the ulceration, we made several split
skin grafts with material from the thigh (Thiersch method), with excellent
results (Figures 12 and 13). In December of 2002 she was able to walk
for ambulatory treatment. Since the patient presented hypochromic anemia,
she received iron sulfate and 500 ml of blood. Only 2 cm of the graft
were lost in the foot, and the perforant plantar ulcer relapsed. Because
of the intense presence of hyperstomy around the lower part of the left
leg's anterior tibia, we decided to submit the woman to surgery at this
point to avoid venous hypertension around the vein and in the foot area.
This was being controlled by 30 mgHg elastic bandages to allow walking.
A simultaneous operation of the left kidney artery and leg hyperstomy
syndromes was planned to cure arterial hypertension.
Figure
12 - Necrotic ulceration of maleolar before in February 2, 1998, and
in March 1999.
Figure
13 - Necrotic ulceration of maleolar (July 1997). Ulcer cured (March
15, 1999).
Case
5
A 30-year old man with lymphedema of the right lower leg secondary to
erysipela and lymphangitis was admitted to Hospital da Gamboa for conservative
treatment with local hygiene, low-salt diet, massage and exercise followed
by elastics bandages and antibiotics. An arteriography of the retrograde
retromalleolar posterior tibial artery of the right leg showed an intense
hyperstomy on the three ascending branches with indication for surgery
(Figure 14). After ligation of the three abnormal branches in the right
leg, hyperstomy was easily controlled with elastic stockings. Fifteen
days after the surgery, he was considered well enough to work normally.
In 1999 (37 years later) he came back for a check up without lymphedema
and capable of leading a normal life, always wearing elastic stockings
and following a low- salt diet. There was no relapse of the erysipela
and lymphangitis.
Figure
14 - Arteriography of retrograde posterior tibial artery, three abnormal
hyperstomy branches.
Case
6
This is a 25-year-old black woman who presented with a grade III lymphedema
on the right arm (Figure 15). She was treated during 6 months at Policlínica
do Botafogo with conservative methods, without any improvement. One
night, she was observed at the clinic to be sleeping with a hard cotton
ball under the right axilla, compressing all the axillar vessels.
When asked about this, the woman said that she did this voluntarily,
because she had problems with her employer, who would not allow her
to walk with her boyfriend. She decided to sleep every night on her
side, over the right axilla, which was responsible for the voluntary
lymphedema. Then, she was immobilized with the right arm raised using
a plaster of Paris, with elevation of the arm 45 cm above the level
of heart. She was able to stay with the arm in hyper abduction during
45 days, when the visible fingers no longer presented lymphedema. The
plaster was removed. To our great surprise the lymphedema was cured.
She also received psychological advice. She has not used any drugs,
only a low-salt diet and elevation of the right arm.
This case demonstrates that to resolve a severe lymphedema of many months
with eight hours of voluntary compression daily, it was only necessary
to immobilize the arm in hyperabduction, without any need for skin hygiene,
manual drainage and exercise.
Figure
15 - Voluntary lymphedema before and after treatment.
This woman
was able to cure the lymphedema without bathing during 45 days, without
any local hygiene, no drugs and no elastic garments. This is the reason
why in our daily routine we always recommend the maximum rest possible,
and elevation of the limb, which was fundamental in this case, supported
by psychological advice.
COMMENTS
Peripheral
hyperstomy was initially described by Pratesi,1,2,
in Italy, to explain peripheral ischemia. However, for us it is an important
entity in the absence of arterial occlusion, and encompasses some venous
and lymphatic disorders, also including cases of cancer.
These documented vascular disorders, described by us as hyperstomy syndrome,
must be considered in the treatment of some complicated lymphatic diseases.
In these patients, the lymphatic dysfunction was aggravated by an arteriolo-venular
communication. These cases were successfully treated only in conjunction
with ligation of the hyperstomic abnormal feeding of the arteriolar-venular
branches. This technique was emphatically presented by Mayall15
at the Madrid Congress of Lymphology, where Campisi,23-26
from Genova, presented his excellent paper about Angiodysplasies, peripheral
lymphedemas and tumorigenous syndromes.
We believe that the consensus on lymphedema must pay more attention
to these problems. They found a much less invasive solution, with skeletizing
and correction by ligation of the abnormal arterial branches with hyperstomy,
so that dysregulated hiperdynamic blood flow is easily treated.
There was the possibility, for some patients, to resume an almost normal
life, and they have been active, without any kind of medical control
for 10 to 40 years.
Patients with hyperstomy syndrome will be very lucky when physicians
remember this disorder in special and difficult secondary cases. The
true significance of these vascular disorders or dyskinesias needs further
investigation to allow a better consensus on the lymphatic dynamic in
primary, and especially in the frequent secondary lymphedema troubles,
avoiding the indication for amputation, as has been done already.
Finally, we hope that the surgeons interested in developing microsurgery
techniques of lymphatic diseases, like Campisi23-26
and Baumeister,27 will be able to achieve
better results for the near future. In 1995, during the 15th International
Congress of Lymphology, when speaking about lymphedemas, we emphasized
that they must be studied not only as lymphatic disorders, but also
as venous-arterial oncologic disorders, stressing the value and need
for arteriography to clear some issues concerning angiodysplasia, and
for phlebography of the deep venous circulation.
We do not have the right to tell the patient or his family that there
is no treatment for the lymphedema. It is better to give the patient
a word of hope.
REFERENCES
1.
Pratesi F. Un nouveau Syndrome vasculaire des membres inferieurs avec
claudication intermittente sans obliteration arterielle. Angéiologie
1960;122:15.
2. Pratesi F, Nuti A, Beccuci V. Due nuove sindromi
vasculari de iperostomie arteriovenosa della coscia. Accademia Medico-Fisica
Fiorentina 1957;1.
3. Malan ED. Bolletino della Società Piemontese
de Chirurgia 1955;XXV(3).
4. Malan ED. Patologia delle communicazione arteriovenose
delle piante del piede. Folia Angiologia 1959;2:4.
5. De Bakey M, et al. The borrowing lending hemodynamic
phenomenon. Ann Surg 1947;20:850.
6. Amir-Jahed AK. Angiodyskinesia. Surg Gynecol Obstet
1968;127(3):609-31.
7. Amir-Jahed AK Angiodyskinesia. A new vascular syndrome.
Vasc Surg. 1968;2(3):164-73.
8. Dramez C, Gerson L, Natali I. Arteriovenous thigh
shunts given to serious ischemic disorders of extremities. Treatment
by ligaturing the artery profound femoral in both sides. Angiology 1965;1:195.
9. Gerson L. Deux cas d'hyperstomic crurale. Évolution
favorable a longue échéance therapeutique et physiopathologie.
Angiologie 1975;2:79-91.
10. Haimovici H, et al. Vascular Roentgenology. New
York: MacMillan Co.; 1964. p. 430-446.
11. Haimovici H, Steinman C, Caplan LH. Angiographic
evaluation of arteriovenous shunting in peripheral vascular diseases.
Radiology 1966;87:696-704.
12. Mayall RC. Síndrome de Hiperostomia. Rio
de Janeiro: Villani e Filhos Ltda.; 1976.
13. Mayall RC, et al. Arteriolar shunt hyperstomy syndrome.
The Cardiovascular Surgery Journal. Special issue of the International
Congress of Cardiovascular Surgery. Minerva Medica 1995. p. 241-245.
14. Mayall AC, et al. Hyperstomy syndrome - Important
on Artery, venous, lymphatic and oncologic diseases. Lymphology 2000;33
Suppl 1:90-104.
15. Mayall RC, et al. Hyperstomy syndrome and lymphedema.
Lymphatic dysfunction and conjunction with disregulated hyperdynamic
blood flow. Progress in Lymphology - XVI. Proceedings of the 16th International
Congress of Lymphology; 1997 Sept 22-27; Madrid, Spain. Tucson: International
Society of Lymphology and LYMPHOLOGY, 1998. p. 378-389.
16. Redish W, Tangco FF, et al. Peripheral circulation
in health and diseases. New York: Grune Straton; 1957.
17. Fontaine R, et al. Du role physiologique des canaux
de dérivation artérioveineuse, de Sucquet, dans certaines
affections vasculaires. Lyon Chir 1978;79:91.
18. Arruda S. Angeiodysplesies congénitales
classification. Progress of Angiology. Proceedings of the 8th International
Congress of Angiology. Rio de Janeiro: Serviço Industrial Gráfico
da UFRJ, 1973. p. 133-150.
19. Brum O. Síndrome de Klippel-Trenaunay. Contribuição
ao estudo clínico [tese de doutorado]. Rio de Janeiro: UFRJ;
1974.
20. Caby F. Fistules arterioveineuses congénitales.
Memoires de l'Académie de Chirurgie 1953;79(4):152-9.
21. Vogler E, Golman G. The significance of the terminal
circulation in development of vascular disease of blood flow vasographic
studies. Angiology 1955;6:540-55.
22. Casley Smith J. Exercícios para pacientes
com linfedema na perna. 2ª ed. Rio de Janeiro: Hospital da Gamboa;
1991.
23. Campisi C. Microsurgery for the treatment of peripheral
lymphedema: 25-year clinical experience. Abstracts of the 17th International
Congress of Lymphology; 1999 Sept. 19-25; Chennai, India. Lymphology
2000;33 (Suppl).
24. Campisi C, Boccardo F, et al. Angiodysplasias peripheral
lymphoedema and tumorigenous syndromes. Progress in Lymphology - XVI.
Proceedings of the 16th International Congress of Lymphology; 1997 Sept.
22-27; Madrid, Spain. Tucson: International Society of Lymphology and
LYMPHOLOGY, 1998. p. 378-380.
25. Campisi C. Mayall's hyperstomic syndrome. Abstracts
of the 17th Congress of Lymphology; 1999 Sept. 19-25; Chennai, India.
Lymphology 2000;33 Suppl:49.
26. Campisi C, et al. Angiodysplasias and lymphedema.
Aspects of diagnosis and treatment. Lymphology 1994;27 Suppl 1:154-8.
27. Baumeister RCG, Frick A. Microsurgery and endoscopy
in the treatment of lymphatic clockades. Abstracts of the 17th International
Congress of Lymphology; 1999 Sept. 19-25; Chennai, India. Lymphology
2000;33 Suppl:76.
RECOMMENDED
BIBLIOGRAPHY
"
Cariati E. La Linfostasi. Padova: Piccin; 1976.
" Földi E; Földi M. Physiotherapie complexe déscongestive.
Paris: Frison-Roche; 1943.
" Maffei FHA, Lastória S, Yoshida WB, Rollo HA. Doenças
vasculares periféricas. 2ª ed. Rio de Janeiro: Medsi; 1995.
" Lemense A, Leduc A. Drainage lymphatique manuel dans l'hypoderme
venulaire. Bruxelles: 1970.
" Cool V. Le technique du drainage manuelle selon. Bruxelles: Vodder
lymphokinetes; 1965.
" Picard JD. Atlas de Résonance Magnétique. Paris:
Laboratoire L. Lafon; 1993.
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