Jan Sloves: Turning Routine Duplex into a Multiparametric Evaluation of Limb Edema
Jan Sloves, President and Consultant at Vascular Imaging Professionals LLC, shared a post on LinkedIn about a recent article by Luca Palombi et al, published in Phlebology:
“We Often Use Venous Duplex to ‘exclude DVT and Reflux’ in Patients with Limb Swelling-But How Often Do We Deliberately Look for Lymphedema?
A just published pictorial essay by Luca Palombi et al. in Phlebology 2026 highlights how duplex ultrasound can directly visualize lymphatic‑related tissue changes and help stage lymphedema, not just rule out venous disease.
The authors remind us that lymphedema is still frequently misdiagnosed as chronic venous insufficiency or lipedema despite distinct tissue changes on ultrasound.
Key sonographic insights that stood out to me:
- Early/mild lymphedema tends to show a ‘vertical‘ pattern: fluid tracking from the dermis toward the superficial fascia along perivascular and peri-lymphatic planes
- Moderate–severe chronic lymphedema shows a ‘horizontal‘ pattern: transversely expanded, fibroadipose subcutaneous tissue with hypoechoic lymphatic lacunae
- Superficial lymphatics appear as thin‑walled, tortuous, non‑compressible, Doppler‑silent channels, even with distal manual compression, helping distinguish them from small veins
- High‑frequency imaging and micro‑flow presets can show intraluminal fibrinous plugs in chronically obstructed lymphatics, offering a window into irreversible damage
- Elastography adds a functional layer: ‘soft‘ fluid‑predominant acute disease versus ‘stiff’ fibrotic chronic disease, supporting assessment of chronicity and treatment planning
- The examinations used high‑frequency probes plus micro‑flow and elastography with AI‑assisted image optimization to enhance lymphatic and soft‑tissue visualization and reduce operator dependency. The authors utilized transducer frequencies from 18-21 MHz for superficial lymphatic channels and skin layers and ultra-high frequencies 48-70 MHz for depicting even smaller lymphatic vessels
For those scanning ‘just to rule out venous disease’, this paper is a useful reminder that a focused lymphatic/soft‑tissue assessment can turn a routine duplex into a genuinely multiparametric evaluation of limb edema and should be part of the standard work‑up when lymphedema is on the table.
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Title: Duplex ultrasound evaluation in lymphedema: Pictorial essay
Authors: Luca Palombi, Fabio Martinelli, Ali Ahmad Chraim, Roberto Parisi, Luca Ferretto, Monica Morelli
Read the Full Article on Phlebology
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