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| ===Computed Tomography and CT Angiography===
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| ''[[Computed tomography]] with [[radiocontrast]]'', effectively a [[pulmonary angiography|pulmonary angiogram]] imaged by CT and also known as [[CT pulmonary angiogram|CT pulmonary angiography]] (CTPA), is increasingly used as the mainstay in diagnosis. Advantages are clinical equivalence, its non-invasive nature, its greater availability to patients, and the possibility of picking up other lung disorders from the [[differential diagnosis]] in case there is no pulmonary embolism.
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| ====CT findings in Acute PE====
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| *Thrombus is located centrally within the vascular lumen or occludes the vessel (vessel cut-off sign)
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| *Commonly causes distention of the involved vessel.
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|
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| ====CT findings in Chronic PE====
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| *Eccentric and contiguous changes of the vessel wall
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| *Reduces the arterial diameter by more than 50%
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| *Evidence of recanalization within the thrombus
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| *An arterial web is present
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|
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| <gallery>
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| Image:DVT-001.jpg|Left leg. [[Deep venous thrombosis]]
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| Image:DVT-002.jpg|Left leg. [[Deep venous thrombosis]]
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| Image:PE on CT angiogram.jpg|CT pulmonary angiogram. Clots in both the left and the right pulmonary arteries (red arrows). [http://www.e-radiography.net Source]
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| </gallery>
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| '''Patient with Shortness of Breath'''
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| <gallery>
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| Image:Pulmonary embolism 001.jpg|[[Pulmonary embolism]]: Patient presented with [[Shortness of breath]]
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| Image:Pulmonary embolism 002.jpg|[[Pulmonary embolism]]: Patient presented with [[Shortness of breath]]
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| Image:Pulmonary embolism 003.jpg|[[Pulmonary embolism]]: Patient presented with [[Shortness of breath]]
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| Image:Pulmonary embolism 004.jpg|[[Pulmonary embolism]]: Patient presented with [[Shortness of breath]]
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| </gallery>
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| '''Patient with Acute RBBB'''
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| <gallery>
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| Image:Pulmonary-embolism-101.jpg|[[Pulmonary embolism]]: Patient presented with Acute [[RBBB]]
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| Image:Pulmonary-embolism-102.jpg|[[Pulmonary embolism]]: Patient presented with Acute [[RBBB]]
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| </gallery>
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|
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| ===MR and MR Angiography===
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|
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| * Gadolinium-enhanced MRI is a non-invasive diagnostic modality and has the advantage of no contrast exposure.
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| * A potential benefit of MR, is that is incredibly sensitive, perhaps even better than contrast venography, in imaging clot in the inferior vena cava (IVC) and pelvic veins, and these images can be obtained at the same time as the lung scan.
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| * It needs to be pointed out, that although the criticism of using CT and MR angio lacks sensitivity when examining the subsegmental arteries, inter-reader agreement was only 66% with pulmonary angiography in PIOPED.
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|
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| {Images shown below are courtesy of RadsWiki)
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|
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| <gallery>
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| Image:Deep-vein-thrombosis-on-MRV-001.jpg|2D TOF GRE MRV images: Bilateral [[deep vein thrombosis]]
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| Image:Deep-vein-thrombosis-on-MRV-002.jpg|2D TOF GRE MRV images: Bilateral [[deep vein thrombosis]]
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| Image:Deep-vein-thrombosis-on-MRV-003.jpg|2D TOF GRE MRV images: Bilateral [[deep vein thrombosis]]
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| </gallery>
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|
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| <gallery>
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| Image:Superficial_vein_thrombosis_MRI_001.jpg|MRI: Superficial vein thrombosis
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| Image:Superficial_vein_thrombosis_MRI_002.jpg|MRI: Superficial vein thrombosis
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| Image:Superficial_vein_thrombosis_MRI_003.jpg|MRI: Superficial vein thrombosis
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| </gallery>
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|
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| ===Contrast Venography===
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|
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| Contrast venography (also called '''Venography''' or '''phlebography''') is the definitive test for diagnosing [[deep venous thrombosis]] which taken after a special dye is injected into the vein or even bone marrow.
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|
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| Contrast venography can also help;
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|
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| * to distinguish blood clots from obstructions in the veins
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| * to evaluate congenital vein problems
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| * to evaluate veins prior to treatment of chronic venous insufficiency
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| * to control functioning of deep leg vein valves
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| * to identify a vein graft for coronary artery bypass surgery
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|
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| <gallery>
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| Image:DVT 1.jpg|Venography: Deep venous thrombosis. [http://www.lakeridgehealth.on.ca Source]
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| Image:Venous thrombosis with collateral.jpg|An occluded vein with collateral vessel formation. [http://www.lakeridgehealth.on.ca Source]
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| </gallery>
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|
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| ===Pulmonary Angiography===
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|
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| '''Pulmonary angiography''' (or '''pulmonary arteriography''') is a [[cardiology|cardiological]] [[medicine|medical]] procedure. Pulmonary arteries are visualized to detect [[blood clot]]s (such as a [[pulmonary embolism]]) or [[arteriovenous malformation]]s.
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|
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| The use of pulmonary angiography has been largely replaced by spiral CT in diagnosis of [[pulmonary embolism]].
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|
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| <gallery>
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| Image:Pe on pulmonary angiography.jpg|Pulmonary angiogram in a patient with [[pulmonary embolus]]. A thrombus is observed in the area within the yellow circle. [http://www.e-radiography.net Source]
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| </gallery>
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|
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| ===Ventilation / Perfusion Scan===
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|
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| ''[[Ventilation/perfusion scan]]'' (or ''V/Q scan'' or ''lung [[scintigraphy]]''), which shows that some areas of the lung are being ventilated but not perfused with blood (due to obstruction by a clot). This type of examination is used less often because of the more widespread availability of CT technology, however, it may be useful in patients who have an allergy to [[iodinated contrast]] or in [[pregnancy]] due to lower radiation exposure than CT. * The ventilation/perfusion ratio (V/Q) Scan: The PIOPED data suggests that normal perfusion scans are almost never associated with recurrent pulmonary embolism, even if anticoagulation is withheld.
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|
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| ===Other Methods===
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|
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| ====Impedance plethysmography====
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|
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| Impedance phlebography or impedance plethysmography is a [[non-invasive (medical)|non-invasive]] medical test that measures small changes in [[electrical resistance]] of the chest, calf or other regions of the body. These measurements reflect [[blood volume]] changes, and can indirectly indicate the presence or absence of [[venous thrombosis]]. This procedure provides an alternative to [[venography]], which is invasive and requires a great deal of skill to execute adequately and interpret accurately.
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|
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| For the chest, the technique was developed by NASA to measure the split second impedance changes within the chest, as the heart beats, to calculate both cardiac output and lung water content. This technique has progressed clinically (often now called BioZ, i.e. biologic impedance) and allows low cost, non-invasive estimations of [[cardiac output]] and [[total peripheral resistance]], using only 4 skin electrodes, oscillometric [[blood pressure]] measurement and lung water volumes with minimal removal of clothing in physician offices having the needed equipment.
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|
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| For leg veins, the test measures blood volume in the lower leg due to temporary venous obstruction. This is accomplished by inflating a pneumatic cuff around the thigh to sufficient pressure to cut off venous flow but not arterial flow, causing the venous blood pressure to rise until it equals the pressure under the cuff. When the cuff is released there is a rapid venous runoff and a prompt return to the resting blood volume. Venous thrombosis will alter the normal response to temporary venous obstruction in a highly characteristic way, causing a delay in emptying of the venous system after the release of the [[tourniquet]]. The increase in blood volume after cuff inflation is also usually diminished.
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|
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| ==Treatment==
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|
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| ===A. Deep Venous Thrombosis===
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|
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| ====Hospitalization====
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| Treatment at home is an option according to a [[meta-analysis]] by the [[Cochrane Collaboration]].<ref name="pmid17636714">{{cite journal |author=Othieno R, Abu Affan M, Okpo E |title=Home versus in-patient treatment for deep vein thrombosis |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD003076 |year=2007 |pmid=17636714 |doi=10.1002/14651858.CD003076.pub2}}</ref>
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|
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| Hospitalization should be considered in patients with more than two of the following risk factors as these patients may have more risk of complications during treatment<ref name="pmid16926081">{{cite journal |author=Trujillo-Santos J, Herrera S, Page MA, ''et al'' |title=Predicting adverse outcome in outpatients with acute deep vein thrombosis. findings from the RIETE Registry |journal=J. Vasc. Surg. |volume=44 |issue=4 |pages=789-93 |year=2006 |pmid=16926081 |doi=10.1016/j.jvs.2006.06.032}}</ref>:
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|
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| * bilateral [[deep venous thrombosis]]
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| * [[renal insufficiency]]
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| * body weight <70 kg
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| * recent prolonged immobility
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| * [[chronic heart failure]]
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| * [[cancer]]
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|
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| ====Anticoagulation====
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| {{main|Anticoagulation}}
| |
| [[Anticoagulation]] is the usual treatment for DVT. In general, patients are initiated on a brief course (i.e., less than a week) of [[heparin]] treatment while they start on a 3- to 6-month course of [[warfarin]] (or related [[vitamin K]] inhibitors). [[Low molecular weight heparin]] ([[LMWH]]) is preferred,<ref name="pmid17261857">{{cite journal |author=Snow V, Qaseem A, Barry P, ''et al'' |title=Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians |journal=Ann. Intern. Med. |volume=146 |issue=3 |pages=204-10 |year=2007 |pmid=17261857 |doi=|url=http://www.annals.org/cgi/content/full/146/3/204}}</ref> though [[unfractionated heparin]] is given in patients who have a contraindication to [[LMWH]] (e.g., [[renal failure]] or imminent need for invasive procedure). In patients who have had ''recurrent DVTs'' (two or more), anticoagulation is generally "life-long." The [[Cochrane Collaboration]] has meta-analyzed the risk and benefits of prolonged anti-coagulation.<ref name="pmid16437432">{{cite journal |author=Hutten BA, Prins MH |title=Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism |journal=Cochrane database of systematic reviews (Online) |volume= |issue=1 |pages=CD001367 |year=2006 |pmid=16437432 |doi=10.1002/14651858.CD001367.pub2}}</ref>
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|
| |
| An abnormal [[D-dimer]] level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked proximal deep-vein thrombosis.<ref name="pmid17065639">{{cite journal |author=Palareti G, Cosmi B, Legnani C, ''et al'' |title=D-dimer testing to determine the duration of anticoagulation therapy |journal=N. Engl. J. Med. |volume=355 |issue=17 |pages=1780-9 |year=2006 |pmid=17065639 |doi=10.1056/NEJMoa054444}}</ref>
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|
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| ====Thrombolysis====
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| {{main|Thrombolysis}}
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| [[Thrombolysis]] is generally reserved for extensive clot, e.g. an iliofemoral thrombosis. Although a [[meta-analysis]] of [[randomized controlled trials]] by the [[Cochrane Collaboration]] shows improved outcomes with [[thrombolysis]],<ref name="pmid15495034">{{cite journal |author=Watson L, Armon M |title=Thrombolysis for acute deep vein thrombosis |journal=Cochrane Database Syst Rev |volume= |issue= |pages=CD002783 |year= |id=PMID 15495034}}</ref> there may be an increase in serious bleeding complications.
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|
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| ====Inferior vena cava filter====
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|
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| {{main|Inferior vena cava filter}}
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| [[Inferior vena cava filter]] reduces pulmonary embolism<ref name="pmid9459643">{{cite journal |author=Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral F, Huet Y, Simonneau G |title=A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group |journal=N Engl J Med |volume=338 |issue=7 |pages=409-15 |year=1998 |id=PMID 9459643}}</ref> and is an option for patients with an absolute contraindiciation to anticoagulant treatment (e.g., cerebral hemorrhage) or those rare patients who have objectively documented recurrent PEs while on anticoagulation, an [[inferior vena cava filter]] (also referred to as a ''[[Greenfield filter]]'') may prevent pulmonary embolisation of the leg clot. However these filters are themselves potential foci of thrombosis,<ref name="pmid16009794">{{cite journal |author= |title=Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study |journal=Circulation |volume=112 |issue=3 |pages=416-22 |year=2005 |id=PMID 16009794}}</ref> IVC filters are viewed as a temporizing measure for preventing life-threatening pulmonary embolism.<ref name="pmid17636834">{{cite journal |author=Young T, Aukes J, Hughes R, Tang H |title=Vena caval filters for the prevention of pulmonary embolism |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD006212 |year=2007 |pmid=17636834 |doi=10.1002/14651858.CD006212.pub2}}</ref>
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|
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| ====Compression stockings====
| |
| Elastic [[compression stockings]] should be routinely applied "beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year after diagnosis".<ref name="pmid17261857">{{cite journal |author=Snow V, Qaseem A, Barry P, ''et al'' |title=Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians |journal=Ann. Intern. Med. |volume=146 |issue=3 |pages=204-10 |year=2007 |pmid=17261857 |doi=|url=http://www.annals.org/cgi/content/full/146/3/204}}</ref> Starting within one week may be more effective.<ref name="pmid15313740">{{cite journal |author=Prandoni P, Lensing AW, Prins MH, ''et al'' |title=Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial |journal=Ann. Intern. Med. |volume=141 |issue=4 |pages=249-56 |year=2004 |pmid=15313740 |doi=}}</ref> The stockings in almost all trials were ''stronger than routine anti-embolism stockings'' and created either 20-30 mm Hg or 30-40 mm Hg. Most trials used knee-high stockings. A [[meta-analysis]] of [[randomized controlled trials]] by the [[Cochrane Collaboration]] showed reduced incidence of post-phlebitic syndrome.<ref name="pmid14974060">{{cite journal |author=Kolbach D, Sandbrink M, Hamulyak K, Neumann H, Prins M |title=Non-pharmaceutical measures for prevention of post-thrombotic syndrome |journal=Cochrane Database Syst Rev |volume= |issue= |pages=CD004174 |year= |id=PMID 14974060 | doi = 10.1002/14651858.CD004174.pub2}}</ref> The [[number needed to treat]] is quite potent at 4 to 5 patients need to prevent one case of post-phlebitic syndrome.<ref name="pmid17003920">{{cite journal |author=Kakkos S, Daskalopoulou S, Daskalopoulos M, Nicolaides A, Geroulakos G |title=Review on the value of graduated elastic compression stockings after deep vein thrombosis |journal=Thromb Haemost |volume=96 |issue=4 |pages=441-5 |year=2006 |id=PMID 17003920}}</ref>
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|
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| ====Surgical Therapy====
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|
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| * Thrombectomy
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| * Venous ligation: Not used anymore
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|
| |
| ===B. Pulmonary Embolism===
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|
| |
| Emergency treatment at a hospital is necessary to treat [[pulmonary embolism]].
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|
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| ===Acute Pharmacotherapy===
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|
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| ===Chronic Pharmacotherapy===
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|
| |
| ===Surgical Therapy===
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|
| |
| * Pulmonary embolectomy: it has a high mortality rate.
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|
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| ===Treatment in Special Population===
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|
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| ====1. Pregnancy====
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|
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| * [[Warfarin]] is '''contraindicated''' during [[pregnancy]]. It crosses the placenta and increases the risk of [[miscarriage]], [[stillbirth]], embryopathy (nasal hypoplasia or stippled epiphyses), [[central nervous system]] abnormalities, maternal hemorrhage and fetal hemorrhage. It is safe to use it in [[postpartum period]] and is compatible with [[breastfeeding]].
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| * [[Low-molecular-weight heparin]] has largely replaced [[unfractionated heparin]] for prophylaxis and treatment.
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|
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| ====2. Elderly====
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|
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| ====3. Renal Failure====
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|
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| ====4. Newborn and Early Childhood====
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|
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| ==American Heart Association's Guidelines==
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|
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| ==American Family Physician's Guidelines==
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|
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| ==Complications==
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|
| |
| * Postthrombotic syndrome
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| * Chronic thromboembolic pulmonary hypertension
| |
|
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| ==Prevention==
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|
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| ==Pathological Findings==
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|
| |
| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
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|
| |
| A 67-year-old male was hospitalized because of extensive atherosclerotic cardiovascular disease. Following surgery, during which diseased portions of the femoral arteries were bypassed, he developed massive pulmonary embolism and expired. At autopsy, thrombi were found in the femoral and iliac veins, as well as in the larger pulmonary arteries.
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|
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| [[Image:Thromboembolus 1.jpg|left|thumb|400px|This is a gross photograph of a cut section of lung demonstrating thromboemboli in the pulmonary arteries (arrows).]]
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| <br clear="left"/>
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|
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| [[Image:Thromboembolus 2.jpg|left|thumb|400px|This is a gross photograph of the heart with the main pulmonary artery opened. Note the thromboembolus filling the pulmonary artery (arrows).]]
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| <br clear="left"/>
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|
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| [[Image:Thromboembolus 3.jpg|left|thumb|400px|This is a gross photograph of portions of muscle from the legs including sections of leg veins. Note that the leg veins contain thrombus (arrows). ]]
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| <br clear="left"/>
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|
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| [[Image:Thromboembolus 4.jpg|left|thumb|400px|This is a low-power photomicrograph of lung. A large thrombus is lodged at this branch point in the pulmonary artery. Note the hemorrhage and congestion in the surrounding lung parenchyma.]]
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| <br clear="left"/>
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|
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| [[Image:Thromboembolus 5.jpg|left|thumb|400px|This is a photomicrograph of the wall of the pulmonary artery (1) containing the thromboembolus. In this case the artery wall looks normal. If this was a thrombus instead of a thromboembolus, you would expect to see some damage in the artery wall that would have initiated the thrombus. Note the lines of Zahn in the thromboembolus (arrows).]]
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| <br clear="left"/>
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|
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| [[Image:Thromboembolus 6.jpg|left|thumb|400px|This is a low-power photomicrograph of the infarcted lung. The tissue is congested and has a very bland appearance due to coagulation necrosis of the lung parenchyma. You can still see the outlines of the alveoli and the cells that make-up the alveoli but there is almost complete loss of nuclei throughout this section.]]
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| <br clear="left"/>
| |
|
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| ===Thromboembolism: Testes===
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|
| |
| [[Image:Thromboembolus 7.jpg|left|thumb|400px|This is a gross photograph of an infarcted testis. Because of the anatomy of the blood supply to the testis, torsion or the blood vessels often leads to venous occlusion (due to compression of the thin walled veins) but not arterial occlusion. Thus, blood still flows into the testis but it can’t get out! This leads to hypoxia and eventually to hemorrhagic necrosis. ]]
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| <br clear="left"/>
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|
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| [[Image:Thromboembolus 8.jpg|left|thumb|400px|This is a gross photograph of cut section of testis from previous image. The tissue is filled with blood. ]]
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| <br clear="left"/>
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|
| |
| ===Thromboembolism: Bowel infarction===
| |
|
| |
| [[Image:Thromboembolus 9.jpg|left|thumb|400px|This is a gross photograph of an opened abdomen at autopsy demonstrating loops of infarcted bowel (arrow). Vascular occlusion can lead to ischemic necrosis of the bowel. In this case, a section of bowel herniated through a fibrous connective tissue band and was strangulated, leading to ischemic necrosis.]]
| |
| <br clear="left"/>
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|
| |
| [[Image:Thromboembolus 10.jpg|left|thumb|400px|This is a gross photograph of the fibrous band between the uterus and adjacent tissues. This fibrous scar tissue is probably left over from a previous surgery or an infection. A loop of bowel herniated through the opening produced by this fibrous band and became incarcerated leading to the ischemic necrosis seen in the previous image.]]
| |
| <br clear="left"/>
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|
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| ===Coronary thrombosis===
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|
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| [http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
| |
|
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| [[Image:Coronary thrombosis 1.jpg|left|thumb|400px|This is a gross photograph of thrombosed coronary artery (arrows).]]
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| <br clear="left"/>
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|
| |
| [[Image:Coronary thrombosis 2.jpg|left|thumb|400px|This is a low-power photomicrograph of thrombosed coronary artery. The thrombus (1) completely occludes the vessel. Note the layering of the thrombus. The fibrous cap is ruptured (arrow) and there is hemorrhage into the atherosclerotic plaque. Note the cholesterol crystals in the plaque.]]
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| <br clear="left"/>
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|
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| [[Image:Coronary thrombosis 3.jpg|left|thumb|400px|This is a higher-power photomicrograph of the ruptured fibrous cap (arrows) with hemorrhage (1) into the atherosclerotic plaque.]]
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| <br clear="left"/>
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|
| |
| [[Image:Coronary thrombosis 4.jpg|left|thumb|400px|This is another high-power photomicrograph of the ruptured fibrous cap (arrows) with hemorrhage (1) into the atherosclerotic plaque. Note the presence of cholesterol crystals.]]
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| <br clear="left"/>
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|
| |
| [[Image:Coronary thrombosis 5.jpg|left|thumb|400px|This is a high-power photomicrograph of thrombus attached to the wall of the vessel. There is early organization of the thrombus (arrow). ]]
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| <br clear="left"/>
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|
| |
| [[Image:Coronary thrombosis 6.jpg|left|thumb|400px|This is a higher-power photomicrograph of thrombus attached to the wall of the vessel. Note the early organization with in-growth of fibroblasts and small blood vessels from the wall of the artery (arrows).]]
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| <br clear="left"/>
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|
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| [[Image:Coronary thrombosis 7.jpg|left|thumb|400px|In this low-power photomicrograph of another coronary artery from this patient, a mural thrombus has undergone re-organization. The mural thrombus has been invaded by the in-growth of fibroblasts and small blood vessels from the wall of the artery. The thrombotic material has been phagocytosed and removed by macrophages and is replaced by fibrous connective tissue and blood vessels. This re-organized thrombus still compromises the lumen of this vessel. ]]
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| <br clear="left"/>
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|
| |
| [[Image:Coronary thrombosis 8.jpg|left|thumb|400px|This is a higher-power photomicrograph of the vessel wall. The adventitia (1) and the media (2) contain inflammatory cells. The recanalized portion of the vessel is composed of fibrous connective tissue and contains numerous small blood vessels. There is a small area of hemorrhage (arrow) in the central portion of this image.]]
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| <br clear="left"/>
| |
|
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| [[Image:Coronary thrombosis 9.jpg|left|thumb|400px|This is a higher-power photomicrograph of another region of the vessel wall. The adventitia (1) and the media (2) contain inflammatory cells. The recanalized portion of the vessel (3) is composed of fibrous connective tissue and contains numerous small blood vessels (arrows). ]]
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| <br clear="left"/>
| |
|
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| [[Image:Coronary thrombosis 10.jpg|left|thumb|400px|This is a high-power photomicrograph of the luminal surface of a re-canalized vessel. Note that the vessel lumen is lined by endothelial cells (arrows). ]]
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| <br clear="left"/>
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|
| |
| ===Artificial heart valve thrombosis===
| |
|
| |
| [[Image:Artificial heart valve thrombosis.jpg|left|thumb|400px|Artificial heart valve thrombosis: Gross, [[aortic valve]] prosthesis with acute thrombus, ventricular view]]
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| <br clear="left"/>
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|
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| [[Image:Artificial mitral valve thrombosis.jpg|left|thumb|400px|[[Mitral valve]] prosthesis with thrombosis: Gross, natural color, view from the left atrium, thrombus around rim of caged ball prosthesis. ]]
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| <br clear="left"/>
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|
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| ==References==
| |
| {{Reflist|2}}
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|
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|
| ==Additional Resources== | | ==Additional Resources== |
| Line 285: |
Line 36: |
| * [http://www.stoptheclot.org The National Alliance for Thrombosis and Thrombophilia] | | * [http://www.stoptheclot.org The National Alliance for Thrombosis and Thrombophilia] |
|
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| ==See Also== | | ==Related Chapters== |
|
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|
| * [[Pulmonary embolism case studies]] | | * [[Pulmonary embolism case studies]] |
| Line 305: |
Line 56: |
| * [http://www.vdf.org Vascular Disease Foundation] | | * [http://www.vdf.org Vascular Disease Foundation] |
| * [http://www.lymphnet.org National Lymphedema Network] | | * [http://www.lymphnet.org National Lymphedema Network] |
| * [http://www.mylymphedema.com MyLymphedema]
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| {{Circulatory system pathology}} | | {{Circulatory system pathology}} |