When people say "Lisp macros" they usually mean Common Lisp defmacro-flavored ones. Any problems introduced by lack of hygiene can be papered over with separate variable and function namespaces and gensyms.
Not really because a huge feature of hygiene is accurate symbol provenance for syntax error reporting. syntax-case (syntax-parse for Racket) lets you do anything a Common Lisp like macro system can do but is still hygienic by default.
