Lymphedema and Venous Stasis

1
Lymphedemaand Venous Stasis

• Pathophysiology and Treatment

2
Lymphatic system physiology

• Retrieval of plasma proteins filtered out through
  capillary walls.
• Lymphangions carry the high protein fluid back to
  the main lymph system.
• Lymphangions have valves and smooth muscle. Low
  pressure system. Skeletal muscle action, blood
  vessel pulsations and gravity assist.

3
Lymphatic system physiology

• Lymphatic fluid is transported back to the venous
  circulation via regional lymph nodes and the long
  thoracic duct.
• Lymphatics can regenerate but if pressures are
  too great valves become incompetent. Regenerated
  lymphatics are sensitive to scar formation.

4
Lymphatic system physiology

• Lymphatic fluid contains fibrinogen and thrombin,
  not thromboplastin. Clots more slowly than
  blood.
• Thromboplastin is present in bacteria and cell
  fragments clotting occurs with infection and
  inflammation.
• Larger proteins pass into the interstitium when
  inflammation is present.

5
Lymphedema Pathophysiology

• Obstruction of lymphatics with fibrosis of
  regional lymph nodes.
• High protein fluid predisposes to infection and
  fibrosis.
• Clotting due to infection/inflammation
• Subdermal fluid accumulation (lowest pressures)

6
Lymphedema PathophysiologyCompensatory factors

• Lymphatic vessel repair/reanastomosis
  (vulnerable)
• Macrophage proteolytic activity
• Mechanical measures to stabilize/improve
  lymphatic outflow.

7
Etiology of Lymphedema

• Primary. Related to inborn defects in the
  lymphatic system, may be evident at
  birth(lymphedema praecox), or manifest in the 2nd
  or 3rd decades (lymphedema tarda).
• Secondary. Acquired lymphedema due to cancer,
  infection (filariasis leading cause worldwide),
  radiation, surgery or trauma

8
Postmastectomy lymphedema

• Incidence about 15-20 after axillary dissection
• Higher incidence in patients who have received
  radiation therapy than in those without this
  modality
• Other risk factors are obesity, local infection
  or delayed healing, dominant side
• Onset may be delayed, even years

9
Stages of lymphedema (Foldi)

• Stage I. Reversible. Pitting and swelling that
  become temporarily reduced by limb elevation.
• Stage II. Spontaneously irreversible.
  Progressive hardening, decreased pitting quality

10
Lymphedema stages, Contd

• Stage III. Lymphostatic elephantiasis. Massive
  increase in volume, cartilagelike hardening of
  dermal tissues, and papillomatous outgrowth.

11
Measurement of Lymphedema

• Volumetric measures. Tracy classification
  (absolute volume) Stillwell classification
  (percent difference from normal limb). Based on
  post-mastectomy studies.
• Circumferential measures

12
Tracy classification

• Insignificant (0-150cc gt normal limb)
• Slight (150-400cc gt normal limb)
• Moderate (400-750cc gt normal limb)
• Severe (more than 750cc gt normal limb)

13
Stillwell classification

• Insignificant (0-10 gt normal limb)
• Slight (11-20 gt normal limb)
• Moderate (21-40 gt normal limb)
• Marked (41-80 gt normal limb)
• Severe (above 80 gt normal limb)

14
Differential Dx Upper Limb

• Lymphedema versus venous thrombosis
• Benign versus malignant lymphedema

15
Differential Dx Lower Limb

• Lymphedema
• Venous thrombosis
• Venous stasis disease
• Postphlebitic syndrome

16
Chronic venous insufficiencyPathophysiology

• Chronic abnormally high venous system pressures
  lead to valve incompetence, dilated leg veins,
  interstitial edema, rupture of small subcutaneous
  vessels.
• Stasis pigmentation from hemosiderin deposition.
• End stage ulceration due to chronic fibrosis and
  atrophy

17
Stages of Venous Insufficiency

• Stage I. Pain, heaviness, superficial
  varicosities, perimalleolar edema
• Stage II. Moderate-severe edema, pigmentation,
  pruritis, dermatitis, moderate varicosities
• Stage III. Severe edema. Marked pigmentation.
  Ulceration. Pain.

18
Lymphedema appearance

• Involves dorsum hand/foot, typically spares
  MCPs/MTPs and distally
• /- Pitting
• Cellulitis common
• Other skin changes uncommon
• Ulceration rare oozing in severe cases
• Involves entire limb

19
Venous insufficiency appearance

• Pitting, dependent edema
• Better response to limb elevation than lymphedema
• Distal limb most affected (especially distal
  tibial area)
• Skin changes, ulceration common
• Pain more common?

20
Laboratory evaluation

• Duplex to exclude DVT
• Imaging and/or electrodiagnosis to screen for
  recurrent tumor as cause of new swelling.
• Lymphoscintigraphy
• Lymphangiography
• Optoelectronic volumetry

21
Treatment

• Skin care
• Limb elevation
• Proximal decongestion
• Gradient compression
• Exercise

22
Acute Lymphedema (sx lt 2 wks)Education and
Stabilization

• Infection?
• Skin care
• Pump down?
• Bandaging and/or compression garment
• Contracture reduction (shoulder exercise to open
  lymphatic channels)
• Exercise

23
Subacute lymphedema(sxgt2 wks) Establish regimen

• Above acute measures plus
• Decongestive lymphatic massage, manual lymphatic
  drainage
• Low stretch bandaging
• Static compression garment

24
Chronic lymphedema (sxgt4 wks) Maintain regimen

• Above measures plus
• Trial of pneumatic sequential compression device
  (gradient pressure)
• Pumpdown versus daily use
• Compliance / preference factors

25
Compression garments

• Available as 30/20, 40/30, and 50/40 (distal
  greater than proximal pressure).
• Stock versus custom
• Use 30/20 for early, mild cases, or when ease of
  donning is a major factor.
• Use 40/30 most of the time
• ?? Role of 50/40. Pressure possibly too high for
  the delicate lymphatic system.

26
Compression garments, contd

• Dual role of edema control and protection from
  trauma
• Standard sleeve (wrist to shoulder) or stocking
  (foot to thigh) for lymphedema
• Glove or gauntlet
• Zippered garments, or use of rubber glove for
  ease of donning

27
Compression garments, misc

• Wearing schedule largely empiric, generally 6-23
  hrs per day, according to severity of the edema
• Provide 2 garments, unless wearing schedule is
  limited/intermittent
• Non-limb options
• Financial barriers

28
Pumping options

• Jobst (single versus multi-chamber)
• Lymphapress
• Wright linear compression

29
Contraindications to pumping

• Absolute active regional metastatic disease or
  infection deep vein thrombosis
• Relative anticoagulated state, congestive heart
  failure, arterial insufficiency, skin lesions, ?
  Active chemotherapy or radiation therapy

30
Pump settings

• Some advocate not going above 80mm Hg
• Maximum distal pressure mean of systolic and
  diastolic blood pressures

31
Other devices

• Reed sleeve
• Circ Aid

• Legacy

32
Decongestive massage therapies

• Proximal decongestion clear adjacent trunk
  (lymphotome) before moving distally down the
  affected extremity
• Gradient compression maintain reduction with
  exercise, garments, bandaging or pump
• Vodder, Foldi, Lerner, Casley-Smith, LeDuc

33
Surgical therapies

• Physiological surgery. Microlymphatic-venous
  anastomosis. But limited experience in
  post-malignancy lymphedema, and recurrence rate
  is high
• Excisional surgery. Removal of excessive tissue,
  suction lipectomy

34
Drug therapies

• Antibiotics for cellulitis or lymphangitis
• No data supporting long-term diuretics
• Benzopyrones? Used in Europe. Stimulates
  proteolysis by macrophages, and increases the
  number of macrophages.

35
Associated issues

• Pain
• Contracture
• Peripheral nerve or plexus pathology
• Psychologic/coping
• Lymphangiosarcoma (rare but aggressively
  malignant)
• Procedures

36
Venous stasis treatment

• Similar mechanical measures (elevation, garment,
  exercises, pumping).
• Distal limb tx may be sufficient.
• Topical steroids to target eczematous skin
  changes and pruritis.
• Vigilance re infection usually not as crucial
• Wound treatment (protective moist dressings).

37
References

• DeLisa, Gans. Rehabilitation Medicine
  Principles and Practice, 3rd ed. 1998.
• Grabois M. Breast Cancer Postmastectomy
  Lymphedema. PMR State of the Art Reviews.
  Vol 8, 2, 1994, 267-277.
• Brennan MJ, DePompolo RW, Garden FH. Focused
  Review Postmastectomy Lymphedema. Arch Phys
  Med Rehabil, Vol 77, 1996, S74-S80.