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Jan Weiss, PT, DHS, CLT-LANA

CoxHealth Venous Symposium

June 2, 2017

IS IT LYMPHEDEMA?

DIFFERENTIATING BETWEEN LYMPHATIC AND OTHER ORIGINS

OF EDEMA&

IMPLICATIONS FOR TREATMENT

Is it lymphedema?

Venous Edema

LE edema resulting from venous hypertension

Often develops the “reverse champagne bottle” appearance

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Diagnosis- CVI• History

• Risk factors: DVT, heredity, obesity

• Gradual onset and slow progression

• Orthostatic edema

• Clinical Exam• Usually bilateral

• Classic hemosiderin staining

• Usually involves ankle-knee- rarely the thigh; can include feet

• c/o aching, heaviness, tightness

• Pitting edema early in disease

• Progressive lipodermatosclerosis, ulceration as condition advances

• Imaging• Duplex Ultrasonography

• Saph-fem US

• Iliac vein IVUS

Lymphedema

• LE edema resulting from impairment in the lymphatic drainage system

• Loss of normal visible anatomical architecture

Diagnosis- Lymphedema

• History• Risk factors: Hereditary (primary); Lymph node dissection, injury to lymphatic

vessels, obesity (secondary lymphedema)

• Onset usually gradual but may be rapid

• Often considered a diagnosis of “exclusion”

• Patients have increased likelihood of cellulitis

• Clinical Exam• May be unilateral or bilateral, but will always be asymmetrical

• Usually is distal involving the foot, but may include entire leg

• Soft pitting edema early, then progressive induration

• In contrast to CVI, the skin remains elastic much longer, and ulceration is atypical; no hemosiderin staining; little or no lipodermatosclerosis

• Typically have minimal discomfort or tenderness, but always “heaviness”

• Imaging• Lymphoscintigraphy

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Lymphoscintigraphy

NIRFLNear-Infrared Lymphatic Imaging

• Injection of Indocyanine Green (ICG) into dermal tissue

• Fluorescent signal eminates from ICG laden subdermal lymph vessels

• Image collected by customized camera using night vision technology

• Only penetrates ~1.5 cm into tissue

• Measures lymphatic flow in real time

NIRFLI imagingNear-Infrared Lymphatic Imaging

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NIRFLI imaging

ICG-Arm-Comparison

Researchgate.net

Comparison of lymphatic flow: normal to impaired

Lipedema

� Symmetrical appearanceof „swelling“ of both legsdue to abnormal production of adiposetissue

� Disproportionate size ofhips/legs to upper body

� Diet and exerciseresistance (?)

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Diagnosis- Lipedema

• History• Affects mainly women; often hereditary

• Often begins in childhood, puberty or after pregnancy

• Clinical Exam• Bilateral and symmetrical from pelvic girdle to ankles

• Spares the feet, unless accompanied by lymphedema • Tissues very soft, almost “fluffy”, no pitting, unless accompanied by

lymphedema• Marked tenderness and pain

• Bruise easily

• Imaging• No imaging necessary, but could identify CVI or lymphedema with

respective imaging for those conditions

Is Lipedema a Disease?

•No ICD-10 code exists for lipedema. However, the following pathological findings are well described in the literature:

� Micro-angiopathy in the adipose tissue

� Elasticity of the skin is decreased

� Weakness of the venous leg pump

� Pre-lymphatic channels abnormal

� Initial lymphatics abnormal

� Lymph collectors: cork screw

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May vary in severity, but always worse when accompanied by obesityMild Severe

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Patient with Lipo-lymphedema

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Before CDT After CDT

Lipedema

• The problem is NOT primarily edema, but is fat accompanied by some edema

• Compression and MLD helps with pain and capillary fragility

• Tissues are very soft, and tender

• Typical high elastic compression stockings are POORLY tolerated due to pain and tissue texture

Treatment similarities; different rationale

• Chronic Venous Insufficiency

• Compression to enhance venous return, reduce venous edema and risk of ulceration

• Lymphedema

• Compression and manual lymphatic drainage to reduce lymphatic edema, risk of infection, and promote tissue health

• Lipedema

• Compression to reduce pain, tenderness, and any orthostatic or lymphatic edema present

• These patients will NOT display the great size reductions noted with lymphedema or some venous edemas

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Klippel-Trenaunay-Weber Syndrome

• Congenital condition consisting of a triad of vascular/lymphatic/soft &boney tissue abnormalities

• Varicose Veins

• Boney and soft tissue hypertrophy

• Port wine stain

• Commonly has DVT and lymphatic impairment

• Limb is enlarged beyond that solely due to edema

• Pre-treatment Post-treatment

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Compression stockings

• Your typical OTC compression stocking

• High elasticity

• Readily cuts into tissues, especially if poorly fitting

• Usually a custom garment

• Lower elasticity

• Lays much flatter/smoother on skin

Circular knit Flat knit

CIRCULAR KNIT VS. FLAT KNIT GARMENTS

Problem: When used for lymphedema and lipo-lymphedema, circular knit garments tend to migrate into tissue creases and create a tourniquet.

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Latex Lycra

Stretch and size tolerance of circular vs flat knit garments

Stretch tolerance of aflat-knit garment with high working pressure

Size tolerance of aflat-knit garment

Size tolerance of acircular-knit garment

Stretch

Pre

ssure

CCL2

Stretch tolerance of acircular-knit garment

Custom flat knit can accommodate any size or shape

Indications for use of flat knit compression

• When body size or contour doesn’t permit fit with OTC garment

• When tissues are very soft

• When edema is poorly controlled with circular knit garment

• When circular knit garments are painful; poorly tolerated

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Assistive donning/doffing devices

Alternative compression

• Velcro-style

• Non-elastic compression

• Eases problem with donning

• Allows for some fluctuation in edema

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Compression therapy options

Ready Wrap

(Solaris)

Tribute

(Solaris)

Farrow Wrap

(BSNmedical)

Juxta Fit

(CircAid)

Compression pumps

Non-segmental or segmental without calibrated gradient compression

Applies compression to limb only

• Segmental calibrated gradient compression

• May apply compression to trunk and limb

Basic Pneumatic Pump Advanced Pneumatic Pump

Benefits of pneumatic compression

• Augment blood and lymphatic flow

• Reduction of swelling and pain

• Prophylaxis against DVT

• Assist in wound healing by improving circulation

• Convenience of treatment at home

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Considerations when recommending pneumatic compression

• When possible a pump should NEVER be considered as a sole means of controlling/reducing edema

• Does the patient actually need edema reduction treatment first, then a pump for home management?

• What else is the patient doing for edema control?

• Are they actively participating in their care?

• Wearing compression garments, elevation, diet, exercise

• Is there lymphatic insufficiency which requires proximal lymphatic drainage?

Would your patient benefit from a referral to Cox Outpatient Lymphedema Clinic?

Services offered

• Individualized patient evaluation

• With physician diagnosis and input, differential diagnosis helps ascertain etiology of edema to guide appropriate treatment

• Rule out contraindications for therapy

• Application of appropriate materials/treatments to assist with edema reduction and wound healing when appropriate

• Individualized fitting of compression garments – there is NO ONE SIZE FITS ALL

• Education in self care for their chronic condition

• Case management for patients with special needs

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When to refer to Cox Lymphedema Clinic?

• When there is chronic edema

• Edema reduction is essential for proper fit and success

with compression garments

• Anytime unsure of compression garment fitting

• When the patient has body contour, size, or tissue texture will not tolerate OTC circular knit garments

• Anytime education will be essential to donning

• Contact Jan Weiss, PT for questions 269-7168

• Contact Sarah West for scheduling 269-9681

• Fax 269-5542

Thank you for your time and attention

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References• Educational materials/photos provided with consent of Klose Training and

Consulting, LLC. Lafayette, CO

• Compression garment slides provided with permission of BSN Medical. www.BSNmedical.US

• Compression pump slides used with permission from Tactile Medical

• Morris RJ, Woodcock JP. Evidence-Based Compression; Prevention of Venous Stasis and Deep Vein Thrombosis. Ann Surg. 2004;239(2):162-171

• Suami H, Chang D, et al. Using indocyanine green fluorescent lymphography to demonstrate lymphatic architechture. J Lymphoedema. 2012;7(2)

• Sevick-Muraca E. Translation of Near-Infrared Flourescence Imaging Technologies: Emerging Clinical Application. Ann Rev Med. 2012;63:217-231