and Venous Stasis
Pathophysiology and Treatment
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
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
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.
Obstruction of lymphatics with fibrosis of
regional lymph nodes.
High protein fluid predisposes to infection
Clotting due to infection/inflammation
Subdermal fluid accumulation (lowest
Lymphatic vessel repair/reanastomosis
Macrophage proteolytic activity
Mechanical measures to stabilize/improve
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
Incidence about 15-20% after axillary
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
Stages of lymphedema (Foldi)
Stage I. Reversible. Pitting and swelling
that become temporarily reduced by limb
Stage II. Spontaneously irreversible.
Progressive hardening, decreased pitting
Lymphedema stages, Cont’d
Stage III. Lymphostatic elephantiasis.
Massive increase in volume, cartilagelike
hardening of dermal tissues, and
Measurement of Lymphedema
Volumetric measures. Tracy classification
(absolute volume); Stillwell classification
(percent difference from normal limb).
Based on post-mastectomy studies.
Insignificant (0-150cc > normal limb)
Slight (150-400cc > normal limb)
Moderate (400-750cc > normal limb)
Severe (more than 750cc > normal limb)
Insignificant (0-10% > normal limb)
Slight (11-20% > normal limb)
Moderate (21-40% > normal limb)
Marked (41-80% > normal limb)
Severe (above 80% > normal limb)
Differential Dx: Upper Limb
Lymphedema versus venous thrombosis
Benign versus malignant lymphedema
Differential Dx: Lower Limb
Venous stasis disease
Chronic venous insufficiency:
Chronic abnormally high venous system
pressures lead to valve incompetence,
dilated leg veins, interstitial edema, rupture
of small subcutaneous vessels.
Stasis pigmentation from hemosiderin
End stage ulceration due to chronic fibrosis
Stages of Venous Insufficiency
Stage I. Pain, heaviness, superficial
varicosities, perimalleolar edema
Stage II. Moderate-severe edema,
pigmentation, pruritis, dermatitis, moderate
Stage III. Severe edema. Marked
pigmentation. Ulceration. Pain.
Involves dorsum hand/foot, typically spares
MCP’s/MTP’s and distally
Other skin changes uncommon
Ulceration rare; oozing in severe cases
Involves entire limb
Venous insufficiency appearance
Pitting, dependent edema
Better response to limb elevation than
Distal limb most affected (especially distal
Skin changes, ulceration common
Pain more common?
Duplex to exclude DVT
Imaging and/or electrodiagnosis to screen
for recurrent tumor as cause of new
Acute Lymphedema (sx < 2 wks)
Education and Stabilization
Bandaging and/or compression garment
Contracture reduction (shoulder exercise to
open lymphatic channels)
wks); Establish regimen
Above acute measures plus
Decongestive lymphatic massage, manual
Low stretch bandaging
Static compression garment
Chronic lymphedema (sx>4
wks); Maintain regimen
Above measures plus
Trial of pneumatic sequential compression
device (gradient pressure)
Pumpdown versus daily use
Compliance / preference factors
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.
Compression garments, cont’d
Dual role of edema control and protection
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
Compression garments, misc
Wearing schedule largely empiric, generally
6-23 hrs per day, according to severity of
Provide 2 garments, unless wearing
schedule is limited/intermittent
Jobst (single versus multi-chamber)
Wright linear compression
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
Some advocate not going above 80mm Hg
Maximum distal pressure: mean of systolic
and diastolic blood pressures
Reed sleeve Legacy
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,
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
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.
Peripheral nerve or plexus pathology
Lymphangiosarcoma (rare but aggressively
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
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Principles and Practice, 3rd ed. 1998.
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Lymphedema. PM&R: State of the Art Reviews.
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Brennan MJ, DePompolo RW, Garden FH.
Focused Review: Postmastectomy Lymphedema.
Arch Phys Med Rehabil, Vol 77, 1996, S74-S80.