Saturday, September 29, 2012

How to Wrap Legs for Lymphedema

How to Wrap Legs for Lymphedema


  • 1 Arrange all of your necessary supplies nearby. Pre-cut the tape strips to keep one layer of wrapping in place while you are applying the next. Preparation, patience and allowing yourself ample time to perform the wrap are crucial to successfully finishing the procedure.
  • Apply moisturizing body lotion to the skin of your affected leg. This will maintain good skin condition by hydrating the skin and preventing cracking which would enable bacteria to invade your leg, causing infection. It will also help to alleviate potential skin irritation from using the layers of bandages.
  • 3 Apply a tubular stockinette to protect your skin. Depending on your individual condition, you may (or may not) also use flexible gauze over the stockinette.

  • Use the thin foam-like fabric that your therapist gave you. Wrap a layer of padding around your leg. This will help to distribute the compression evenly.
  • 5 Apply the lymphedema bandages, which are also known as short-stretch bandages. Apply more pressure at your foot, gradually decreasing the pressure as you move upward. The narrower bandages can go around your foot with the wider bandages spiraling up your leg. The exact number of bandages necessary will largely depend on the length and size of your leg as well as the amount of compression that you need.
  • Tips & Warnings

    • Other potential treatments all aim to encourage lymph fluids to flow out of the affected leg and include light exercising of the affected leg, massage, pneumatic compression (a special sleeve which connects to a pump to place pressure on the affected leg) and compression garments. Some of the treatments can be combined for CDT (complete decongestant therapy).
    • Severe lymphedema may require surgical removal of excess leg tissue to help reduce swelling.
    • Avoid wearing socks that constrict your legs and avoid long periods of standing. If you must be on your feet for work, your doctor may recommend wearing compression stockings.
    • Do not use ACE bandages as lymphedema wraps. Lymphedema bandages have limited stretching capacity and offer proper skin pressure for aiding the flow of lymph fluid. These special bandages also prevent constriction which can occur with ACE bandages.
    • Contact your doctor immediately if you see a rash, redness or have any signs of infection in the affected leg. Do not apply compression or bandaging.
    • This article does not take the place of your doctor's guidance or teaching by an experienced therapist. Individualized lessons and supervision are crucial for learning proper technique.

    • Read more: How to Wrap Legs for Lymphedema | 

    Pathophysiology of Lower Extremity Edema in Acute Heart Failure Revisited.

    Pathophysiology of Lower Extremity Edema in Acute Heart Failure Revisited.

    Aug 2012


    Department of Internal Medicine, University Hospital, Basel, Switzerland; Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom; Department of Nephrology, University Hospital, Basel, Switzerland.



    The pathophysiology and key determinants of lower extremity edema in patients with acute heart failure are poorly investigated.


    We prospectively enrolled 279 unselected patients presenting to the Emergency Department with acute heart failure. Lower extremity edema was quantified at predefined locations. Left ventricular ejection fraction, central venous pressure quantifying right ventricular failure, biomarkers to quantify hemodynamic cardiac stress (B-type natriuretic peptide), and the activity of the arginine-vasopressin system (copeptin) also were recorded.


    Lower extremity edema was present in 218 (78%) patients and limited to the ankle in 22%, reaching the lowerleg in 40%, reaching the upper leg in 11%, and was generalized (anasarca) in 3% of patients. Patients in the 4 strata according to the presence and extent of lower leg edema had comparable systolic blood pressure, left ventricular ejection fraction, central venous pressure, and B-type natriuretic peptide levels, as well as copeptin and glomerular filtration rate (P=NS for all). The duration of dyspnea preceding the presentation was longer in patients with more extensive edema(P=.006), while serum sodium (P=.02) and serum albumin (P=.03) was lower.


    Central venous pressure, hemodynamic cardiac stress, left ventricular ejection fraction, and the activity of the arginine-vasopressin system do not seem to be key determinants of the presence or extent of lower extremity edemain acute heart failure.

    Unilateral pitting edema of the leg as a manifestation of Graves' disease: a case report.

    Unilateral pitting edema of the leg as a manifestation of Graves' disease: a case report.

    August 2012


    Internal Medicine Clinic, South Estonian Hospital, Meegomäe, Võru vald, 65526, Estonia.




    Graves' hyperthyroidism has a number of well-recognized but relatively rare extrathyroid manifestations such as thyroid acropachy, pretibial myxedema, and congestive heart failure.


    A 38-year-old Caucasian woman presented to the out-patient clinic with symptoms of hyperthyroidism lasting for approximately five months. Remarkably, she had developed pitting edema of her left leg four months before. She had gone through a conventional assessment, but the reason for the edema was not revealed. At presentation to the endocrinology clinic, the skin of both legs was of normal color and pitting edema on her left leg was of a diffuse nature and spread from her toes to two thirds of her leg. The skin surface of her left leg was smooth and had no elevations or discoloration, whereas her right leg appeared normal. Based on signs and symptoms of thyrotoxicosis and suppressed thyroid-stimulating hormone level (less than 0.001mIU/L, local reference of 0.4 to 4), treatment of 10mg of thiamazole three times a day was started. Additional blood tests revealed marked Graves' hyperthyroidism with elevated free T4 and anti-thyroid receptor antibodies. Within a month, the free T4 level was normalized and the edema was completely cleared and never reappeared during the treatment course of 12 months.


    To the best of our knowledge, this is the first description of unilateral treatment-responsive leg edema as a manifestation of Graves' hyperthyroidism. However, the pathophysiological mechanism underlying this case of edema remains unclear.

    An unusual case of chronic urinary retention and bladder diverticulum presenting with unilateral lower limb swelling.

    An unusual case of chronic urinary retention and bladder diverticulum presenting with unilateral lower limb swelling.

    Sept 2012


    Department of Urology, Countess of Chester Hospital, Chester, UK.


    A 64-year-old man presented with month of gradual-onset left leg swelling and lower urinary tract symptoms including enuresis, frequency and poor stream. He was initially treated for suspected cellulitis, however, he returned ;weeks later with persistence of his symptoms. 
    Routine biochemical investigation revealed renal failure (Cr 623, Ur 29.9) and hyperkalaemia (K 7.2). Abdominal examination revealed a distended urinary bladder and an ultrasound scan revealed hydronephrosis, confirming the diagnosis of chronic high-pressure urinary retention. A urinary catheter was passed that initially drained 1.5 litre of clear urine. Shortly after insertion, this became heavily blood stained. A CT kidney ureter bladder (CTKUB) revealed a large mass behind the bladder thought to represent either an abscess or tumour. Cystoscopic correlation showed this to be a large, narrow-necked bladder diverticulum tensely distended with clot. Following successful clot evacuation and decompression of the bladder the leg swelling resolved and renal function improved.

    Thursday, September 20, 2012

    Technical note: MRI lymphangiography of the lower limb in secondary lymphedema

    Technical note: MRI lymphangiography of the lower limb in secondary lymphedema.



    Department of Radiology, BGS Global Hospital, Bangalore, India.


    We would like to describe a case of MRI lymphangiography of the left leg, performed by subcutaneous injection of gadopentetate in the foot, followed by serial acquisitions of images, in a 52-year-old female, who presented to us with progressive leg swelling following total hysterectomy and radiation therapy. Successful demonstration of lymphatic channels, along with faint visualization of the venous system, was achieved. This technique allows excellent visualization of lymphatic channels.
    The credit for the first description of lymphatic channels goes to the Italian anatomist Gasparo Asellius who saw these milky white channels in a dog. However, Kinmonth et al. were the first to demonstrate lymphatics after injecting a blue dye subcutaneously. Since then, there have been various advances in the imaging techniques for identifying and visualizing the lymphatic system and its diseases. Techniques described in the past include lymphangiography and lymphoscintigraphyWe describe an MRI lymphangiography (MRL) technique in a case of secondary lymphedema following surgery and radiation for endometrial carcinoma.
    Case Report
    A 52-year-old lady presented to us with progressive, huge, swelling of her left leg of 5 year’s duration and swelling of her right leg for the past 1 year. She had been diagnosed to have endometrial carcinoma in 2002 and had undergone radical hysterectomy and pelvic lymph node dissection, followed by 35 fractions of radiotherapy. She had been asymptomatic till 2005.
    Doppler study for both legs showed a normal venous system. MRI angiography of both legs showed a normal arterial system. A CT scan of the abdomen done 7 months back had shown no tumor recurrence or metastases.
    MRL of the left leg was performed on a 1.5-T (Wipro GE, Milwaukee, WI, USA) machine after obtaining informed consent. Following painting and draping of her left foot, 0.5 ml of 2% lignocaine was injected subcutaneously into the interdigital web spaces and between the first and second proximal metatarsal space with a 24-G needle. 
    Following this, 1 ml of meglumine gadopentetate (Magnevist, Bayer Schering Pharma, Berlin, Germany) was injected into each of these five sites at the recommended dose (for intravenous use) of 0.1 mmol/kg body weight. The injected sites were massaged for 1 min. Imaging was performed using a 3D spoiled gradient-echo sequence (LAVA-XV) with the following parameters (TR-4, TE-1.9, TI-7, bandwidth 62.5 kHz, matrix 320 × 192, NEX-0.73, thickness 4 mm with 0 interslice gap, FOV 48 × 43.2, and scan time of 28 s). The scan was performed with an eight-channel body array coil. The acquisition was done at 5, 15, 25, 35, 45, and 55 mi. Dilated lymphatic channels were first visualized at 5 min followed by 15 min, 35 min  and by 55 min, lymphatics up to the groin could be seen. 
    There was excellent visualization of multiple lymphatic channels on the superomedial aspect of the leg and, in addition, there was also faint visualization of the veins. Dermal backflow was noted in the medial aspect of the lower leg at the ulcer site. No dilated lymphatics were noted in the lateral and posterior aspects of the leg. The patient was kept on antibiotics after the procedure. 
    There was no pain at the puncture site and no other complications were noted.
    The incidence of symptomatic lymphedema in a single lower extremity after surgery for uterine corpus malignancy has been found to be 69%, while bilateral lymphedema occurs in 31% of cases. Lymphedema develops after a median time of 5.3 months after the initial surgery. This development of lower extremity lymphedema is associated with the removal of 10 or more lymph nodes during surgery.
    Lymphovenous anastomosis is often performed to treat lymphedema. For this, prior visualisation of the lymphatic channels is important. The more the number of lymphovenous anastomoses performed, the better are the results.
    Initially, invasive techniques of the exploration of lymphatic vessels and injection of oil-based dyes were used for the assessment of the lymphatic drainage, but these are no longer used due to technical difficulties, the nonavailability of the contrast medium, and associated risks like pulmonary embolism. Lymphoscintigraphy is another technique that detects peripheral lymphatics and can yield quantitative flow information but has limited use in the evaluation of mild lymphedema. It suffers from poor spatial and temporal resolution.
    With the development of new MRI sequences, it is now feasible to demonstrate lymphatic channels with MRL and thus help the surgeons plan adequate surgery. This can be achieved with or without the use of contrast. Laor et al. have demonstrated lymphatic channels noninvasively in children and infants with lymphatic pathologies, but in a few cases they were unable to suppress signals from veins. Excellent visualization of dilated lymphatic channels is possible with intracutaneous injection of gadodiamide or gadolinium-DTPA, without much venous contamination.
    We have modified the technique by using a subcutaneous injection of 1 ml of meglumine gadopentetate in each interdigital web space as well as between the first and second metatarsals after first injecting the sites with 0.5 ml of 2% lignocaine. We were able to clearly demonstrate the lymphatic channels and also faintly visualize the venous system.

    Diagnosis and treatment of venous lymphedema.

    Diagnosis and treatment of venous lymphedema.

    Jan 2012


    The Rane Center, Flowood, MS. USA.



    Chronic venous disease (CVD) is a common cause of secondary lymphedema. Venous lymphedema is sometimes misdiagnosed as primary lymphedema and does not receive optimal treatment. We have routinely used intravascular ultrasound (IVUS) imaging in all cases of limb swelling. The aim of this study is to show that (1) routine use of IVUS can detect venous obstruction missed by traditional venous testing, and (2) iliac-caval venous stenting can yield satisfactory clinical relief and can sometimes reverse abnormal lymphangiographic findings.


    The study comprised CVD patients who underwent iliac vein stenting. Lymphangiography was abnormal in 72 of 443 CEAP C(3) limbs, with leg swelling as the primary complaint (abnormal lymphangiography group). Clinical features and stent outcome were compared with a control group of 205 of 443 with normal lymphangiography (normal lymphangiographic group).


    Clinical features were a poor guide to the diagnosis of lymphedema. Isotope lymphangiography was not helpful in differentiating primary from secondary lymphedema. Venography had 61% sensitivity to the diagnosis of venous obstruction. IVUS had a sensitivity of 88% for significant (50% area stenosis) venous obstruction. At 40 months, cumulative secondary stent patency was similar for the abnormal (100%) and normal lymphangiographic (95%) groups. Swelling improved significantly after stent placement in the abnormal lymphangiographic group (mean [standard deviation] swelling grade improvement 0.8 ± 1.1) but was less  than in the control group

    Complete swelling relief was 16% and 44% and partial improvement  was 45% and 66%  in the abnormal and normal lymphangiographic groups, respectively. 

    Associated pain was present in 50% and 36% of the swollen limbs in the abnormal and normal lymphangiographic groups. Pain relief at 40 months was 87% and 83%, respectively (P = .3), with 65% and 71%, experiencing complete pain relief. Quality of life criteria improved after stent placement in both groups but to a better extent in the normal lymphangiographic group. Abnormal lymphangiography improved or normalized in 9 of 36 (25%) of those tested after stent correction.


    Prevailing practice patterns and diagnostic deficiencies probably result in the misdiagnosis of many cases of venous lymphedema as "primary" lymphedema. IVUS is recommended to rule out venous obstruction as the associated or initiating cause of lymphedema. Iliac venous stenting to correct the obstruction has excellent long-term patency and good clinical outcome, although results are not as good as in those with normal lymphatic function.

    Lower limb lymphedema treated with lymphatico-venous anastomosis based on pre- and intraoperative icg lymphography and non-contact vein visualization: A case report.

    Lower limb lymphedema treated with lymphatico-venous anastomosis based on pre- and intraoperative icg lymphography and non-contact vein visualization: A case report.

    Mar 2012


    Department of Plastic and Reconstructive Surgery, University of Tokyo, Japan.


    Lymphatico-venous anastomosis (LVA) is used to resolve lymph retention in lymphedema. However, the postoperative outcome of lower limb lymphedema is poorer than that for upper limb lymphedema, because of the location lower than the heart level. Improvement of the therapeutic outcome requires application of as many anastomoses as possible in a limited operation time, particularly since there is a positive correlation between the number of anastomoses and the therapeutic effect of LVA. In this case, we described a method to increase the efficiency of lymphatico-venous anastomosis for bilateral severe lower limb lymphedema through efficient identification of lymph vessels and veins suitable for anastomosis using indocyanine green (ICG) contrast imaging and AccuVein, a noncontact vein visualization system, respectively. Ten LVAs were succeeded at seven incisions, and the operation time was 3 hours and 5 minutes. Accuvein can be used for identification of subcutaneous venules with a diameter of about 0.5-1.0 mm. We used this approach in surgery for a case of bilateral lower limb lymphedema, with a resultant improvement in the surgical outcome.

    The efficacy of complex decongestive physiotherapy (CDP) and predictive factors of response to CDP in lower limb lymphedema (LLL) after pelvic cancer treatment.

    The efficacy of complex decongestive physiotherapy (CDP) and predictive factors of response to CDP in lower limb lymphedema (LLL) after pelvic cancer treatment.

    June 2012


    Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan.



    The aim of this study was to estimate the efficacy of an intensive CDP program, as well as to identify the predictors associated with lymphedema severity and response to CDP in lower limb lymphedema (LLL) after pelvic cancer therapy.


    We performed a retrospective review of post-pelvic cancer LLL patients that were treated with a CDP program between January 2004 and March 2011.


    Twenty-seven (61.4%) of the total 44 patients had cervical cancer, 9 (20.5%) had endometrial cancer, and 8 (18.2%) had ovarian cancer. The mean age was 62.2 years, 18 (40.9%) patients received radiotherapy and a mean of 12.6 sessions of daily CDP, and mean lymphedema duration was 34.8 months. The interval from pelvic cancer treatment to LLL development was 63.4 months. Lymphedema severity, baseline and post-CDP percentage of excess volume (PEV) were 32.9% ± 18.4% and 18.8%± 16.7%. Baseline PEV was not correlated with duration of lymphedema, number of CDP sessions, age or radiotherapy, and was significantly different to post-CDP PEV, CDP efficacy, percentage reduction of excess volume, was minus fifty-five percent and was correlated with baseline PEV, but not with the number of CDP sessions, duration of lympheema, or age.  PEV was the only predictive factor for CDP efficacy.

    The key to predicting successful lymphedema treatment of LLL is the initial PEV. The intensive CDP program was effective and successful. We should encourage and refer patients to undergo treatment for LLL, even when the LLL is mild.

    Stewart-Treves syndrome arising in patients with lymphaticovenular anastomosis for chronic lymphedema of the leg.

    Stewart-Treves syndrome arising in patients with lymphaticovenular anastomosis for chronic lymphedema of the leg.

    Eur J Dermatology 2012

    Case 1. A 51-year-old woman presented with lymphedema of the left leg in 2000, without past history of surgery or radiation. She underwent lymphaticovenular anastomosis twice for her left lymphedema in 2003 and 2006. The skin incision
    was made at the thigh, knee and ankle. However, the surgery was unsuccessful, and conservative pressure therapy was continued. In 2010, she was referred to our department with a one-year history of a purplish lesion on her left lower leg. Examination revealed a slightly indurated, ecchymotic lesion, measuring 8×7 cm on the lymphedematous lower leg. 

    A biopsy specimen of the lesion showed some vascular channels lined by atypical endothelial cells with an extravasation of erythrocytes and scattered 
    atypical cells in the dermis (figure 1C). Double immunofluorescence analysis showed that tumor cells were positive for podoplanin and negative for von Willebrand factor (figure 1D), indicating the development of lymphangiosarcoma.

    FDG PET/CT imaging showed a mottled, abnormal
    accumulation in the left lower leg (figure 1B). She was
    treated with X-ray at a dose of 60 Gy and eight courses
    of monthly docetaxel. There has been no evidence of local recurrence or metastases 13 months after the radiation.

    Case 2. A 71-year-old woman, who was treated for cervical carcinoma in 1996, undergoing a hysterectomy and radiotherapy, developed chronic lymphedema of both legs. She underwent lymphaticovenular anastomosis twice in 2000 and 2001. However, the lymphedema gradually progressed, accompanied by hyperkeratotic papules of lymphangiectases.

    In 2010, she was referred to our department for
    further evaluation regarding a two-month history of a hemorrhagic lesion on her right buttock with high uptake of FDG as determined by PET/CT (figure 1E). Physical examination revealed hemorrhagic nodules on the right buttock and lower abdomen (figure 1F). Under a diagnosis of STS, she was treated by electron beams at a total dose of 60 Gy, followed by intravenous injections of interleukin-2 for five weeks. However, she developed several recurrences on her buttock and died of sepsis.

    Stewart-Treves syndrome (STS) is a rare form of lymphangiosarcoma that occurs as a complication of lymphedema. The lymphedematous region becomes an immunologically vulnerable area that is predisposed to malignancy. Lymphedema in the extremities is troublesome for patients and conventional therapies are not always satisfactory.

    Lymphaticovenular anastomosis is a novel treatment of lymphedema in the extremities [1]. The supermicrosurgical anastomosis of a lymphatic collector and a subdermal venule is performed through two or three incisions. This surgery has good results in most patients with upper extremity lesions and in about half of those with lower extremity lesions [2].

    In the present cases, chronic lymph stasis might predispose the onset of the lymphangiosarcoma. The association between lymphangiosarcoma and lymphaticovenular anastomosis is unclear. A history of prior trauma and surgery has been noted in some studies on cutaneous angiosarcoma.

    However, Holden et al. [3], found no definitive predisposing factors in any of 72 patients reviewed. We previously reported a case of metastatic angiosarcoma in a skin graft donor site associated with the Koebner phenomenon, and proposed that this phenomenon may be involved in the pathogenesis of angiosarcoma [4].

    Furthermore, a fewcases of angiosarcoma have occurred in post-transplant patients with arteriovenous fistula (AVF) [5, 6]. Oscillatory blood flow in AVF causes shear stress at the endothelium, providing a pro-inflammatory stimulus to upregulate growth peptides, and enhances the activity of the DNA transcription regular NFkB by phosphorylation [5]. Similarly, the aberrant flow through lymphaticovenular anastomosis may be one of the factors contributing to the tumorigenesis of
    STS. The prognosis is poor despite aggressive treatment.

    Therefore, we should be aware of the possible occurrence of this condition during the treatment and follow-up of chronic lymphedema.

    Disclosure. Financial support: none. Conflict of interest: None

    Wednesday, September 12, 2012

    Pseudosarcoma - massive localized lymphoedema in morbidly obese - a rare entity: Case report.

    Pseudosarcoma - massive localized lymphoedema in morbidly obese - a rare entity: Case report.


    **Editors note: massive localized lymphedema is generally always in the legs if a morbidly obese patient has it, this is why I wanted to put this piece in our Leg Lymphedema blog. Pat - blog editor


    Andhra Medical College, Chief Surgeon, King George Hospital,Visakhapatnam, Andhra Pradesh, India.



    Massive localized lymphoedema (MLL) first described in 1998 by Farshid and Weiss. Usually MLL present like huge pedunculated mass and appear like sarcoma hence called Pseudosarcoma. Morbid obesity is a growing epidemic in our society. Morbid obesity is usually associated with hypertension, Diabetes mellitus, dermatological complications like Acanthosis nigricans, skin tags, leg ulcers, edema, lymphoedema, plantar hyperkeratosis and massive localizedlymphoedema (MLL) is one of the complications of morbid obesity. Pseudosarcoma is due to derangement of lymphatic channels secondary to excessive deposition of adipose tissue.


    We report a patient afflicted with this unique disorder presented with huge mass arising from monspubis in morbidly obese individual with body mass index (BMI) 55.


    Massive localized lymphedema presenting like pseudosarcoma in morbidly obese individuals is rare. Awareness of this disease is essential to avoid misdiagnosis as soft tissue neoplasm. It is a term used to describe a benign over growth of lymhoproliferative tissue in morbidly obese patients. Because of its size patients have difficult to do daily activities. Histopathologically characterized by dilated lymphatic channels with fibrotic and edematous tissue, without evidence of malignancy. Patient seeks treatment only if there is huge swelling causing discomfort, complications like excoriation, wound break down occur. The treatment of choice is complete excision.


    Surgical treatment is effective if done along with bariatric surgery. Functional rehabilitation was achieved. No recurrence was observed within the follow up period of twenty months and BMI was reduced to 28.