Download Edema - Center for Vein Restoration

Chronic Venous Insufficiency
The Challenge of Edema
S. Lakhanpal MD, FACS
President & CEO
Center for Vein Restoration
Case Presentation
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67 year old male
Presents with Left Calf Ulceration
• Duration: 2 months
Associated Symptoms
• Pain and Heaviness left leg
• Cramps
• Itching
PMH:
• Arthritis, GERD, Gout, Hypertension
• Right knee Surgery
• Ex Smoker
Meds:
• Atenolol, Omeprazole, Nortriptyline, Allopurinol, Lasix,
Oxycodone
Physical Findings
• Left leg Ulcer – lateral and posterior calf
• Hyperpigmentation
• Pitting Edema lower leg
Images
Images
The Challenge of Edema
• Chronic Unilateral edema if trauma and malignant
obstruction is ruled out is invariably due to venous
insufficiency
• Acute onset edema U/L or B/L is not due to ‘chronic’
venous insufficiency
• For chronic B/L edema first document the presence of
significant reflux, and the exclude systemic causes
(cardiac, renal, hepatic, abdominal malignancies, thyroid
disorders, sleep apnea and medications causing edema )
• Despite all the testing it remains a close call
• Try treatment on one side and reassess?
Edema: Salient Features
• The most common cause of leg edema in adults over 50 is
venous insufficiency
• The most common cause in women between menarche
and menopause is idiopathic edema, formerly known as
“cyclic” edema
• A common but under-recognized cause of edema is
pulmonary hypertension, which is often associated with
sleep apnea
Duplex Evaluation
• Ultrasound evaluation in office
• Left Leg:
• Reflux present in greater saphenous vein
• No evidence of DVT
Duplex Ultrasound Evaluation
Lt gsv
Management
• Multidisciplinary approach
• Wound Care
• Management of Venous Insufficiency
• Lymphedema management
Minimally Invasive Procedures
• Radiofrequency – Heating element in contact with the
vein wall: endothelium denudation, collagen contraction, vein
shrinkage and fibrosis
• Laser – Hemoglobin is the chromosphere. Steam bubble
injures the endothelium. Non thrombotic occlusion
• Sclerosants – Detergents with removal of endothelium
and damage of the media
What is Lymphedema?
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Fluid accumulation in a limb
Due to an impairment in the
lymphatic system
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Functions of lymphatic system:
– Immunological functionlymphocytes break down
bacteria
– Intestinal lymph vessels
absorb fat
– To transport lymph fluid
from the interstitium to
the cardiovascular
system
• Lymph fluid = water,
protein, larger
molecules
Lymphedema and Phlebopathies
Four ways his can occur:
1. Developmental defect
lymphedema
accompanied by valveless veins
2. Every kind of lymphedema causes pathological changes in blood
vessels
LE lymphedema
impaired ambulatory venous function
mild venous insufficiency
3. Late stage CVI
combination form of lymphedema
4. Phlebectomies in a patient with lymphedema can cause it to worsen
Phlebolymphedema
The accumulation of fluid in the
interstitial tissue that is caused by a
combination of venous and lymphatic
disorders.
Treatment for Lymphedema:
Complete Decongestive Therapy
• Phase I (Intensive)
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Manual Lymph Drainage
Compression Bandaging
Exercise
Skin & Nail Care
Instruction in Self Care
In clinic
• Phase II (Self Care)
– Compression garment during the
day
– Bandage at night
– Self MLD
– Skin & Nail Care
– Exercise
At home
Thank You