by W. Randall Russell MD, FACS Medical Director Lankenau Hospital Wound Healing Center

Appearances can be deceiving. This is often the case when diagnosing the etiology of lower extremity edema. Not always is heart failure the ubiquitous diagnosis. Veno-lymphatic disease should always be considered in the differential diagnosis of leg edema. Inaccurate diagnosis can delay the patient access to advanced technologies, such as intermittent pneumatic compression therapy.

77 year old J.P. has experienced many years of progressive leg swelling. Her legs always seemed disproportionately larger than the rest of her body. She has typical co-morbidities seen in “over weight” patients, including hypertension, dyslipidemia and pre-diabetes. Her primary care physician associated her large legs to her dietary indiscretions, and often described them simply as swollen and edematous.

The status-quo continued until the day she presented to our Wound Center with 3+ pitting leg edema, and blistering of her left anterolateral calf. An arterial and venous doppler ultrasound of her left leg was immediately obtained and showed no deep vein thrombosis or evidence of atherosclerotic occlusive disease. 

Closer examination of her lower extremities revealed typical trophic skin changes of secondary lymphedema – hemosiderin staining, dermatoliposclerosis, skin atrophy with loss of hair, stasis dermatitis and hyperkeratosis. Note the absence of varicosities, which are often thought to co-exist with chronic venous insufficiency, but frequently are absent. The patient was afebrile and preliminary blood work showed no leukocytosis or bandemia. The erythema noted was consistent with severe stasis dermatitis and not a bacterial infection. Therefore, the patient did not require hospitalization for parenteral antibiotics.

The caveats in treating this patient are:

• Achieving rapid fluid balance through appropriate diuresis, and fluid restriction.
• Consistent extremity elevation
• Off-loading of symptomatic extremities using compression garments or multi-layer compression wraps.
• Optimization of the wound bed and periwound skin using absorptive and bacteriostatic topical wound products

An Unna Boot was applied at the time of the patient's first visit, with resultant rapid and effective reduction in edema, venous hypertension and dermatitis. The Unna Boot was removed after 72 hours and the extremity inspected.

Following initial Unna Boot

The patient continued to follow her recommended lifestyle changes, particularly structured leg elevation and consistent use of knee-high tubular stockings, providing approximately 20-25mmHg compression. Her progress was followed weekly, not only by physical examination, but also with closely monitoring her weight. The patient responded nicely to treatment, but even after her stasis ulcer had resolved, she still complained of leg heaviness, easily fatigability, and diminished functional capacity due to her lower extremity lymphedema. Having met all insurance requirements, she was considered a good candidate to start intermittent pneumatic compression therapy. She was well motivated, capable of adhering to a routine, and very fearful of future episodes of lower extremity ulceration and cellulitis. Insurance preauthorization for a 4-chamber intermittent pneumatic compression pump with bilateral thigh high leg garments was handled by Medical Solutions Supplier (medsolsupplier.com). Within two weeks, the patient was using her newly acquired pump three times daily, for sixty minutes each session, at a pressure of 50mmHg. Results were amazing, as depicted in the photo below.

Establishing the diagnosis of lymphedema early in the course of treatment will avoid potential delays in qualifying the patient for beneficial intermittent pneumatic compression (IPC) therapy. The use of IPC therapy complements extremity off-loading by extremity elevation, gradient compression garments and a physical therapy regimen. The patient should be closely monitored for response to treatment and to insure compliance with the designated care plan. IPC therapy is a dynamic treatment, where adjustments can be made in frequency of application, session duration and operating pressure. Aggressively managed, lymphedema is quite treatable, and often times function status can be maintained, if not improved.

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