Lymphedema People Logo



Deep Venous Thrombosis and Lymphedema

Related Terms:  Blood clots, DVT, Venous Stasis, leg swelling, deep vein thrombophlebitis, pulmonary embolism, deep vein blood clots, venous thrombosis, leg edema, Homans sign, lymphedema fibrosis, sepsis, nephrotic syndrome, congestive heart failure, stroke, acute myocardial infarction, heart attack, lymphedema

Discussion:

Medical condition that affects mainly the lower legs and thigh and involves the formation of a blood clot.  The clot cuts off blood circulation and can lead to several serious complications.  The signs and symptoms of the condition will vary depending on the intensity or size of the clot.

Risk factors:

There are a number of general risk factors associated with DVT.  These include age, immobilization for longer than three days, pregnancy and the post-partum period, extensive surgical procedure within the previous month.

In addition to the general risk factors, there are important medical based risk factors as well.  These include cancer, sepsis, nephrotic syndrome, congestive heart failure (CHF), fibrosis in lymphedema limbs, stroke, acute myocardial  infarction (AMI - heart attack).

Other causes include trauma injury, inherited hematologic disordes, and drugs and medications.

Complications:

Edema of the affected limb, pulmonary embolism, post-thrombotic syndrome, hemorhagic complications from anticoagulants and blood thinners, chronic venous insufficiency, soft-tissue ischemia, risk of cellulitis from the edema

Symptoms:

Homans sign (Slight pain at the back of the knee or calf when the ankle is slowly and gently dorsiflexed (with the knee bent), indicative of incipient or established thrombosis in the veins of the leg.)

Unexplained sharp leg pain in only one leg, sudden edema in only one leg, leg tenderness, increased warmth in the affected leg, changes in the coloration (red) of the affected leg, venous distension (often visible or noticeable by touch), 

Diagnosis:

Diagnostic radiological tests are standard protocol for the diagnosis and assessment of deep venous thrombosis.

These tests include contrast venography, duplex ultrasonography, impedance  plethysomography and MRI.

Treatment:

The main treatment for deep venous thrombosis has been the use of the blood thinner Heparin. This is started immediately, often through inter-venous application.  Within a few days another anticoagulant drug called warfarin is administered. Heparin and warfarin are used together for several days, then warfarin is continued, often for months.

After the resolution of the clot, standard patient treatment protocol will focus on the initial cause of the thrombosis.

Prognosis:

The patient recovery expectation is excellent as most thrombosis disappear without difficulty.  However, they may reoccur therefore it is critical that the patient has long term follow up.  It may also be necessary to continue preventative drug therapy for an extended period of time.

WARNING

If you have sudden unexplained swelling (especially of the legs)
you must let your doctor know as it could be caused from a blood clot
which untreated can be fatal.

----------------------------------------------------------------------

Blood Clots

Deep Venous Thrombosis (DVT) & Blood Clots in Lymphedema

Discussion

Venous thrombosis is a serious and life threatening potential complication of lymphedema,, especially in stages 2 and 3 where the fibrosis is extensive.

Simply defined venous thrombosis or blood clot is where there is a rapid coagulation of blood due to either sluggish
blood flow  or from a cut off of blood flow. (See Lymphedema Stages)

A blood clot will be immediately quite painful, can cause a profound change in the coloration of the limb to dark pink or purplish, and cause a localized bulge or increased edema.

The three biggest causes of these clots are fibrosis and its affect on the vascular system and blood flow, infections such a recurrent cellulitis and lymphangitis, and cut off of circulation in long airlines flights or even automobile trips.

When you travel you should from time to time get up and "stretch" your legs allowing the circulation to move.


Prevention of Deep Venous Thrombosis in Lymphedema Patients

Obtain systematic and consistent decongestive therapy  to decrease, and control the lymphedema.  This will help prevent fibrosis which is a prime factor in deep venous thrombosis.

When traveling any distance, move around, walk, stretch.  While you are sitting move your legs around from time to time.

Undertake proper skin care  to prevent cracks, wounds, peeling or drying out of the skin. This will help prevent cellulitis, another factor in DVT.

Depending on accompanying medical conditions, if you do have cellulitis, lymphangitis or any other type of infection and especially if you are bed ridden, discuss with your physician the possible use of heparin or another blood thinner  to temporarily decrease the risk.

Follow a sensible and healthy diet that will help prevent cardiovascular difficulties.  This is good common sense even if you do not have lymphedema.

Deep Venous Thrombosis - Airline Traveling Tips    

Wear loose, comfortable clothing and avoid tight stockings.   

Drink enough water or non-alcoholic beverages during flights  (2 dl per hour).   

Be careful that the space for the legs in front of the seat is not blocked by hand luggage.   

Avoid sleeping in an uncomfortable position and be careful with sleeping drugs.   

Limiting the length of time you sit still can reduce the possibility of circulatory problems, particularly traveler's thrombosis. Simple exercises (stretching and moving arms and legs and ankles) can help. 

The risk of thrombosis is elevated for persons with a history of thrombosis and pulmonary embolism. These people should consult their doctor in advance of a flight. She/he will instruct them concerning the use of elasticised low-compression stockings and/or the need of specific medication (low molecular heparins).  

Talk with your healthcare provider about taking aspirin for its blood-thinning properties. 

A short walk at transit stations and after landing to stimulate circulation is recommended           

Treatment of Deep Venous Thrombosis in Lymphedema Patients

The main treatment for DVT in lymphedema patients will be the same as for the general population.  This has traditionally involved the usage of blood thinners, typically heparin.  This drug acts as not just a thinner, but also an anticoagulant.  Several days therapy with heparin is started another drug called Warfarin is used. Whereas this drug usually takes several days to become effective both are used for a short period of time.

Deep Venous Thrombosis

Due to the potential complication of deep venous thrombosis (blood clots) in lymphedema below are some info articles on this.

If you have sudden unexplained swelling (especially of the legs) you must let your doctor know as it could be caused from a blood clot which untreated can be fatal.

Tips on Treament of Lymphedema with Deep Venous Thrombosis

WARNING:

If you recently had or currently have a blood clot, DVT, thrombosis, in other words a vascular blockage in any form, you must not have lymphedema massage physiotherapy.  This is critical as the massage could potentially cause the clot to break loose and travel to your heart or lungs.

Compression garments - It is also important to remember that the compression strength for DVT versus lymphedema is different.  You will need to wear the compression hosiery for DVT, which is the most life threatening condition.

Compression Pneumatics Pumps - Under no circumstance should any pneumatic compression device be used if you have DVT, or a clot of any type.

--------------------------------------

Deep Venous Thrombosis

Gisele de Azevedo Prazeres

Diagnosis

Three tests have good accuracy for diagnosing Deep Vein Thrombosis (DVT) in symptomatic patients : venography, impedance plethismography (IPG) and duplex venous ultrasound (B - mode imaging ). In most patients with clinically suspected venous thrombosis, venous ultrasound is the diagnostic method of choice.

In addition, the simpli -red -D-dimer test, which is performed on blood obtained by finger prick at the patient’s side and which has high sensitivity and moderate specificity, shows considerable promise as a test to rule out venous thrombosis. The D-dimer test is often false-positive after surgery or trauma, thereby limiting its value in these clinical situations

Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are also useful in some circumstances (see TABLE 1 ). Venography, although invasive, is the “gold standard” diagnostic procedure, and the best noninvasive substitute for venography is duplex ultrasound.

TABLE 1

Exam Main use
Venography Considered “gold standard”. Used when other
test results are not conclusive
Duplex ultrasound Most sensitive for thrombosis above the knee
MRI, Contrast CT Most sensitive for thrombosis of pelvic veins
IPG Good alternative to duplex ultrasound, but
less specific/sensitive

Differential Diagnosis

There are many other conditions that cause localized pain or edema in the lower extremities, and may be confused with DVT. These differential diagnosis include: ruptured popliteal synovial membrane or cyst (Baker’cyst), ruptured calf muscles or tendons, a severe muscle cramp, cellulitis and lymphedema. The examiner should be attempt to the patient’s history and physical signs, because in the situations described above some signs of DVT may be present but not all of them, and in each one of these conditions the management is different.

Complications

Pulmonary embolism (PE ) is a serious and frequent complication of DVT. Pulmonary emboli are detected by perfusion lung scanning in approximately 50% of patients with documented DVT, and asymptomatic venous thrombosis is found in 70% of patients with confirmed clinically symptomatic PE. Although DVT may begin frequently in the veins of the calf, it is only when the thrombosis extends above the knee that serious pulmonary embolism occurs.

Postthrombotic syndrome occurs in about 25% of cases. It is caused by venous hypertension, which occurs as a consequence of recanalization of major venous thrombi leading to patent but scarred and incompetent valves, or less frequently, persistent outflow obstruction produced by large proximal vein thrombi. This high pressure results in edema and impaired viability of subcutaneous tissues and, in its most severe forms, ulceration of venous origin.

In patients with extensive thrombosis involving the ileofemoral veins, swelling may never disappear, while in patients with less severe proximal vein thrombosis, swelling may subside after the initial event but may return in the next few years. Other manifestations of postthrombotic syndrome are pain in the calf relieved by rest and elevation of the leg, pigmentation and induration around the ankle and the lower third of the leg, and, less commonly venous claudication, a bursting calf pain that occurs during exercise (mainly in ileofemoral thrombosis).

The diagnosis of postthrombotic syndrome is sometimes obvious on clinical grounds if the symptoms are gradual in onset. However, patients can have subacute symptoms of leg pain and swelling, which may mimic acute recurrence of DVT. Although these symptoms are usually superimposed on a background of chronic pain and swelling, it may be difficult to exclude acute recurrence on clinical grounds alone, and a diagnosis of postthrombotic syndrome as the cause of the patient’ symptoms can be made only after acute recurrent venous thrombosis has been excluded (the best exam to do this is MRI ).

Treatment

As soon as the diagnosis of DVT has been made, treatment (which consists of anticoagulation ) should begin, in the way to prevent local extension of the thrombus, prevent the thrombus from embolizing, and, in certain clinical circumstances, accelerate fibrinolysis. Full anticoagulation is the best treatment for DVT. Heparin is preferred to initiate treatment because of its immediate action, whereas warfarin-type drugs may not become fully effective for a considerable period of time. See TABLE 2 with the guidelines for use of anticoagulants in the treatment of DVT. Furthermore, patients should be encourage to use graduated compression stockings after the acute episode of DVT to prevent postthrombotic syndrome.

TABLE 2

Treatment of DVT
Bolus dose of heparin: 5000-10000 U EV
Initial maintenance dose of heparin: 32000 U EV per 24h by continuous
infusion or 17000 U subcutaneously to be repeated after adjustment at 12h
Adjust dose of heparin at 6h according to normogram. Maintain aPTT
2 times the control
Repeat aPTT 6 times every hour until in therapeutic range and then
daily (see nomogram)
Start warfarin 10mg at 24h and 10mg next day.
Overlap heparin and warfarin for at least 4 days
Perform PT daily and adjust warfarin dose to maintain INR at 2.0-3.0
Continue heparin for a minimum of 5 days, then stop if INR has been in
therapeutic range for at least 2 consecutive days.
Continue warfarin for 3 months and monitor PT daily until in therapeutic
range, then 3 times during first week, twice weekly for 2 weeks , or until
dose response is stable, and then every 2 weeks
Obtain pretreatment hemoglobin level, platelet count, PT, and aPTT.
Repeat platelet count daily until heparin stopped.
aPtt= activated Partial Thromboplastin Time;PT= Prothrombin
time; INR= International Normalized Ratio

Prophylaxis

The most effective way of reducing death from PE and morbidity from postthrombotic syndrome is to institute primary prophylaxis in patients at risk for venous thromboembolism (VTE). Safe and effective forms of prophylaxis are available for patients at high risk, and primary prophylaxis is cost-effective.

Prophylaxis is achieved by either modulating activation of blood coagulation or preventing venous stasis The following prophylactic approaches are of proven value: low dose subcutaneous heparin, intermittent pneumatic compression of legs, oral anticoagulants, adjusted doses of subcutaneous heparin, (low doses which means 5000u every 12 hours), graduated compression stockings, and LMWH (low molecular weigh heparin). Antiplatelet agents such as aspirin are less effective for preventing VTE. See TABLE 3 with some clinical situations of risk for VTE and their suitable prophylaxis

Table 3

Risk for DVT Patients Recommendations
Low Risk Hospitalized medical patients without risk factors Ambulatory leg exercises
Surgical patients under age 40, surgery lasting < 30 minutes, no additional risk factors Ambulatory leg exercises
Moderate risk Hospitalized medical patients with one or more risk factors Low-dose heparin
Surgical patients over age 40 having abdominal or thoracic surgery lasting > 30 minutes Low-dose heparin
Neurosurgery or others patients with high bledding risk Intermittent pneumatic compression of legs
High risk Hip fracture Warfarin(low dose regimen)
Hip replacement Warfarin(low dose regimen) or LMWH
Knee replacement Warfarin(low dose regimen) and intermittent pneumatic compression of the legs
Open prostatectomy intermittent pneumatic compression of the legs
Ginecology Malignancy Intermittent

References

Kontos H.A.: Vascular diseases of the limbs. In: Bennett J.C., Plum F.[eds].Cecil Textbook of Medicine, pp. 353-356. W.B.Saunders Company, 1996
Creager M.A., Dzau V.J.:Vascular Diseases of the Extremities. In: Isselbacher K.L., Braunwald E., Wilson J.D., Martin J.B., Fauci A.S., Kasper D.L. [eds]. Harisson’s Principles of Internal Medicine, pp. 1140-1142. Mc Graw Hill, 1994.
Goldhaber S.Z. : Deep Vein Thrombosis and Pulmonary Embolism. Harvard Medical School - Board Review Course, 1996.
Hirsh J., Hoak J.: Management of Deep Venous Thrombosis and Pulmonary Embolism. In Circulation, 1996; 93: 2212-2245.

http://www.medstudents.com.br/medint/medint5.htm

Medstudents 
-----------------------------------------------------------

Compression Stocks and Deep Venous Thrombosis

Stockings to prevent edema in Post thrombotic Syndrome

Medscape

Wearing below-knee stockings after deep vein
thrombosis (DVT) reduced the incidence of complications from post-
thrombotic syndrome (PTS) by nearly 50% for up to two years,
according to the results of a randomized trial published in the Aug.
17 issue of the Annals of Internal Medicine. The editorialist gives a
practical approach.

"Because only limited evidence suggests that elastic stocking prevent
the post-thrombotic syndrome in patients with symptomatic deep venous
thrombosis (DVT), these stockings are not widely used," write Paolo
Prandoni, MD, PhD, from the University Hospital of Padua in Italy,
and colleagues.

One third to one quarter of patients with DVT develop complications
including swelling, skin discoloration and numbness, chronic pain,
induration of the skin, and leg ulcerations. Elastic compression
stockings exert graduated pressure on the lower leg and can be
purchased in medical supply stores for U.S. $30 to $50.

In this study, 180 patients diagnosed with a first episode of DVT
were randomized before discharge to wear below-knee graded
compression elastic stockings (30 to 40 mm Hg at the ankle) every day
for two years or to not wear these stockings. All patients also
received appropriate anticoagulant therapy for DVT and were followed
up for up to five years. PTS severity was scored using a standardized
scale.

After two years, the group wearing compression stockings had
developed fewer post-thrombotic complications, which occurred in 44
(49%) of 90 controls (severe in 10) and in 23 (26%) of 90 patients
wearing elastic stockings (severe in 3). The overall incidence of
complications was reduced from 49% to 26%, and the incidence of
severe complications was reduced from 12% to 3.5%. However, the
stockings did not reduce recurrent episodes of DVT.

The cumulative incidence of PTS in the control group vs the stocking
group was 40.0% (95% confidence interval [CI], 29.9% to 50.1%) vs
21.1% (95% CI, 12.7% to 29.5%) after six months, 46.7% (95% CI, 36.4%
to 57.0%) vs 22.2% (95% CI, 13.8% to 30.7%) after one year, and 49.1%
(95% CI, 38.7% to 59.4%) vs 24.5% (95% CI, 15.6% to 33.4%) after two
years. Compared with the control group, the hazard ratio for PTS in
the elastic stockings group was 0.49 (95% CI, 0.29 to 0.84; P = .01)
after adjustment for baseline characteristics.

Study limitations were lack of double-blind design and inability to
explain the mechanism of reduced risk of PTS.

New Medical Service, Linea Flebologica Flebysanin in Rovigo, Italy,
supported this study. The authors report no potential financial
conflicts of interest.

In an accompanying editorial, Jeffrey S. Ginsberg, MD, FRCPC, from
McMaster University in Hamilton, Ontario, offers a practical
approach, and Dr. Ginsberg recommends that stocking therapy be
routinely offered after DVT.

"The stockings are sometimes hard to get on; some find them
unattractive, and if the patient has only mild ankle swelling at the
end of the day, frequently elevating the legs or avoiding long bouts
of standing or sitting might be enough to reduce the symptoms," Dr.
Ginsberg says. "Still, elastic compression stockings are a relatively
inexpensive, noninvasive way to reduce risk of complications from
DVT, and physicians and patients should consider them."

Dr. Ginsberg notes that severe symptoms usually indicate extensive
thrombus, causing massive edema, for which a lightweight stocking
such as support hose may be useful until the edema resolves.

"If symptoms persist or worsen despite these measures, or ulceration
seems imminent (as evidenced by severe skin changes), a full-strength
stocking (30 to 40 mm Hg of pressure at the ankle) can be
prescribed," Dr. Ginsberg writes. "However, if symptoms subside and
the patient remains asymptomatic or has only trivial persistent signs
or symptoms with little or no effect on quality of life (for example,
venous ectasia or mild ankle swelling at the end of the day),
stockings can be avoided and the patient can be followed for
clinically important signs and symptoms of the post-thrombotic
syndrome."

Dr. Ginsberg has received a Career Investigator Award from the Heart
and Stroke Foundation of Ontario. The author reports no potential
financial conflicts of interest.

Ann Intern Med. 2004;141:249-256, 314-315

http://www.medscape.com/viewarticle/487691?src=mp

-----------------------------------------------------

Medical Encyclopedia

Venous blood clot

Venous blood clot

Deep venous thrombosis (DVT) affects mainly the veins in the lower leg and the thigh. It involves the formation of a clot (thrombus) in the larger veins of the area.

Update Date: 3/23/2001

Updated by: A.D.A.M. Medical Illustration Team

Medline Plus Medical Encyclopedia

National Institutes of Health

http://www.nlm.nih.gov/medlineplus/ency/article/000156.htm

-----------------------------------------------------------------------

Medical Encyclopedia

Deep venous thrombosis, ileofemoral

Deep venous thrombosis, ileofemoral

This picture shows a red and swollen thigh and leg caused by a blood clot (thrombus) in the deep veins in the groin (ileofemoral veins) which prevents normal return of blood from the leg to the heart.

Update Date: 1/17/2004

http://www.nlm.nih.gov/medlineplus/ency/article/000156.htm

--------------------------------------------------------

Diagnostic Imaging of Lower Limb Deep Venous Thrombosis

THOMAS J. BARLOON, M.D., GEORGE R. BERGUS, M.D., and JAMES E. SEABOLD, M.D.
Departments of Radiology and Family Medicine
University of Iowa College of Medicine
Iowa City, Iowa

Figure 1

------------------------------------------

Pathogenesis of Lower Deep Venous Thrombosis

Figure 1
FIGURE 1. Anatomy of the deep venous system of the lower limb, using the nomenclature given in Nomina Anatomica.


FIGURE 2. Thrombus formation on a venous valve cusp. (A) Normally, blood flow (straight arrows) proceeds through the valve with the formation of eddy currents (curved arrows). (B) A clot nidus may form on the valve cusp in the setting of stasis. (C) The clot may then extend into the venous lumen.

 

                 

 

 

 

 

 

 

 

 

 

 

 

--------------------------------------------------------

Venous thrombosis and thromboprophylaxis

Pathophysiology

Risk factors for venous thrombosis

Patient Factors Disease or surgical procedure
Age Trauma or surgery esp. pelvis, hip, lower limb
Obesity Malignancy
Varicose veins Heart failure
Immobility Recent myocardial infarction
Pregnancy Lower limb paralysis
Puerperium Infection
High-dose oestrogen therapy Inflammatory bowel disease
Previous DVT or PE Nephrotic syndrome
Thrombophilia: Polycythaemia
Antithrombin III deficiency Paraproteinaemia
Protein C deficiency Paroxysmal nocturnal haemoglobinuria
Protein S deficiency Behcet's disease
Antiphospholipid antibody Homocystinuria
Lupus anticoagulant  

Epidemiology of DVT and pulmonary embolus

 

Calf DVT

Proximal DVT Fatal PE
Low risk group <10% <1% 0.01%
Moderate risk group 10-40% 1-10% 0.1-1%
High risk group 40-80% 10-30% 1-10%

Risk of venous thrombosis during surgery

Prevention of thromboembolism

Prevention of stasis

Pharmacologically reduce hypercoagulable state

Heparin

Warfarin

New drugs

THRIFT recommendations

Current recommendations for DVT prophylaxis

Investigation of suspected DVT

D-dimers

Venography

Ultrasound

Treatment of venous thrombosis

Anticoagulation

Surgical thrombectomy

Pulmonary embolism

Clinical presentation

Symptoms Signs
Dyspnoea Low grade pyrexia
Pleuritic chest pain Central cyanosis
Haemoptysis Tachycardia
  Tachypnoea
  Hypotension
  Neck vein distension
  Pleural rub
  Increased pulmonary second sound

Investigations of possible pulmonary embolus

Management of pulmonary embolus

Inferior vena caval filters

http://www.surgical-tutor.org.uk/default-home.htm

--------------------------------------------------------

Abstracts and Studies

-----------------------------------------------------------

Concorde Deep Venous Thrombosis and Edema Study: prevention with travel stockings

Abstract

A San Valentino Vascular Screening Project, Department of Biomedical Sciences, Irvine2 Vascular Laboratory, G D'annunzio University, Chieti, Italy.

BACKGROUND: The LONFLIT1+2 studies have established that in high risk subjects after long flights (> 10 hours) the incidence of deep venous thrombosis (DVT) is between 4% and 6%. The LONFLIT4 study was designed to evaluate the control of edema and DVT in low-medium risk subjects. The aim of this study was to evaluate edema and its control with specific stockings (ankle pressure between 20 and 30 mm Hg) in long-haul flights. The first part of the study included flights lasting 7-8 hours and the second part included flights lasting 11-12 hours. Ultrasound scans were used to assess thrombosis before and after the flights and a composite edema score was used to evaluate edema and swelling. A group of patients with microangiopathy associated to edema (diabetes, venous hypertension, anti-hypertensive treatment) were also included to evaluate the preventive effects of stockings during flight. Part I: DVT evaluation: Of the 74 subjects in the stocking group and 76 in the control group (150), 144 completed the study. Dropouts were due to low compliance or traveling and connection problems. Age and gender distribution were comparable in the 3 groups as was risk factor distribution. In this part of the study there were no DVTs.

Edema Evaluation: The level of edema at inclusion was comparable in the two groups of subjects. After the flight there was an average score of 6.9 (1) in the control group. In the stocking group, the score was on average 2.3 (1), three times lower than in the control group (p < 0.05). 

Part II: 

DVT evaluation: Of the 66 included subjects in the stocking group and 68 in the control group (134), 132 completed the study. Dropouts were due to low compliance or connection problems. Age and gender distribution were comparable in the two groups. In the stocking group no DVT was observed. In the control group, 2 subjects had a popliteal DVT and 2 subjects had superficial venous thrombosis (SVT); in total 4 subjects (6%) in the control group had a thrombotic event; the incidence of DVT was 3%. The difference (p < 0.02) is significant. 

EDEMA EVALUATION: The composite edema score at inclusion was comparable in the two groups. After the flight there was a score of 7.94 (2) in the control group, while in the treatment group the score was 3.3 (1.2). 

MICROANGIOPATHY STUDY: In all these subjects, the level of edema was very high in the control group and significantly lower in the compression stocking group. Stockings are effective in controlling edema during flights even in subjects with microangiopathy and edema. Compression was well tolerated in normal subjects and in patients. 

CONCLUSION: The Kendall Travel Socks (Tyco Healthcare, Mansfield, MA, USA) which provide 20-30 mm Hg pressure at the ankle, are effective in controlling edema and reducing the incidence of DVT in both low-medium-risk subjects and in patients with microangiopathy and edema in long-haul flights (7-11 hours).

Publication Types:


PMID: 12678188 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12678188&dopt=Abstract

-------------------------------------------------------------------

Flight microangiopathy on long-haul flights: prevention of edema and microcirculation alterations with Venoruton.

Cesarone MR, Belcaro G, Geroulakos G, Griffin M, Ricci A, Brandolini R, Pellegrini L, Dugall M, Ippolito E, Candiani C, Simeone E, Errichi BM, Di Renzo A.

Irvine2 Vascular Laboratory, Department of Biomedical Sciences, Chieti University, Italy.

The aim of this study was the evaluation of the effects of Venoruton (HR) on the prevention and control of flight microangiopathy and edema in subjects with varicose veins flying for more than 7 hours. A group of 80 patients with varicose veins, edema, and initial skin alterations due to chronic venous hypertension were included. Measurements of skin laser Doppler (LDF) resting flux (RF), PO2 and rate of ankle swelling (RAS), were made before and after the flights (within 2 hours before the flights and within 2 hours after the flights). The length of the flights was between 7 and 9 hours; all seats were in coach class. The two groups (treatment and control) were comparable for age and sex distribution. The variation (decrease) in PO2 was significant in both groups. In subjects treated with HR the decrease in PO2 was smaller (p < 0.05). The decrease in LDF-RF was significant in both groups with a higher flux at the end of the flight in the treated subjects (p < 0.05). The venoarteriolar response was decreased at the end of the flights. The decrease was less evident in the treatment group (p < 0.05). The increase in RAS was significant in the control group while it was limited in the HR group. In conclusion, HR is useful for reducing the increased capillary filtration and in controlling edema in patients with chronic venous disease in long-haul flights. HR is effective to control flight microangiopathy associated with edema.

Publication Types:

PMID: 12812378 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12812378&itool=iconabstr

-------------------------------------------------------------------

Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial.

Scurr JH, Machin SJ, Bailey-King S, Mackie IJ, McDonald S, Smith PD.

Department of Surgery, Royal Free and University College Medical School, London, UK. medleg@mailbox.co.uk

BACKGROUND: The true frequency of deep-vein thrombosis (DVT) during long-haul air travel is unknown. We sought to determine the frequency of DVT in the lower limb during long-haul economy-class air travel and the efficacy of graduated elastic compression stockings in its prevention. METHODS: We recruited 89 male and 142 female passengers over 50 years of age with no history of thromboembolic problems. Passengers were randomly allocated to one of two groups: one group wore class-I below-knee graduated elastic compression stockings, the other group did not. All the passengers made journeys lasting more than 8 h per flight (median total duration 24 h), returning to the UK within 6 weeks. Duplex ultrasonography was used to assess the deep veins before and after travel. Blood samples were analysed for two specific common gene mutations, factor V Leiden (FVL) and prothrombin G20210A (PGM), which predispose to venous thromboembolism. Asensitive D-dimer assay was used to screen for the development of recent thrombosis. FINDINGS: 12/116 passengers (10%; 95% CI 4.8-16.0%) developed symptomless DVT in the calf (five men, seven women). None of these passengers wore elastic compression stockings, and two were heterozygous for FVL. Four further patients who wore elastic compression stockings, had varicose veins and developed superficial thrombophlebitis. One of these passengers was heterozygous for both FVL and PGM. None of the passengers who wore class-I compression stockings developed DVT (95% CI 0-3.2%). INTERPRETATION: We conclude that symptomless DVT might occur in up to 10% of long-haul airline travellers. Wearing of elastic compression stockings during long-haul air travel is associated with a reduction in symptomless DVT.

Publication Types:


PMID: 11377600 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11377600&itool=iconabstr

Comment in:

---------------------------

External Pnuematic Compression Device/Compression Stockings

EXCERPTS

Efficacy of Mechanical Prophylaxis for Venous Thromboembolism in Patients With Brain Tumors

Kurtis I. Auguste, M.D.; Alfredo Quiñones-Hinojosa, M.D.; Mitchel S. Berger, M.D.

Abstract and Introduction Abstract

Patients with brain tumors are at considerable risk for the formation of venous thromboemboli. One method of preventing these complications is mechanical prophylaxis in which an external pneumatic compression device and graduated elastic compression stockings are used.

Evidence indicates that these devices prevent deep venous thrombosis (DVT) and pulmonary embolism (PE) by limiting venous stasis and increasing fibrinolytic activity at both the local and systemic levels.

The authors present evidence for the occurrence of both mechanisms and discuss the use of mechanical compression in the setting of surgery for brain tumors. They also present data proving the efficacy of these devices in patients who undergo craniotomy with motor mapping for resection of glioma and in whom the contralateral leg receives no prophylaxis.

Finally, they comment on the use of anticoagulation therapy both in addition to and in place of mechanical prophylaxis.

Introduction

The incidence of DVT in neurosurgical patients ranges between 2 and 50%.[1,5,10,12,19,23,27,40,47,48,51,53] The rate of DVT and PE is thus quite significant and can lead to fatal outcomes. Neurosurgical procedures entail a 1.5 to 5% risk of PE and a 9 to 50% rate of mortality from this disorder.[23]

The prevention of VTE in neurosurgery by using mechanical prophylaxis is well established. Current modalities for mechanical prophylaxis involve pneumatic compression devices, graduated elastic compression stockings, or a combination of both.

Prevention of VTE by using mechanical devices addresses tenets of the Virchow[54] triad: endothelial damage, venous stasis, and hypercoagulability.

Mechanical prophylaxis appears to prevent thromboembolic complications by limiting venous stasis and diminishing hypercoagulability.

Pneumatic Compression Devices

External pneumatic compression devices have been shown to prevent the formation of DVTs in neurosurgical patients.[47,50,51] Modern devices evacuate blood from lower-extremity vessels in an automated fashion. In brief, a microprocessor directs pressurized air (for example, at 45 mm Hg) into segmental diaphragms secured around the leg for a fixed period of time (for example, for 11 seconds).

[30] The compression is delivered in a sequential manner up the leg, producing a wavelike milking effect to evacuate leg veins. Sequential devices have been proven to be more effective than single-chamber, evenly distributed pressure in preventing DVTs.[37] The compression is set to cycle regularly (for example, every 60 seconds). Devices are available for feet, calves, and/or thighs.

Published contraindications for the use of these devices include: dermatitis

postop vein ligation - gangrene - recent skin graft - severe ischemic vascular disease

severe lower extremity edema - extreme leg deformity - suspected preexisting DVT

Pneumatic compression may exert its protective effect against thrombus formation in part by limiting venous stasis. Calnan, et al.,[11] were one of the first groups to illustrate that intermittent, rhythmic compression of the lower extremity mimics the normal pumping of calf muscles. Soon after, Sabri, et al.,[42] demonstrated a 400% increase in femoral vein pulsatility and a 250% increase in peak femoral venous blood flow when the devices were applied to the lower limbs of greyhound dogs.

Comparable results were found in the lower extremities of humans who received pneumatic compression.[41] In more modern studies investigators have shown increased blood flow velocities in the popliteal and common femoral veins by applying intermittent pneumatic compression to the foot alone.[31] Mittel man, et al.,[36] compared the use of calf and thigh compression with calf compression alone and found an enhanced effect of blood clearance with sequential compressions of the calf and thigh.

Similarly, Delis, et al.,[16] found greater outflow during foot plus calf compression when comparing it with foot compression alone. Current prophylactic devices most frequently compress at least two regions of the lower extremity, although more limited devices have retained some popularity.

Mechanical compression devices appear to exert part of their prophylactic effect through enhanced fibrinolysis.[14,25,49]

Early studies in which euglobulin clotting times were analyzed as a marker for systemic fibrinolysis activity in postoperative patients demonstrated that calf compression augments clot breakdown.[3,33,43] Weitz, et al.,[55] showed that intermittent pneumatic calf compression, by preserving the normal thrombin/plasmin ratio in blood samples obtained in patients who receive this therapy when compared with those not receiving pneumatic compression, averts the hypercoagulable state noted by Owen, et al.[39] Intermittent pneumatic compression has been shown to increase the amount of tPA release and to de crease levels of plasminogen activator inhibitor.[25]

This benefit may be short-lived, however; diminished fibrinolytic activity is seen from several minutes[25] to 18 hours[33] after discontinuation of pneumatic compression.

Various permutations of both upper- and lower-extremity compression have been tested to increase blood clearance and ultimately prevent VTEs. Nearly 30 years ago, Knight and Dawson[33] conducted a study in which they applied intermittent compression to the upper extremities of patients who had undergone surgery, and noted a reduced incidence of DVTs in the legs and increased serum fibrinolytic activity.

Tarnay, et al.,[49] also showed increased fibrinolysis in patients receiving compression in the arms, although this difference was not statistically significant. Another interesting finding of this study was the increased fibrinolysis detected in serum samples obtained in the patient's arm after administration of pneumatic compression to the legs. This effect appeared to be proportional to the volume of tissue compressed; increased fibrinolysis was detected in patients who wore long compression boots when compared with those given shorter boots.

The results of these studies indicate that the fibrinolytic activity promoted by mechanical prophylaxis has both local and systemic effects in protecting against clot formation.

Compression Stockings

An alternative or additional means of preventing thromboembolic complications is the graduated elastic compression stocking.[2,24,26,45] These devices apply continuous circumferential pressure to the lower extremity in a graduated fashion (~18 mm Hg at the ankle to ~8 mm Hg at the thigh)[46] as a means of increasing venous clearance and preventing venous stasis.

The stockings are contoured to the lower extremity to prevent tenting and focal constriction. Similar care should be exercised in selecting patients to receive stockings as is taken in choosing patients for treatment with pneumatic devices. The contraindications listed in Table 1 can be applied for stocking use as well.

In most neurosurgical practices, compression stockings are combined with pneumatic devices as a standard of care, presumably to enhance the prophylactic benefit of each. To test the theory that the protective effect of these devices is additive, Keith, et al.,[29] used Doppler ultrasonography imaging to measure the peak venous velocities produced in superficial femoral veins by the individual and simultaneous use of graduated compression stockings and intermittent pneumatic compression boots.

Although their study was not designed to consider the effect on thrombosis formation, blood flow velocity served as a surrogate measure for the limited stasis and venous evacuation that could ultimately lead to the formation of thromboses. The results showed no synergistic effect on venous out flow when these devices were used simultaneously.

Two separate groups performed direct comparisons between compression stockings and pneumatic devices to assess the effectiveness of these modalities in reducing the risk of venous thrombosis.[9,52] Based on their results, stockings appear to be as effective in VTE prevention as pneumatic compression devices, and stockings have the added benefit of lower cost.

Patients also suffer less discomfort with stockings when compared with the pressure associated with intermittent leg compressions from pneumatic devices. In addition, the garments do not require assembly once fitted, are not subject to malfunction or trouble shooting, and facilitate patient mobility and ambulation during the postoperative recovery period.

Despite these findings, the combined approach in which both stockings and pneumatic devices are used remains popular, likely because of their relative ease of application or simply out of habit. Cost-conscious healthcare may limit their combined use in the future.

In the meantime, practitioners should not be overly concerned when discomfort leads to discontinuation of pneumatic compression; these patients are not at any proven risk as long as they continue to use their compression stockings.

Conclusions

Mechanical prophylaxis for thromboemboli is an integral part of modern neurosurgical practice. It remains an effective means of preventing DVT and PE, both intra- and postoperatively.

Compression stockings and pneumatic devices are relatively equivalent in their prevention of VTE. Their effectiveness is not diminished when one leg is not treated with compression during motor mapping.

Concomitant anticoagulation therapy during the postoperative period appears not only to be safe but also to protect patients further against thromboembolic complications

Neurosurg Focus 17(4), 2004.

Thanks to MEDSCAPE.com

--------------------------------------------------------

External Links

Low serum iron levels are associated with elevated plasma levels of coagulation factor VIII and pulmonary emboli/deep venous thromboses in replicate cohorts of patients with hereditary haemorrhagic telangiectasia. Dec 2011

http://www.ncbi.nlm.nih.gov/pubmed/22169361

-----------------------------------------------------------

Soluble p-selectin, D-dimer, and high-sensitivity C-reactive protein after acutedeep vein thrombosis of the lower limb. Dec 2011

http://www.jvascsurg.org/article/S0741-5214(11)01340-1/abstract

----------------------------------------------------------

Deep vein thrombosis after total knee or hip arthroplasty is associated with increased preoperative calf muscle deoxygenation as measured by near-infrared spectroscopy. Dec 2011

http://www.jvascsurg.org/article/S0741-5214(11)01331-0/abstract

----------------------------------------------------------

Postthrombotic syndrome and quality of life in patients with iliofemoral venous thrombosis treated with catheter-directed thrombolysis.

http://www.jvascsurg.org/article/S0741-5214(11)01383-8/abstract

----------------------------------------------------------

Deep Venous Thrombosis and Thrombophlebitis

Last Updated: January 14, 2002

Author: Donald Schreiber, MD, CM, Assistant Professor of Surgery, Stanford University School of Medicine; Research Director, Division of Emergency Medicine, Stanford University Hospital

http://www.emedicine.com/emerg/topic122.htm

-----------------------------------------------------------

Treatment of Calf Deep Venous Thrombosis  - DVT

http://www.aafp.org/afp/2005/0601/p2157.html

-----------------------------------------------------------

Deep venous thrombosis

Medline Plus Medical Encyslopedia

http://www.nlm.nih.gov/medlineplus/ency/article/000156.htm

-----------------------------------------------------------

Deep Venous Thrombosis

http://www.healthinaging.org/public_education/pef/deep_venous_thrombosis.php

-----------------------------------------------------------

Deep Venous Thrombosis, Lower Extremity

Author: Robert D Bloch, MD, PhD, Assistant Professor, Department of Interventional and Endovascular Therapy, Southwest Washington Medical Center

http://www.emedicine.com/radio/topic773.htm#section~differe

ntials

-----------------------------------------------------------

Deep Vein Thrombosis - Topic Overview

http://www.webmd.com/dvt/tc/deep-vein-thrombosis-topic-overview

-----------------------------------------------------------

Deep vein thrombosis (DVT)

http://www.mayoclinic.com/health/deep-vein-thrombosis/DS01005

-----------------------------------------------------------

Upper-Extremity Deep Vein Thrombosis

http://circ.ahajournals.org/content/106/14/1874.full

-----------------------------------------------------------

Venous thromboembolism in hospitalised patients: a public health crisis?

April 2008

Blackwell Synergy

-----------------------------------------------------------

Pleural mesothelioma and venous thrombosis: the eosinophilia link

2008.

Thrombosis Journal

-----------------------------------------------------------

Diagnostic role of 64-slice multidetector row CT scan and CT venogram in cases of cerebral venous thrombosis.

2008

SpringerLink

-----------------------------------------------------------

The incidence of venous thromboembolism after oncologic head and neck reconstruction.

May 2008

Annals of Plastic Surgery

-----------------------------------------------------------

Distal deep-venous thrombosis: Diagnostic and therapeutic issues

April 2008

Elsevier ScienceDirect

-----------------------------------------------------------

Antiplatelet drugs for polycythaemia vera and essential thrombocythaemia

April 2008

Cochrane Library

-----------------------------------------------------------

Management of mesenteric vascular occlusion

April 2008

Singapore medicine

-----------------------------------------------------------

Prophylactic implantation of inferior vena cava filter during endovascular therapies for deep venous thrombosis of the lower extremity: is it necessary?

May 2008 

Pub Med

http://www.ncbi.nlm.nih.gov/pubmed/18415781

=======================================================

ICD-10 and ICD-9

I80 

Phlebitis and thrombophlebitis
Includes: endophlebitis
inflammation, vein
periphlebitis
suppurative phlebitis
Use additional external cause code (Chapter XX), if desired, to identify drug, if drug-induced.
Excludes: phlebitis and thrombophlebitis (of):
· complicating:
  · abortion or ectopic or molar pregnancy ( O00-O07 , O08.7 )
  · pregnancy, childbirth and the puerperium ( O22.- , O87.- )
· intracranial and intraspinal, septic or NOS ( G08 )
· intracranial, nonpyogenic ( I67.6 )
· intraspinal, nonpyogenic ( G95.1 )
· portal (vein) ( K75.1 )
postphlebitic syndrome ( I87.0 )
thrombophlebitis migrans ( I82.1 )
I80.0 Phlebitis and thrombophlebitis of superficial vessels of lower extremities
I80.1 Phlebitis and thrombophlebitis of femoral vein
I80.2 Phlebitis and thrombophlebitis of other deep vessels of lower extremities
Deep vein thrombosis NOS
I80.3 Phlebitis and thrombophlebitis of lower extremities, unspecified
Embolism or thrombosis of lower extremity NOS
I80.8 Phlebitis and thrombophlebitis of other sites
I80.9 Phlebitis and thrombophlebitis of unspecified site
I81 Portal vein thrombosis
Portal (vein) obstruction
Excludes: phlebitis of portal vein ( K75.1 )
I81 Portal vein thrombosis
Portal (vein) obstruction
Excludes: phlebitis of portal vein ( K75.1 )
I82 Other venous embolism and thrombosis
Excludes: venous embolism and thrombosis (of):
· cerebral ( I63.6 , I67.6 )
· complicating:
  · abortion or ectopic or molar pregnancy ( O00-O07 , O08.7 )
  · pregnancy, childbirth and the puerperium ( O22.- , O87.- )
· coronary ( I21-I25 )
· intracranial and intraspinal, septic or NOS ( G08 )
· intracranial, nonpyogenic ( I67.6 )
· intraspinal, nonpyogenic ( G95.1 )
· lower extremities ( I80.- )
· mesenteric ( K55.0 )
· portal ( I81 )
· pulmonary ( I26.- )
I82.0 Budd-Chiari syndrome
I82.1 Thrombophlebitis migrans
I82.2 Embolism and thrombosis of vena cava
I82.3 Embolism and thrombosis of renal vein
I82.8 Embolism and thrombosis of other specified veins
I82.9 Embolism and thrombosis of unspecified vein
Embolism of vein NOS
Thrombosis (vein) NOS

2008 ICD-9-CM Diagnosis 453.40

Venous embolism and thrombosis of unspecified deep vessels of lower extremity

  • 453.40 is a specific code that can be used to specify a diagnosis
  • 453.40 contains 4 index entries
  • View the ICD-9-CM Volume 1 453.* hierarchy

453.40 also known as:

  • Deep vein thrombosis NOS
  • DVT NOS

=========================================================

See also:

Edema 

http://www.lymphedemapeople.com/wiki/doku.php?id=edema

Edema and Chronic Venous Insufficiency

http://www.lymphedemapeople.com/thesite/edema_chronic_venous_insufficiency.htm

Edema and Deep Venous Thrombosis

http://www.lymphedemapeople.com/thesite/lymphedema_deep_venous_thrombosis.htm

Edema and Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome

http://www.lymphedemapeople.com/thesite/edema_and_reflex_sympathetic_dystrophy.htm

Edema and Venous Pooling

http://www.lymphedemapeople.com/thesite/edema_and_venous_pooling.htm

Angioedema

http://www.lymphedemapeople.com/wiki/doku.php?id=angioedema

Edema of the Neck

http://www.lymphedemapeople.com/thesite/lymphedema_of_the_neck.htm

Edema and Nephrotic Syndrome

http://www.lymphedemapeople.com/thesite/edema_nephrotic_syndrome.htm

Edema of the Face

http://www.lymphedemapeople.com/thesite/edema_of_the_face.htm

Thrombophlebitis

http://www.lymphedemapeople.com/wiki/doku.php?id=thrombophlebitis

Edema and Diabetes

http://www.lymphedemapeople.com/thesite/lymphedema_and_diabetes.htm

===========================

Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

http://health.groups.yahoo.com/group/AdvocatesforLymphedema/

Subscribe: AdvocatesforLymphedema-subscribe@yahoogroups.com

Pat O'Connor

Lymphedema People / Advocates for Lymphedema

===========================

For information about Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema\

For Information about Lymphedema Complications

http://www.lymphedemapeople.com/wiki/doku.php?id=complications_of_lymphedema

For Lymphedema Personal Stories

http://www.lymphedemapeople.com/phpBB2/viewforum.php?f=3

For information about How to Treat a Lymphedema Wound

http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound

For information about Lymphedema Treatment 

http://www.lymphedemapeople.com/wiki/doku.php?id=treatment

For information about Exercises for Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=exercises_for_lymphedema

For information on Infections Associated with Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=infections_associated_with_lymphedema

For information on Lymphedema in Children

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_in_children

Lymphedema Glossary

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing

===========================

Lymphedema People - Support Groups

-----------------------------------------------

Children with Lymphedema

The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.

http://health.groups.yahoo.com/group/childrenwithlymphedema/

Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com

......................

Lipedema Lipodema Lipoedema

No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.

Come join, be a part of the family!

http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515

Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com

......................

MEN WITH LYMPHEDEMA

If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.

http://health.groups.yahoo.com/group/menwithlymphedema/

Subscribe: menwithlymphedema-subscribe@yahoogroups.com

......................

All About Lymphangiectasia

Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.

http://health.groups.yahoo.com/group/allaboutlymphangiectasia/

Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com

......................

Lymphatic Disorders Support Group @ Yahoo Groups

While we have a number of support groups for lymphedema... there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.

DISCRIPTION

Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People.

http://health.groups.yahoo.com/group/lymphaticdisorders/

Subscribe: lymphaticdisorders-subscribe@yahoogroups.com

===========================

Lymphedema People New Wiki Pages

Have you seen our new “Wiki” pages yet?  Listed below are just a sample of the more than 140 pages now listed in our Wiki section. We are also working on hundred more.  Come and take a stroll! 

Lymphedema Glossary 

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing 

Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema 

Arm Lymphedema  

http://www.lymphedemapeople.com/wiki/doku.php?id=arm_lymphedema 

Leg Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=leg_lymphedema 

Acute Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=acute_lymphedema 

The Lymphedema Diet 

http://www.lymphedemapeople.com/wiki/doku.php?id=the_lymphedema_diet 

Exercises for Lymphedema  

http://www.lymphedemapeople.com/wiki/doku.php?id=exercises_for_lymphedema 

Diuretics are not for Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=diuretics_are_not_for_lymphedema 

Lymphedema People Online Support Groups 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_people_online_support_groups 

Lipedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=lipedema 

Treatment 

http://www.lymphedemapeople.com/wiki/doku.php?id=treatment 

Lymphedema and Pain Management 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_and_pain_management 

Manual Lymphatic Drainage (MLD) and Complex Decongestive Therapy (CDT)

http://www.lymphedemapeople.com/wiki/doku.php?id=manual_lymphatic_drainage_mld_complex_decongestive_therapy_cdt 

Infections Associated with Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=infections_associated_with_lymphedema 

How to Treat a Lymphedema Wound 

http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound 

Fungal Infections Associated with Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=fungal_infections_associated_with_lymphedema 

Lymphedema in Children 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_in_children 

Lymphoscintigraphy 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphoscintigraphy 

Magnetic Resonance Imaging 

http://www.lymphedemapeople.com/wiki/doku.php?id=magnetic_resonance_imaging 

Extraperitoneal para-aortic lymph node dissection (EPLND) 

http://www.lymphedemapeople.com/wiki/doku.php?id=extraperitoneal_para-aortic_lymph_node_dissection_eplnd 

Axillary node biopsy 

http://www.lymphedemapeople.com/wiki/doku.php?id=axillary_node_biopsy

Sentinel Node Biopsy 

http://www.lymphedemapeople.com/wiki/doku.php?id=sentinel_node_biopsy

 Small Needle Biopsy - Fine Needle Aspiration 

http://www.lymphedemapeople.com/wiki/doku.php?id=small_needle_biopsy 

Magnetic Resonance Imaging 

http://www.lymphedemapeople.com/wiki/doku.php?id=magnetic_resonance_imaging 

Lymphedema Gene FOXC2

 http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_foxc2

 Lymphedema Gene VEGFC

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_vegfc

 Lymphedema Gene SOX18

 http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_sox18

 Lymphedema and Pregnancy

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_and_pregnancy

Home page: Lymphedema People

http://www.lymphedemapeople.com

Page Updated: Dec. 15, 2011