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At WoundCon Summer, Frank Aviles, Jr., PT shared what providers need to know about phlebolymphedema, a condition resulting from concurrently impaired venous and lymphatic systems. In order to better understand this pathology, one must also understand its individual components and characteristics.

Chronic venous insufficiency, he explained, can lead to lymphedema. Both venous insufficiency and lymphedema can lead to wounds. Accordingly, wounds can have components of both vein and lymphatic pathology. Therefore, phlebolymphedema treatment must consider both etiologies.1 Diagnosis of the vein component is usually via duplex ultrasound, while the lymphedema component diagnosis usually occurs via clinical assessment. In the case of phlebolymphedema, however, the failure of one system (venous) usually puts burden on the other (lymphatic). As a result, proper, timely diagnosis is key.^1,2

The swelling that patients with phlebolymphedema experience will often keep them from progressing past the inflammatory phase of healing. So, Mr. Aviles went on to discuss edema at the cellular level, as it impacts healing on many levels. First, consider perfusion versus oxygenation. A patient may indeed have normal arterial flow, but oxygenation can decrease in the context of edema, as it takes longer for the oxygen to get from the capillary to the skin, he said. Compression can help this circumstance. 

It is also important, he shared, to understand that edema and lymphedema are indeed different. Edema is water fluid that collects in tissues, with intact lymphatics. It is a symptom. Whereas, lymphedema is the same fluid, but protein-rich, in the context of lymphatic damage. This is a disease, he explained. All edema is interstitial fluid and lymphatic system is responsible for removing it, said Mr. Aviles. And, it is possible for a patient to have lymphatic dysfunction but not necessarily damage.

Important Aspects of Chronic Venous Insufficiency

Venous insufficiency characteristics shared by Mr. Aviles may include:

·      swelling in the legs or ankles

·      brown discoloration of the skin

·      achy or tired legs

·      tightness in the calf

·      leg pain relieved with elevation

Chronic venous insufficiency can lead to ulceration, of which he said 20 percent of these ulcers have a mixed arterial etiology. Management of chronic venous insufficiency may include lifestyle modification, compression, medication, and/or other nonsurgical or surgical approaches.

 The Basics of Lymphedema

Lymphedema can be classified in stages, explained Mr. Aviles:

·      Stage 0 – Presents as lymphangiopathy as pre-stage, latency phase. There is no visible swelling, but there is reduced transport capacity.

·      Stage 1 - (reversible) Characterized by soft, pitting edema reduced by elevation. There are no secondary skin changes evident.

·      Stage 2 – (spontaneously irreversible) In this stage, the skin hardens[FA2]  with time, pitting is difficult, and frequent infections may occur.

·      Stage3 - (lymphostatic elephantiasis) Here one will see skin breakdown, deepening of the natural skin folds, increase in limb size, and frequent infections.

Lymphedema can present on any part of the body, but most frequently in one or more extremities, the neck, or the thorax. He noted that if it is bilateral in presentation, it is usually asymmetric. Lymphedema can involve the external genitalia. He added that it can also result in cellulitis, infection, skin changes, ulceration, and/or[FA3]  lymphorrhea.

Lymphedema treatment can include the following, he explained:

·      Surgical approach

·      Complete Decongestive Therapy (CDT) – This is the gold standard, comprised of skin care, compression/bandaging, decongestive exercises, and manual drainage[FA4] .

·      Compression – Initially using short stretch bandages, then maintenance garments.

·      Hygiene

·      Exercise

·      Education

Concluding Thoughts

Overall, Mr. Aviles stressed that careful, timely, and accurate diagnosis of the etiology of edema, along with appropriate targeted interventions are key in achieving better outcomes for phlebolymphedema.

References

1.    Farrow W. Phlebolymphedema-a common underdiagnosed and undertreated problem in the wound care clinic. J Am Col Certif Wound Spec. 2010;2(1):14-23.

2.    Lee BB. Phlebolymphedema: neglected outcome of combined venous and lymphatic insufficiency. Editorial. Vascular Specialist Int. 2020;36(1):1-3.