Peripheral edema: causes, diagnosis and treatment with compression therapy.

Background

Peripheral edemas are very heterogeneous. Patients presenting with a swelling in one or more limbs are often misdiagnosed and not treated accordingly.

Causes

Peripheral edemas are of systemic or local origin. Systemic edema is caused by an underlying systemic disease (cardiac, renal, hepatic, endocrine, obesity). Local edema is caused by a primary or secondary failure of the vascular system in the limb (phlebedema & lymphedema; inflammatory, post-traumatic, arthrogenic, inactivity & orthostatic edemas). Special case: Lipedema (see below).

Underlying mechanisms

Capillary fluid exchange and lymphatic uptake are carefully regulated processes. In a healthy subject, filtration (F) is greater than reabsorption (R); excess fluid is taken up by the lymphatic system (LS). In peripheral edema, capillary fluid exchange and/or lymphatic uptake are dysfunctional; as a result, fluid accumulates in the interstitial space.

Pathophysiology

Underlying mechanisms of phlebedema, lymphedema & lipedema.

Phlebedema

Localized swelling caused by chronic venous insufficiency (impaired venous return; venous stasis & hypertension).

Lymphedema (primary/secondary)

Localized swelling caused by a compromised lymphatic system. Primary: congenital; secondary: acquired (after surgery, cancer treatment etc.).

Lipedema

Subcutaneous fat disorder primarily affecting the extremities. The symmetrical increase in fatty tissue is influenced by hormones.

Differential diagnosis

Please note that peripheral edemas are usually of mixed etiologies.

Treatment plan

Phlebedema

Conservative: compression therapy (usually circular knit compression garments).

Interventional procedures: vein stripping, sclerotherapy, thermal and
mechanical endovenous ablation.

Lymphedema

Step 1 - Volume reduction: complex physical decongestive therapy with MLD, compression therapy, skin care, physiotherapy.

Step 2 - Maintenance therapy: customized compression therapy (flat knit / adjustable compression wraps), supported by situation-dependent MLD.

Lipedema

Conservative: customized compression therapy, weight stabilization, exercise, body self-acceptance, MLD (lipolymphedema).

Interventional: liposuction. A conservative therapy must first be exhausted without success before a liposuction should be considered.

Compression therapy

Beneficial effects

• Reduction & prevention of edema
• Enhancement of venous & lymphatic flow
• Reduction of signs & symptoms; wound healing
• Improvement & prevention of skin conditions
• Reduction of mechanical impairment & pain (lipedema)
• Increase of physical activity & tissue stabilization (lipedema)

Mechanisms of action

Medical compression garments exert a controlled pressure on a limb, thereby improving the circulatory rate. Regarding edema reduction, compression therapy:

1. Decreases filtration
2. Increases lymph formation (interstitial fluid shift into the lymphatic system)
3. Increases lymphatic flow in functional lymphatic vessels
   (particularly in combination with exercise)

Conclusion

• In peripheral edema, fluid accumulates in the interstitium due to a dysfunctional capillary fluid exchange and/or a compromised lymphatic uptake.
• Depending on the underlying cause of fluid accumulation, different pathophysiological mechanisms take place that are specific to the edema in question.
  Individualized treatment plans are therefore required in each case.
• Compression therapy is the mainstay of treatment for the management of peripheral edema. Benefi cial effects include, among others, reduction & prevention of edema, enhancement of venous & lymphatic flow, reduction of signs & symptoms, and overall improvement in patient well-being.

Abbreviations: A, artery; C, capillary; F, filtration; I, interstitial space; L, lymphatic vessels; LS, lymphatic system; MLD, manual lymphatic drainage; PTS, post-thrombotic syndrome; R, reabsorption; V, vein.

References: SIGVARIS GROUP Schulung zu Lymphödem-Lipödem, andere Ödeme und die Kompressionstherapie, Dr. Stephan Wagner, 2021; SIGVARIS GROUP leaflet The Big Leg, Dr. Stefan Küpfer, FMH Consultant for Internal Medicine and Angiology (Bad Ragaz Vein Center), 2020; Peprah, K., & MacDougall, D. Liposuction for the Treatment of Lipedema: A Review of Clinical Effectiveness and Guidelines, 2019; Baumgartner, A., et al., Beschwerdebesserung bei Lipödempatientinnen vier, acht und zwölf Jahre nach Liposuktion(en), LymphForsch 24 (2), 2020.

Notes: This One-Pager is a summary of generally known and established medical knowledge, the current body of research, and clinical experience. It makes no claim to completeness of the contents or to conclusive relevance for all medical conditions, which must be reviewed by the physician on a case-by-case basis. The treating physician is responsible for making the choice regarding diagnostic tools and therapy.