Impact of manual lymphatic drainage on hemodynamic parameters in patients with heart failure and lower limb edema

Manual lymphatic drainage (MLD), intermittent sequential pneumatic therapy (ISPT), multilayered bandages (MLB), and compression garments are main techniques in conservative treatment of peripheral lymphedema. Since 1990, it has been thought that ISPT applied to both lower limbs simultaneously should not be used for patients with heart failure because right atrial, pulmonary arterial, and pulmonary wedge pressures may increase to a critical point. In 2005, these same results were observed in patients with heart failure wearing MLB. For these reasons, MLB and ISPT have been contraindicated during lymphedema treatment in cardiac patients. The aim of this study was to determine if we may continue the treatment of lower limb lymphedema using MLD in patients with heart failure. We evaluated hemodynamic parameters using echography during MLD in patients with cardiac disease and obtained circumferential measurements of the edematous limb before and after treatment. MLD treatment significantly decreased the limbs as expected. The heart rate also decreased following MLD in contrast with all other hemodynamic parameters which were not affected by MLD. The findings suggest that there is no contraindication to use MLD in patients with heart failure and lower limb edema.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

MR imaging, proton MR spectroscopy, ultrasonographic, histologic findings in patients with chronic lymphedema

Lymphedema is a progressive disease with multiple alterations occurring in the dermis. We undertook this study using high-frequency ultrasonography (US), magnetic resonance imaging, proton MR spectroscopy and histology to examine structural changes occurring in the subcutaneous tissue and precisely describe the nature of intralobular changes in chronic lymphedema. Four cutaneous and subcutaneous tissue biopsies from patients with chronic lymphedema during lymphonodal transplantation were studied. We performed US with a 13.5 MHz transducer, TSE T1 and TSE T2 magnetic resonance images with and without fat-suppression, MR Chemical Shift Imaging Spectroscopy and histological evaluation on these biopsies. We found that normal subcutaneous septa are seen as hyperechogenic lines in US and hyposignal lines in MRI and that hyperechogenic subcutis in US can be due to interlobular and intralobular water accumulation and/or to interlobular and intralobular fibrosis. Our study also confirms the usefulness of MR spectroscopy to assess water or fat content of soft tissue. Thus, multiple imaging modalities may be necessary to precisely delineate the nature of tissue alterations in chronic lymphedema.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Identification and description of the axillary web syndrome (AWS) By clinical signs, MRI and US imaging

The Axillary Web Syndrome (AWS) follows surgery for breast neoplasia and consists of one, or more frequently two or three, cords of subcutaneous tissue. Cords originate from the axilla, spread to the antero- medial surface of the arm down to the elbow and then move into the antero-medial aspect of the forearm and sometimes into the root of the thumb. The purpose of this study was to compare two techniques, ultrasound (US) and Magnetic Resonance Imaging (MRI) for their sensitivity and accuracy in identifying AWS cords and to provide insights to the origin of this pathology. US examinations were performed on fifteen patients using a high frequency probe (17MHz). We first palpated and marked the cord with location aided by maximum abduction. To identify the cord with MRI (1.5 Tesla), a catheter filled with a gel detectable under MRI was placed on the skin at the site of the cord. We found that in some US cases, the dynamic abduction maneuver was essential to facilitate detection of the cord. This dynamic method on ultrasound confirmed the precise location of the cord even if it was located deeper in the hypodermis fascia junction. US and MRI images revealed features of the cords and surrounding tissues. Imaging the cords was difficult with either of the imaging modalities. However, US seemed to be more efficient than MRI and allowed dynamic evaluation. Overall analysis of our study results supports a lymphatic origin of the AWS cord.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Axillary web syndrome: Nature and localization

Axillary Web Syndrome (AWS) is a complication that can arise in patients following treatment for breast cancer. It is also known variously as syndrome of the axillary cords, syndrome of the axillary adhesion, and cording lymphedema. The exact origin, presentation, course, and treatment of AWS is still largely undefined. Because so little is known about AWS, we undertook a case series study consisting of 15 women who had undergone breast cancer surgery and presented with AWS. All subjects received a clinical examination which included body size determination and detailed measurements of the size and location of the cords. The cords were found to originate from the axilla, continue on the medial aspect of the arm up to the epitrochlea region, then to the antero-median aspect of the forearm, and finally reaching the base of the thumb. The cords averaged approximately 44% of the limb length. Correlation of the cord location with anatomical studies shows that in fact this path follows the specific course taken by the antero-radial pedicle which arises at the anterior aspect of the elbow from the brachial medial pedicule to anastomose in the axilla at the level of the lateral thoracic chain nodes. Although our series is small, the correspondence between the physical findings and the anatomical studies strongly supports the notion that the cords are lymphatic in origin.SCOPUS: ar.jinfo:eu-repo/semantics/publishe