A lot of patients with chronic venous disease develop lymphedema. The “red legs” they get can be mistaken for cellulitis although they are usually the commonly seen vasodilation of blood vessels seen with lymphedema, sometimes superimposed on hemosiderin staining. Even though these change are clinically obvious to those who practice in the field, without a way to image the lymphatics, it has been hard to explain this story to our colleagues.
For years I’ve had the chance to work with Eva Sevick and her team developing real-time lymphatic imaging using microdoses of indocyanine green (ICG) dye and highly sensitive infrared cameras. We just published an article in the Journal of Vascular Surgery showing that patients with chronic venous insufficiency have the same sort of lymphatic changes often seen in cancer patients. These changes included “dermal backflow” of the lymphatic fluid (even in patients without venous ulcers).
Subjects with the longest duration of active venous ulcers had few visible lymphatic vessels and were the least likely to show proximal movement of indocyanine green (ICG) in response to the use of a sequential lymphatic pump (SPC) although 9/12 subjects recruited new lymphatics and improved lymphatic return in response to the use of an SPC.
The study provides visible confirmation that lymphatic dysfunction starts early in the etiology of venous
ulcer formation and demonstrates the potential therapeutic mechanism of SPC therapy in removing excess fluid. Perhaps most importantly, it points out the elephant in the room. Patients with longstanding venous disease have secondary lymphedema — just like the man in this photograph.
J Vasc Surg: Venous and Lym Dis 2015;-:1-9.