Lymph-venous insufficiency is a defect of the lymphatic and venous system that presents with pain, swelling, varicose veins, changes in the skin color (brown or red pigmentations, ulcers, dry scaling, and infection. This essay will provide an overview of the pathophysiology, aetiology, prevalence, and prognosis of lymphovenous insufficiency. The paper will give an overview of the management of lymphovenous insufficiency based on grade, classification, and severity. Lastly, the essay will discuss a detailed plan of skin management and other professionals who may need to be referred to or consulted in the management of a client with lymphovenous insufficiency.
Lymphovenous insufficiency commonly results from failure of the veins to return blood properly back to the heart leading to a back-up of blood in the veins at the legs hence raising the venous pressure. Increased venous pressure forces the lymphatic fluid in the blood to leak out into the body tissues leading to edema. The elevated venous pressure forces the blood to flow back into the smaller blood veins of the subcutaneous tissue beneath the skin leading to varicose veins. Varicose veins are associated with pain and delayed healing especially if they are located under wounds or ulcers (Gainutdinov, Pushkarev, & Perevozchikova, 2013)
There are two major types of lymphovenous namely: primary (deep) lymphovenous insufficiency which affects the deep veins of the legs causing swelling and skin changes. On the other hand, superficial venous insufficiency affects the small and great saphenous veins resulting to swelling, reticular and spider veins, painful varicose veins, impaired healing of wounds, ulcers, and wounds, infections and changes in skin color and integrity (Gainutdinov et al, 2013)
Lymphovenous insufficiency is caused by trauma, nerve injury and previous surgery. Surgical interventions may be implemented to remove some sections of the lymphatic system in treatment of cancer. Damage of the lymphatic system interferes with the lymphatic flow of blood and other fluids leading to insufficiency. In cancer treatment, use of radiotherapy can destroy cancerous cells and tissues and health tissues since it uses high-energy controlled doses of radiation. Use of radiotherapy in the destruction of cancerous cells in the lymphatic system is associated with a greater risk of permanent damage of the lymphatic system. Consequently, permanent damage to the lymphatic system may lead to its inability to properly drain the lymphatic fluid leading to lymphovenous insufficiency (Armer et al, 2013).
Infections are also key contributors to lymphovenous insufficiency. For example, cellulitis is commonly associated with lymphoedema which leads to damage to the surrounding tissues of the lymphatic system leading to scarring. Filariasis, which is an infection caused by thread-like worms affects the lymphatic system by blocking lymph drainage. Blockage of the lymphatic system by the worms leads to lymphoedema which then results in insufficiency (Kaczmar et al, 2016).
Lymphatic inflammation due to hypersensitivity reactions, injuries, infections, and other medical conditions can cause redness and swelling of tissues causing permanent damage to the lymphatic system. The damaged lymphatic system is unable to drain the lymphatic fluid to various body tissues leading to venous insufficiency. Some of the conditions that cause inflammation of the lymphatic system are rheumatoid arthritis and eczema which is associated with skin itching, redness, dryness and cracking (Olszewski, 2013).
Venous diseases interfere with blood flow through the veins leading to edema and damage of veins. Some of these venous diseases are Deep Vein Thrombosis (DVT), enlarged and swollen veins due to varicose veins. Damaged and abnormal veins cause an overflow of the lymphatic fluid from veins into the tissues spaces. Consequently, this overwhelms and exhausts the lymphatic part of the lymphatic system that is responsible for drainage of the lymph fluid (Olszewski, 2013).
Obesity is a potential cause of lymphovenous insufficiency. Obesity is associated with a high risk of development of swellings in body parts. Injuries and trauma can lead to accidental damage to the lymphatic system. Immobility may lead to lymphatic insufficiency since exercise and movement enhance drainage of the lymph. During physical activity, the activity of the muscles around the lymphatic vessels usually massages the lymph along them. Immobility, therefore, leads to lymphatic insufficiency since the lymph becomes stagnant in the lymphatic tissues. Other risk factors of lymphovenous insufficiency include; pregnancy, blood clots, muscle weakness, leg injury, smoking, family history, phlebitis, standing or sitting for long periods (Todd, 2014).
The signs and symptoms of lymphovenous insufficiency ae edema at the legs and ankles, leg cramps, itchy and weak legs, throbbing, aching and heaviness of client’s legs, leg ulcers, varicose veins, skin changes in color, skin thickening at the ankles and legs, tightness at client’s legs (Whitaker, 2012).
Prevalence of lymphovenous insufficiency widely varies based on geographical location, but the highest rates are reported in Western Countries whereby it ranges from 1%–17% in men and 1%-40% in the female gender. The most common risk factors include; pregnancy, physical inactivity, obesity, female gender, older age, diet, family history of lymphovenous disease and occupations that involve orthostasis (Hayes et al, 2011).
The client should always be reassured that Lymphovenous insufficiency is not always life-threatening. The patient should be put on lifelong graded compression and other therapies which lead to marked improvement but do not eliminate the sequelae. Non-compliance with prescribed treatment modalities is commonly associated with recurrence and complications (Whitaker, 2012).
Lymphovenous insufficiency usually has various stages in which it progresses. Stage 0 (sub-clinical stage)-the lymphatic system is in a position to compensate for an increased in tissue fluid due to venous hypertension making the affected areas not to develop edema. The management strategies for this stage is observation and self-monitoring for any changes in skin color. In this stage, it is also important to encourage physical exercises and skin care as preventative measures of further complications (Todd, 2012).
Stage 1 (phlebo-lympho-dynamic insufficiency)-the lymphatic system functions to its maximum capacity but fails to drain the increased amount of tissue fluid leading to the development of ambulatory venous hypertension. In this stage, edema develops due to dynamic insufficiency following overload in the lymphatic system. In this stage, the most effective management strategies are compression hosiery, elevation, physical exercises, skin care and self-lymphatic drainage (Todd, 2013).
Compression therapy in this stage is important in the reduction of swelling by reducing the flow of the excess fluid to the interstitial tissues (Capillary filtration) hence reducing the lymphatic load. Compression increases the interstitial pressure hence enhancing reabsorption of excess amount of fluid into the lymphatic and facilitates break down of fibrotic tissues. Compression facilitates movement of the excess fluid into the body areas which are non-compressed. This technique uses pressure which assists the venous pump of the legs and supports the weak valves hence improving their function. Improved functioning of these valves helps in reduction of venous hypertension (Todd, 2014).
Compression technique uses pressure which prevents dilatation of veins when standing or walking hence stopping backflow of blood into the veins. Compression approach works by increasing the speed of venous blood flow. Increased venous flow prevents trapping of leucocytes hence reducing inflammation. Reduction of valvular insufficiency in compression helps in preventing venous backflow in lymphovenous insufficiency. Lastly, compression technique helps in improvement of the flow of blood hence improving transportation and supply of nutrients to the skin (Lasinski, 2013).
Stage 2 (phlebo-lympho-static insufficiency)-This stage involves damage of blood capillaries due to elevated pressure and overworking of the lymph vessels. The Red Blood Cells (RBCs) leak from the blood capillaries via their stretched walls leading to reddish-brown color of the skin because of deposition of hemosiderin (tissue storage form of iron). Subsequently, elevated lymphatic pressure makes the walls of the lymph vessels be fibrotic along with inefficiency of the valves inside the larger vessels resulting in lymphatic system impairment to the extent that it can no longer carry out its basic roles and functions (Murdaca et al, 2012).
Consequently, this does not only cause fluid accumulation in tissues, but also proteins. In this stage, compression technique may also be applied to the reduction of swelling. Elevation and physical exercises are also effective in the management of this stage of lymphovenous insufficiency. Elevation and exercise help in improvement of lymphatic drainage by pumping the lymph fluid out of the inflamed areas hence reducing lymphovenous insufficiency (Olszewski, 2013).
Stage 3 of Lymphovenous insufficiency involves severe changes in sub-cutaneous tissues and the skin. Reduced nutrition and oxygenation of tissues may lead to the development of ulcerations. Apart from edema and ulcers, there is also lipodermatosclerosis which includes; increased skin hyperpigmentation, moderate skin redness, pain, small and white scarred areas and localized skin thickening. The applicable techniques of management in this stage are surgical intervention, Complete Decongestive Therapy (CDT) and wound care. CDT encompasses Manual Lymphatic Drainage (MLD), skin care, compression, exercise, training, and self-care management (Maksimov, Feiskhanov, Makarimov, & Feiskhanova, 2015).
Healthy skin involves lipid and water balance which maintains skin moisture and supple. In correction of lymphovenous impairment, skin optimization through leave on emollient and washes is important. The client should be encouraged on daily and regular washing of the skin with warm water and application of emollients or cream to prevent skin deterioration (Bianchi, 2013).
Daily skin care helps in the prevention of fungal and bacterial manifestations through the removal of dead skin and enhancing superficial lymphatic drainage. Emollients help in re-establishment of the protective lipid layer of the skin surface hence enhancing rehydration which prevents fluid loss and bacterial invasion. The client should be encouraged not to vigorously rub the skin since it causes irritation and epidermal changes. The dry skin should be gently pat not forgetting the skin folds, creases and between fingers and toes (Ridner et al, 2012).
One should avoid injections and ensure immediate and proper treatment of scratches and cuts with antiseptic cream. To prevent insect bites, the patient should use protective repellants. The client can use gloves for household tasks or when gardening to prevent skin cuts especially if the upper limbs are affected. Use of antifungal powder is important in prevention of fungal infections on the affected areas of both lower and upper limbs. The patient should be encouraged on keeping his nails short and putting on loosely-fitting jewelry and clothes and properly fitting shoes (Nowicki, & Siviour, 2013).
The healthcare professionals who may be needed in the holistic management of a patient with lymphovenous insufficiency are; dermatologist, physiotherapist, vascular surgeon, psychologist, dietician, and social worker. In this instance, the dermatologist has a role in provision of consultation services, dermatological screening, the performance of diagnostic tests, prescription of medications, the performance of dermatological procedures and educating the patient on the management of the condition and best skin, nail and hair care (Whitaker, 2012).
The vascular surgeon would help in the surgical intervention of the patient’s condition. Lymphovenous insufficiency is associated with psychological consequences such as depression, distress, social inhibition/isolation and concerns on sexuality and physical appearance due to disfigurement. Therefore, a psychologist would be important in the provision of psychological care and support to the client hence enhancing effective coping with his or her health condition (Papadopoulou et al 2012).
A social worker can work in collaboration with the psychologist to provide social support and rehabilitative services to the patient. Psychosocial support is also important in promotion of skills of self-management by the client. The physiotherapy is also an important aspect of patient management for lymphovenous insufficiency. The role of the physiotherapist is the implementation of physiotherapy techniques such as Complex Decongestive Therapy (CDT), Laser Therapy, High Voltage Electrical Stimulation, and Pneumatic Compression. These techniques help in the reduction of edema and improvement of lymph drainage hence relieving lymphovenous insufficiency. Lastly, a dietician would help in the provision of nutritional and dietary prescriptions and recommendations for the client to ensure proper skin hydration and moisturization, fluid balance and weight control (Papadopoulou et al, 2012).
Conclusion:
Lymphovenous insufficiency is a defect of the lymphatic and venous system that is caused by varicose veins, blood clots, infections, Deep Vein Thrombosis (DVT), obesity, smoking, trauma, injuries, muscle weakness, and pregnancy. Some of the effective approaches of managing Lymphovenous insufficiency are; compression, physical exercises, skincare, elevation, diet, and prevention of infections. For holistic management of lymphovenous insufficiency, members of the multidisciplinary team such as dermatologist, vascular surgeon, physiotherapist, dietician, psychologist, and social workers should be involved in client management.
References:
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Bianchi, J. (2013). The Chross Checker: a tool kit to detect early skin changes associated with venous and lymphovenous disease. J Community Nurs, 27(4), 43-9.
Gainutdinov, V. O., Pushkarev, V. N., & Perevozchikova, O. S. (2013). New methods for Diagnosis and Correction of Lymphodynamics in Chronic Lymphovenous Lower Extremity Insufficiency. Perm Medical Journal, 30(6), 72-76.
Hayes, S., Sipio, T. D., Rye, S., López, J. A., Saunders, C., Pyke, C., … & Newman, B. (2011). Prevalence and prognostic significance of secondary lymphedema following breast cancer. Lymphatic research and biology, 9(3), 135-141.
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Lasinski, B. B. (2013, February). Complete decongestive therapy for treatment of lymphedema. In Seminars in oncology nursing (Vol. 29, No. 1, pp. 20-27). WB Saunders.
Maksimov, A. V., Feiskhanov, A. K., Makarimov, E., & Feiskhanova, L. I. (2015). Reconstructive operations in pathology of central veins, associated with vascular approach. Angiology and vascular surgery, 21(4), 171-177.
Murdaca, G., Cagnati, P., Gulli, R., Spano, F., Puppo, F., Campisi, C., & Boccardo, F. (2012). Current views on diagnostic approach and treatment of lymphedema. The American journal of medicine, 125(2), 134-140.
Nowicki, J., & Siviour, A. (2013). Best practice skin care management in lymphoedema. Wound Practice & Research: Journal of the Australian Wound Management Association, 21(2), 61.
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