Pearls for Practice: Phlebolymphedema

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James D. McGuire, PT, DPM, CPed, FAPWHc Temple University School of Podiatric Medicine, Philadelphia, PA

Phlebolymphedema is a swelling of mixed etiology that occurs because the lymphatic system is unable to adequately drain the interstitial fluid that accumulates in severe chronic venous hypertension. A host of contributing factors such as systemic disease (eg, congestive heart failure, cirrhosis, or nephropathy) can increase demand on the lymphatic system; insufficiency of the venous or lymphatic system (or both), in combination with possible systemic contributors, leads to the accumulation of interstitial protein-rich fluid in the interstitial space and subsequent phlebolymphedema.

The circulatory and lymphatic systems in the human body maintain a delicate balance. If the venous system is damaged, it usually affects the lymphatic vessel system. It is not unusual for the legs of affected patients to be swollen in the evening. Lower leg volume can increase up to 100 mL after a long working day or up to 200 mL after a long flight during which the legs remain stationary. Edema that does not resolve spontaneously within a few hours or after a walk is considered pathological.  

Bilateral and marked edema with few symptoms is mostly caused by systemic circulatory dysfunction involving the heart, kidneys, and/or liver. Venous edema is almost always associated with symptoms and/or clinical signs that include dilated superficial veins, varicose veins, and skin changes. Chronic venous edema is only partially reversible and soon becomes hard, which is mainly confirmed on palpation. All skin structures are affected, and the lower leg can take on the appearance of an upside-down champagne bottle. Secondary lymphedema may develop, accompanied by thickening of skin folds, hyperkeratosis, and papillomatosis.2

Drawtex Hydroconductive Wound Dressing (SteadMed Medical, LLC, Fort Worth, TX) features a combination of 3 physical actions on the wound bed that actively draw exudate, bacteria, and deleterious chemicals out of the wound.3 Capillary action draws water and fluids into porous materials such as textiles against gravity, hydroconductive action allows water to be drawn in both a vertical and horizontal direction as governed by Darcy’s Law (the ability of fluid to move through a porous media), and electrostatic action facilitates attraction or repulsion between electrically charged bodies. The hydroconductive mechanism is much like the mechanism by which a tree transfers water from its roots to its leaves. The electrostatic action (the strongest action) that draws bacteria and deleterious chemicals from the wound tissue (not just the wound surface) into the Drawtex dressing causes the surface of the dressing closest to the wound to have a positive electrical charge. Bacterial cell walls and the chemicals in cytokines have a negative charge. These charge differences are responsible for drawing the substances from the tissue into the dressings.3 Drawtex, with its patented LevaFiber technology, allows the drawing action to be both vertical and horizontal so the exudate, bacteria, and deleterious cytokines are drawn to the opposite dressing surface and dispersed. Therefore, Drawtex does not become supersaturated and or leak exudate. No other dressing has this combination of actions. 

In addition, research has demonstrated that the bacterial level and the matrix metalloproteinase (MMP) level in the wound tissue are decreased and the bacterial level and the MMP levels are increased in the Drawtex dressings4,5; as a result, nutrients to support biofilm production are reduced,6 which has been shown to improve perfusion.

Recently, Drawtex was presented in a new iteration, Drawtex Edema Wrap, a more pliable and functional dressing that can reduce edema, manage fluid, and support enhanced wound management in legs.  Two (2) cases of phlebolymphedema treated with the Drawtex Edema Wrap are described.

Case Reports

Case 1 (see Figure 1). This patient presented with a recurrent venous leg ulcer with secondary phlebolymphedema of approximately 2 months’ duration that developed at the site of previous ulceration. His case was complicated by morbid obesity and type 2 diabetes. Previous treatments consisted of 4-layer and short-stretch compression systems and foam dressings that were unsuccessful at addressing the amount of fluid produced by the wound and the multiple satellite lesions with recurrent biofilm that developed on the wound whenever it became macerated. An iodine paste was used to address the biofilm. Compression was delivered using a combination of Drawtex Edema Wrap and a self-adherent outer layer (Coban, 3M, St Paul, MN). The Drawtex facilitated more efficient management of the wound fluid, and the small satellite lesions resolved within several days. The use of the Drawtex wrap also eliminated the need for a secondary dressing over an oil emulsion contact layer. The biofilm and excess exudate resolved quickly with this dressing. owm_0418_pearls_figure1

Case 2 (see Figure 2). This patient also had a history of diabetes, morbid obesity, hypertension, and multiple recurrences of a venous leg ulcer complicated by phlebolymphedema. He presented with a multispecies biofilm, excessive exudate, and small dermal ulcers in the skin around the wound. The treatment consisted of a pigment-based antibacterial foam contact layer for the biofilm; Drawtex Edema Wrap was substituted for the first layer of a commercial 2-layer compression system. Edema was well controlled, the satellite lesions resolved, and the exudate was removed from the wound, eliminating an environment favorable for biofilm formation and reducing the maceration. The wound went on to heal in 21 days. owm_0418_pearls_figure2

Conclusion

Drawtex Edema Wrap proved to be an effective therapy for 2 challenging wounds. In the first case, the product allowed for more efficient management of the wound fluid and satellite lesions, eliminated the need for a secondary dressing over the oil emulsion contact layer, and resolved the biofilm and excess exudate. In case 2, the edema was controlled, satellite lesions resolved, and exudate was removed from the wound, eliminating an environment favorable for biofilm formation and reducing maceration. 

References

1. Farrow W.  Phlebolymphedemaa common underdiagnosed and undertreated problem in the wound care clinic. J Am Col Certified Wound Spec. 2010;2(1):14–23.

2. Weissleder H, Schuchhardt C, eds. Lymphedema — Diagnosis and Therapy. 4th ed. Berlin, Germany: Vinvitel Verlag GmbH;2007:20.

3. Smith DJ, Karlnoski RA, Patel A, Cruse CW, Brown KS, Robson MC. The treatment of partial-thickness burns with a hydroconductive dressing: clinical and mechanistic effects. Surg Sci. 2013;4(5):268–272. 

4. Ochs D, Uberti MG, Donate GA, Abercrobie M, Mannari RJ, Payne WG.  Evaluations of mechanisms of action of a hydroconductive dressing, Drawtex, in chronic wounds. Wounds. 2012;24(9 suppl):6–8.

5. Carney BC, Ortiz RT, Bullock RM, et al.  Reduction of a multidrug-resistant pathogen and associated virulence factors in a burn wound infection model: further understanding of a hydroconductive dressing. ePlasty. 2014;14:e45.

6. Wolcott RD. The effects of a hydroconductive dressing on the suppression of wound biofilm.  Wounds. 2012;24(5):132–137.

7.  McGuire J, Sadoughi N. Hydroconductive wound dressings. Podiatr Manage. 2013;6(8):145–151.

 

Pearls for Practice is made possible through the support of SteadMed Medical, LLC, Fort Worth, TX (www.steadmed.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of SteadMed Medical, LLC; OWM; or HMP Global. This article was not subject to the Ostomy Wound Management peer-review process.