Lymph Flow and Contractility Pattern of Lymphatic Vessels in Lymphedema Stage I

Introduction, Objectives, and/or Purpose: Objective. The main force propelling lymph along lymphatics is spontaneous autoregulated lymphangion contraction. This lymphangion contraction (pulse) can now be observed on ICG lymphography. Inflammation, trauma, and lymph hypertension due to proximal collector obstruction may deteriorate lymphatic work. Endothelial and muscle cells undergo destruction. The first changes we can observe on ICG lymphography in tissue fluid/lymph flow are slow down and lymphatic dilatation. Early diagnosis of lymphatic vessel insufficiency and prophylaxis implementation can stop further destructive changes leading to advanced edema with tissue changes.
Aim. To evaluate foot and calf lymphatics collector contraction capacity and lymph flow in the early stages of lymphedema.

Methods: Methods. We investigated 34 patients with unilateral lower limb lymphedema stage I. All patients underwent ICG lymphography. Injection of 0.4 ml 5% of ICG dye (Pulsion, Munich, Germany) was done into the toe webs in both feet. We observed and recorded lymphatic contraction and their fluorescent intensity after 3 min of feet flexion in a horizontal position and after a 1-hour walk (Photodynamic Eye; Hamamatsu Photonics). The lymph flow velocity, appearance of lymphatic vessels (dilated, intermittent), dye diffusion around the non-contracting lymphatics, and the fluorescent intensity along the entire limb were analyzed. In the standard ankle area, the contraction frequency and amplitude were also analyzed (ICcalc, Pulsion Medical Systems, Munich) as control served the normal contralateral limb.

Results: Results. We observed slower lymph flow in lymphedema than in normal limbs. After 3 min of foot movement, lymphatics are seen in the lower calf level in 64.7% (22) edema limb compared with 100% (32) of normal limb (p < 0.05) and in the upper calf level in 26.6% (9) compared with 58.8% (20) (p < 0.05) respectively. In 47.1% (16) of feet with edema, there was a dye spot, and in 44.1% (15) dilated lymphatics compared with zero and 14.7% (5) in normal limbs, respectively. In the calves in 2 patients (5.9%), we observed dye spots and in 19 (55.9%) dilated lymphatics in edema limbs compared with zero and 6 (17.6%) in normal limbs, respectively. There were different patterns of contraction curves (the examples will be shown), but in the majority, the frequency (below 6/min) and amplitude were lower than in normal limbs. The fluorescent intensity was higher in edema than in normal limbs (30% vs. 15%).

Conclusion(s): Conclusions. We can evaluate lymphatic vessel insufficiency now on ICG lymphography. Early diagnosis of decreased collectors contracting capacity and their dilatation point to the necessity of establishing etiology and initiating early prophylaxis or even therapeutic intervention.