Management of People With Lymphoedema in the Presence of Deep Vein Thrombosis

Overview

This Guidelines summary covers practical information for clinical decision-making surrounding the management of deep vein thrombosis (DVT) and lymphoedema.

Recommendations include:

• symptoms of lower limb DVT and pulmonary embolism (PE)
• risk factors for developing DVT
• the use of compression in venous thromboembolism
• general advice for patients following a diagnosis of DVT.

Reflecting on Your Learnings

Symptoms of Lower Limb DVT

• Symptoms of lower limb DVT include:
  • unilateral leg pain, worse on flexing ankle. NB in patients with advanced disease (for example, advanced cancer) bilateral presentation can sometimes occur and may indicate inferior vena cava compression or thrombus
  • unilateral pitting limb oedema, tender to touch
  • symptoms may be confined to calf or thigh or can affect the whole limb
  • sudden onset oedema over 12 hours
  • red/purple discolouration, warm to touch
  • often preceding change in mobility, for example, recently bedridden, previous surgery, currently/recently in lower limb cast
• If a patient is suspected to have DVT, follow local DVT pathway for referral into rapid access clinic for D-dimer (a blood test to help diagnose thrombosis), and, if needed, complete a venous duplex ultrasound scan
• In relation to lymphoedema, one of the ways to reduce a patient’s risk of DVT is to ensure that decongestive lymphatic therapy (multilayered lymphoedema bandaging or compressive wraps, manual lymphatic drainage/sequential pneumatic compression, exercise, and skincare) has been optimised where possible to reduce the volume of oedema, reshape the limbs, soften any thickened subcutaneous tissues, and improve the skin condition.

Risk Factors for Developing DVT

• Risk factors for developing DVT include:
  • increased age
  • history of DVT or PE
  • family history of blood clots
  • rapid change in mobility, for example, post-operation or cast in situ
  • cancer (including chemotherapy and radiotherapy treatment)
  • cardiovascular disease
  • thrombophilia
  • pregnancy
  • obesity
  • the combined contraceptive pill and hormone replacement therapy
  • heart failure
  • non-infectious inflammatory conditions
• A serious complication of DVT is when one (or more) emboli, usually arising from a thrombus formed in the veins, become lodged in, and obstruct, the pulmonary arterial system, causing severe respiratory dysfunction
• If the clot is small, and with appropriate treatment, people can recover from PE. However, there could be some damage to the lungs. If the clot is large, it can stop blood from reaching the lungs and is fatal
• It is important to remember that you can have a ‘silent’ PE without any clinical symptoms of a PE, and a symptomatic PE may occur without DVT being clinically obvious (a PE without symptoms of DVT).

Signs and Symptoms of PE

• Signs and symptoms of PE include:
  • shortness of breath/difficulty breathing
  • rapid heartbeat
  • sweating
  • sharp chest pain, especially during deep breathing—some patients describe it as ‘catching their breath’ (pleuritic) or like severe bronchitis pain
  • haemoptysis
  • very low blood pressure, light headedness, or fainting.

Use of Compression in Venous Thromboembolism

• Although many patients following DVT have a complete resolution of symptoms, approximately 20–50% of patients will develop post-thrombotic syndrome (PTS), and this will be severe in 5–10% of cases. PTS refers to the clinical manifestations of chronic venous insufficiency (CVI) following DVT
• DVT causes venous outflow obstruction and persistent reflux, leading to venous pooling, which directly affects the veins causing dilation and further valvular incompetence. As a result, the calf muscle pump becomes ineffective, and the ambulatory venous pressure fails to fall significantly with walking or exercise (as it does in the healthy state), which eventually leads to venous hypertension. The venous hypertension initiates a chronic inflammatory cascade, which leads to the features of PTS, including:
  • venous claudication
  • ankle swelling
  • skin changes
  • ulceration
• Considering that patients with lower limb lymphoedema often present with swelling in combination with symptoms of CVI, they are considered at high risk of developing PTS and then entering a cycle of increased swelling, increased reliance of lymphatic drainage, and increasing inflammation; all of which lead to increasing venous and lymphatic insufficiency
• The graduated elastic compression stocking has been central to PTS prevention for several decades, and has been shown to reduce patients’ pain, oedema, and signs of CVI. For patients at risk of PTS, or showing symptoms of PTS, it is important that compression therapy is commenced as soon as possible. There is evidence that early compression can also improve the acute symptoms of DVT
• If patients are already wearing compression hosiery daily when DVT is suspected, a same-day assessment/scan (within 24 hours) is required. There will be a pause in compression, as this should be removed until DVT status is confirmed. When diagnosis is confirmed and anticoagulant therapy commenced, compression hosiery can recommence during the acute DVT phase if pain allows. Note that reassessment may be necessary due to volume changes and/or any skin changes/breakdown
• If there has been skin breakdown or ulceration, a period of increased compression therapy may be required, or the patient may require a period of bandaging or the use of compressive wrap systems. The care of these patients should follow standard venous leg ulceration pathways. Remember the importance of skin care—including washing, thorough drying, and moisturisation—is essential.

General Advice for Patients Following Diagnosis of DVT

• Advise patients to:
  • keep well hydrated
  • avoid drinking a lot of caffeine/alcohol
  • identify any risk factors and then avoid or address them wherever possible—for example, healthy weight advice
  • keep active—early mobilisation results in better outcomes, so return to exercise as soon as possible
  • not to cross the legs for long periods if the DVT was in the leg, as this may impact the return of blood/fluid to the heart. Chair-based exercises can be useful if walking is limited
  • perform elevation as able if there is extensive swelling, but ensure hosiery is well fitting, comfortable, and worn daily.

British Lymphology Society DVT Statements

• If patients are already wearing compression hosiery daily when DVT is suspected, a same-day assessment/scan (within 24 hours) is required. There will be a pause in compression, as this should be removed until DVT status is confirmed. When diagnosis is confirmed and anticoagulant therapy commenced, compression hosiery can recommence during the acute DVT phase if pain allows. Note that reassessment may be necessary due to volume changes and/or any skin changes/breakdown
• If patients diagnosed with DVT are not wearing compression, it is safe to apply compression once anticoagulation has been initiated; however, in patients with extensive iliac/femoral DVT, this may need to be negotiated with the hospital team managing the patient. There is no evidence currently that PE is increased as a result of appropriately applied graduated compression.