Poor Circulation

Poor blood circulation within the lower extremities is caused by the build-up of plaque in the blood vessels (especially the arteries) called atherosclerosis.

Risk factors for the development of peripheral artery disease (PAD) include:

• Smoking
• Older Age
• High cholesterol
• High blood pressure
• Diabetes
• Ischaemic heart disease
• Stroke
• Metabolic syndrome

Over time, the build-up of plaque in the arteries results in reduced flow of oxygen-rich blood to the tissues. This may result in symptoms of the legs and/or feet including:

• Leg pain, especially with exercise (called, intermittent claudication)
• Weak or absent pulses
• Sores / ulcers
• Skin colour and / or temperature changes
• Poor hair and / or nail growth

More seriously, the build-up of plaque in the arteries may lead to blood clots causing heart attack and/or stroke.

A diagnosis of PAD will require a comprehensive assessment by a medical professional or vascular consultant and will include a review of medical and family history, a physical examination and referral for relevant diagnostic testing. The goal of PAD treatment is to improve the blood supply to the legs and therefore reduce symptoms, improve mobility and quality of life, and reduce the risk of serious complications such as heart attack and / or stroke. The type of treatment required will be based on the medical assessment, though commonly includes lifestyle changes, medication and / or surgery.

 

Chronic Venous Disease

Chronic venous disease (CVD) is a chronic condition related to or caused by veins that become diseased or abnormal. It is a quite common disease with progressing severity. Early symptoms of chronic venous disease are a sensation of swelling and heaviness, most commonly in the legs. If the disease progresses varicose veins occur. Left untreated, varicose veins can enlarge and worsen. As a result, the symptoms will become more severe e.g., irritation, swelling and painful rashes.

Severe pooling of blood in the veins slows the return of blood to the heart. This can lead to condition can cause deep vein thrombosis and pulmonary embolism. Another potential consequence is chronic venous insufficiency (CVI), which leads to skin changes and development of venous leg ulcers (VLU).

VLUs have a big impact on the daily life, they can be painful, so that the ability to work may be compromised. Without proper treatment, these potential consequences of chronic venous disease can lead to prolonged disability and have an important socioeconomic impact, and significant psychosocial morbidity. Due to the potential seriousness of chronic venous disease, it is especially important to be correctly diagnosed in good time. The problem will not go away, and the earlier it is diagnosed and treated, the better the chances of preventing serious complications. There are several procedures that can be used alone or in combination to treat CVD. Compression therapy is considered the corner stone of treatment for chronic venous disease. Compression bandages and stockings gently compress the legs and help to improve blood flow in the veins by preventing backward flow of blood. Nevertheless, in some cases compression therapy cannot be applied and venous surgery may be necessary.

 

Lymphedema

Lymphedema is a term used to describe the accumulation of protein-rich fluid (called lymph) in a particular part of the body, resulting in swelling of the affected area(s).  The lymphatic system is made up of a network of lymphatic vessels, lymph nodes and other lymph tissue.  It forms part of both the circulatory and immune systems and is essential for both the transport of lymph and the body’s immune function.  Lymphedema occurs either because the lymphatic system is not working properly, or there is simply too much fluid for a normal lymphatic system to process. 

Traditionally, there are two types of lymphedema, primary and secondary.  Primary lymphedema occurs because of congenital abnormalities of the lymphatic system.  Symptoms may be present from birth or appear later in life.  Secondary lymphedema occurs due to damage to a previously intact lymphatic system.  A common cause of secondary lymphedema is cancer or its treatment.

Lymphedema is not easy to diagnose because sometimes first symptoms occur after many years.  Nevertheless, it is important to get the accurate diagnose and treatment as soon as possible.

First signs of lymphedema include:

• feeling of heaviness, tightness, or fullness
• aching of the affected area
• clothing or jewellery feeling tighter
• visible swelling

Diagnosis of lymphedema requires assessment by a doctor or healthcare professional who has undergone specialist training in lymphedema assessment and its management.  Early diagnosis is essential to facilitate timely treatment.  Receiving lymphedema risk-reduction education is also important for those at risk of the development of secondary lymphedema.

Following an accurate diagnosis, lymphedema may be classified into different stages.  While there are several different staging systems utilised internationally, the International Society of Lymphology (ISL) Lymphedema staging system is commonly used, as outlined in the table below adapted from the Lymphedema Framework, 2006.

ISL stage 0

A subclinical state where swelling is not evident despite impaired lymph transport. This stage may exist for months or years before edema becomes evident.

ISL stage I

This represents early onset of the condition where there is accumulation of tissue fluid that subsides with limb elevation. The edema may be pitting at this stage.

ISL stage II

Limb elevation alone rarely reduces swelling and pitting is manifest.

ISL late stage II

There may or may not be pitting as tissue fibrosis is more evident.

ISL stage III

The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening, hyperpigmentation,

increased skin folds, fat deposits and warty overgrowths develop.

 

Treatment plans should be holistic, multidisciplinary, and coordinated. The goals of lymphedema treatment should be to optimise lymph flow, reduce (and maintain) swelling and improve skin condition.  Achieving these goals will also reduce the risk of cellulitis (also called, erysipelas).

While mild lymphedema may be managed with exercise, skin care and compression stockings, more advanced lymphedema may require a course of complete decongestive therapy (CDT).  CDT is considered the ‘gold standard’ of lymphedema treatment, and consists of an initial reductive phase, followed by a maintenance phase. 

CDT consists of a combination of:

• manual lymphatic drainage (MLD)
• multi-layer compression bandaging followed by compression stockings
• exercise
• skin care
• education

Additional treatments may include intermittent pneumatic compression therapy (IPC), laser or lymph taping. Several surgical interventions are also available for the management of lymphedema, all of which require long-term post-surgical compression therapy.

 

Lipedema

Lipedema is a chronic disease which is characterized by a chronic disproportional distribution of the subcutaneous fat accompanied with pain, the feeling of heaviness and discomfort.  The disproportional increase in fat occurs most often in the legs and sometimes also in the arms and is an important criterion for this disease.   It is important to differentiate lipedema from obesity because lipedema is often incorrectly diagnosed as obesity and wrongly treated.  Many patients try “diet and exercise” but experience the jo-jo-effect gaining weight again. Whereas mismatch of waist-to-height/waist-to-hip ratio can be observed in case of lipedema the case of obesity patients experience BMI increase. Furthermore, in contrast to lymphedema edema is only a minor symptom of lipedema since it is only present in a small subgroup of lipedema patients. In contrast to the traditional view now experts agree that lipedema usually is not progressive. Nevertheless, obesity is often progressive.  If obesity is progressive, lipedema can get worse and maybe hormonal changes play a role. Lipedema is a chronic condition which needs an individual holistic treatment approach focusing on patient’s needs and enabling daily functioning.  Thereby self-management is especially important. Important corner stones of lipedema treatment are skin care and protection, pain management and compression therapy.  In addition, regular exercises, most suitable for each patient, must be integrated into the daily life. 

MLD has been reported to have a positive psychological effect. Furthermore, relaxation (yoga, mindfulness training) and psychotherapy are helpful.  Liposuction is suitable only for some patient groups. Optimizing the health situation, avoiding risk factors and continues lipedema treatment are essential to manage lipedema.

 

Deep Vein Thrombosis

Sometimes known as economy class syndrome, deep vein thrombosis (DVT) is caused by the formation of a blood clot (thrombus) in the deep veins of the leg.  The precise number of people affected by DVT and PE (pulmonary embolism) is unknown. DVT occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs, groin or arm.  It can cause swelling and pain in the leg, although it often occurs without any symptoms, and may have long-term consequences. Blood clots are dangerous because they can break off and move with the flow of blood into the heart or lungs, where they can block major blood vessels and cause a potentially fatal pulmonary embolism.

The typical signs of deep vein thrombosis are:

• Pain, swelling and tenderness in one of your legs (usually your calf)
• A heavy ache in the affected area
• Warm skin in the area of the clot
• Red skin, particularly at the back of the leg, below the knee
• However, DVT can often occur without any obvious symptoms.

Post-thrombotic syndrome (PTS) is also characterized by swelling, pain, discoloration, scaling in the affected limb and can result in leg ulcers development. DVT leg symptoms can occur during long-haul flights.  Aggravating factors are the low cabin pressure that increases the tendency of the blood to stagnate in the veins and low humidity that causes large amounts of body fluid to evaporate.  As a result, the blood thickens even more, thereby increasing the likelihood of blood clots. 

Several risk factors that increase the risk of developing a blood clot (thrombosis) have been identified, such as:

- Obesity

- Pregnancy

- Immobility (including prolonged inactivity, long trips by plane or car)

- Smoking

- Oral contraceptives

- Certain cancers

- Trauma

- Certain surgeries

- Age

- A family history of venous thrombosis (blood clots)

- Chronic inflammatory diseases

- Diabetes

- High blood pressure

- High cholesterol

The most serious consequence of deep vein thrombosis is the development of fatal pulmonary embolism (PE).  If a blood clot disconnects and travels in the circulation into an artery in the lung it can block the blood flow to part of the lung, leading to fatal PE.
Signs of PE can include:
- Shortness of breath

- Pain or discomfort in the chest

- Feeling dizzy or lightheaded

- Fast pulse

- Coughing up blood
Post-thrombotic syndrome (PTS), also called postphlebitic syndrome, is also a potential long-term complication of DVT.  PTS reduces quality of life and has important socioeconomic consequences.  Patients with severe PTS may even develop venous ulcerations. Blood clots are among the most preventable types of blood conditions, and there are several ways to decrease the chances of developing DVT, such as controlling your risk factors wherever possible.  If you think you are at risk because of family history or behavioral factors, consult your doctor.  Also, make sure your doctor is aware of your complete medical history and any family history of blood clotting disorders. Thrombosis prevention is also known as thrombosis prophylaxis.  It comprises treatments that are designed to counteract the formation of blood clots inside blood vessels. These prevention measures often begin just after someone has had surgery, as this puts them at higher risk of having deep vein thrombosis, largely due to lack of movement afterward.  Additionally, DVT (deep vein thrombosis) is often linked to air travel as sitting in confined spaces without moving for long periods of time negatively influences the blood flow in the vessels.

Being aware of these common risk factors, and taking steps to avoid them, is an important part of helping to prevent thrombosis:
- Lack of exercise

- Taking oral contraceptives

- Being overweight/obese

- Smoking

- Dehydration

- Long periods of inactivity, lying or sitting down, such as on long journeys (especially long-haul flights) or while in hospital

A risk assessment is a helpful way to begin DVT prophylaxis begin with a risk assessment.  The risk assessment considers risk factors related to exposure (type of surgical procedure/trauma/acute disease, extent of immobilization) and disposition (individual inherited and acquired factors).  In addition, the health status (diseases such as cancer, the age, dehydration, obesity, the VTE risk and the bleeding risk) influences the personal risk for DVT development. There are several ways to help prevent thrombosis.  For example, wearing compression stockings can help reduce swelling in tissues and promote better blood flow.  In high-risk patients – such as hospitalized patients at increased risk of thrombosis who are bleeding or are at high risk of major bleeding – medical compression stocking (MCS) (from 15 to 30 mmHg) and anticoagulant thromboprophylaxis are recommended.  Medical compression stockings are especially recommended for thromboprophylaxis, if anticoagulants are contraindicated.
Their use is also suggested during long-distance travelling, to prevent DVT incidence in patients at risk.  This is especially effective when combined with regular exercise during the journey, such as walking down the aisle and doing leg exercises. Drug therapy is also a quite common form of thrombosis prophylaxis.  The use of compression stockings and medication can be supplemented with the simple technique of resting with your legs above the level of your heart.  This can be done after surgery, for example, which assists in taking pressure off the legs and promotes the flow of blood out of the leg veins and to move throughout the body.

 

Chronic Venous Insufficiency

Chronic venous insufficiency (CVI) is best described as the inability of the valves in someone’s veins to properly transport blood back to the heart.  The condition is common but can lead to health problems if allowed to progress in severity.  Common effects include skin discoloration, swelling, and pain in the legs and feet.  When chronic venous insufficiency occurs, it is because there is a problem with the valves and consequently blood is flowing backward.  This means that blood will begin to pool in the veins, generally in the legs and feet. Leading phlebologists developed the C.E.A.P. classification to standardize diagnosis and judge the outcomes of venous insufficiency.  This classification spans six stages (C0-C6), which map the progressing severity of chronic venous disease.  Chronic venous disease refers to the early stages (C0-C3), while chronic venous insufficiency specifically refers to the later and more severe stages (C3-C6). 

C0: no visible or palpable signs of venous disease 
C1: telangiectasies or reticular veins 
C2: varicose veins 
C3: edema 

C4a: pigmentation or eczema

C4b: lipodermatosclerosis or atrophie blanche 
C5: healed venous ulcer 
C6: active venous ulcer S: symptomatic, including ache, pain, tightness, skin irritation, heaviness, and muscle cramps, and other complaints attributable to venous dysfunction A: asymptomatic.

 

As a progressive disorder, the symptoms change as the condition worsens.  Early symptoms associated with chronic venous disease – such as a feeling of heaviness in the legs, dull aching, or throbbing – are bothersome for patients.  However, as the disease progresses into varicose veins, edema, and then symptoms of chronic venous insufficiency, it poses a considerable impairment to patients’ quality of life.  Especially in stage C6, where active venous leg ulcers occur, patients may experience pain and difficulties with mobility, which can affect other areas of a patient’s life.

It should be noted that not all causes of CVI will be the same for everyone, but the following are the most typical risk factors:

• Family history of chronic venous insufficiency
• Experiencing blood clots or deep vein thrombosis 
• Experiencing varicose veins
• Lack of regular exercise
• Pregnancy
• Recent leg surgery
• Obesity
• Smoking tobacco
• Experiencing phlebitis (swelling of superficial veins)
• Standing or sitting for long periods

The correct chronic venous insufficiency treatment will be quite different for each person, as it often depends on the person’s age, sex, and current health status.  Medication is sometimes prescribed to help manage chronic venous disease, but compression therapy is often crucial when it comes to managing the different stages of chronic venous insufficiency.  Wearing   compression stockings applies pressure to the leg and foot, which helps to reduce swelling and alleviate venous symptoms in patients with SVI. In addition to compression therapy, it is important to exercise regularly and elevate the legs above the heart, such as by lying flat and resting the feet on pillows.  This helps in the treatment of chronic venous insufficiency treatment by encouraging the blood to flow from the legs towards the heart.  Exfoliating and moisturizing also helps to prevent dryness and flaking of skin on the legs.
After a detailed chronic venous insufficiency diagnosis, surgical and non-surgical procedures can be done by a professional. Wearing medical compression stockings is a common non-surgical procedure. There are several lifestyle factors that can help you reduce the risk of developing chronic venous insufficiency complications.  While it is true that some may not be able to avoid chronic venous diseases entirely, it is still important to take action to reduce your risk. This can include exercising regularly, not wearing high heels, avoid sitting or standing for a long time, and maintaining a healthy body weight.
The condition is usually not life threatening, but it can lead to the development and progression of venous disease.  For this reason, it is best to see a doctor right away is vital if you are experiencing symptoms of chronic venous insufficiency.

 

Spider Veins

Spider veins are tiny veins that lie directly under the skin surface and appear either bluish or reddish in color.  They usually develop on the legs and occur when the venous valves become leaky.  This means the blood cannot flow back towards the heart as normal.  Contrary to popular opinion, spider veins do not just affect older people: they are widely distributed among all age groups, appearing more frequently in women than in men. Chronic venous insufficiency is usually the underlying cause of varicose veins, reticular veins, and spider veins.  In this case, the valves in the veins are damaged or weakened, which inhibits blood circulation back towards the heart and allows the blood to pool in the affected body part. Spider veins are like varicose veins in that they are both connected to chronic venous insufficiency.  As a result, a common cause of spider veins is when the valves in the veins are damaged or weakened, which inhibits blood circulation back towards the heart and allows the blood to pool in the legs.  This increased pressure weakens the vein walls further and causes them to bulge, leading to spider veins in the feet, legs or elsewhere on the body.  However, there are other potential risk factors besides venous insufficiency, such as hormonal changes.

Despite the similarities between the two venous conditions, spider veins have distinct symptoms from varicose veins:

• Visibly small and thin lines on the surface of the skin
• Red, blue, or purple color
• Usually flat, or very slightly raised
• May cause some discomfort, but rarely cause significant pain

Spider veins are quite common and mostly harmless. Healthy living is an important factor in preventing more of the blueish-red veins from forming. It is worth noting that there are genetic or hormonal factors that lead to the formation of spider veins, so a healthy lifestyle does not necessarily guarantee a spider vein-free existence. Nonetheless, it is advisable to lose weight, to do more exercise, drink less and avoid nicotine to reduce your risk of venous insufficiency. If you want to get rid of spider veins forever, there is the option of having them lasered or ablated away. However, there is no guarantee that new spider veins will not appear in a few years. Therefore, wearing specially designed compression stockings has proved highly valuable in relieving the venous system in a sustainable way.

 

Varicose Veins

Varicose veins are bluish blood vessels, often visible at the back of the knee, or on the lower leg and ankle.  They are fairly common, and, in the long term, many people will develop them at some point.
But what are varicose veins precisely? Simply put, they are expanded, swollen and twisted veins in which the venous valves are no longer functioning properly.  When standing or sitting, the blood in these pathologically altered veins is no longer transported back rapidly enough to the heart.  This results in so-called vascular congestion. Varicose veins usually do not constitute a serious medical condition.  For many people, they are simply a cosmetic concern, while for other varicose veins cause aching pain and discomfort.  Nevertheless, if this venous disease progresses, it can cause much more severe issues like venous leg ulcers.

Varices can lead to symptoms like:

• Heavy and tired legs
• Aching and/or swollen legs 
• Muscle cramps in your legs at night, particularly the calf muscles
• Dry and itchy skin in the affected area, which may sometimes be discolored
• Varices may also hinder wound healing, due to the tissue being under-supplied with blood

If you are experiencing some of these symptoms and a medical professional recommends treatment, there are a few options available.  Compression, for example, is an effective method of relieving the symptoms. Additionally, exercising regularly and elevating your legs when you sit or lie down is highly beneficial. If you are still in discomfort, or have any concerns, consult your doctor – they can help you further. Varicose veins are usually caused by weak vein walls and valves.  The veins contain exceedingly small one-way valves that open to let the blood through, and then close to prevent it flowing backwards. Sometimes the walls of the veins stretch and lose their elasticity, causing the valves to weaken. If the valves do not function properly, this can cause the blood to leak and flow backwards.  If this happens, the blood collects in the veins, which become visibly swollen and blue. The reasons why the walls of the veins stretch and the valves in the veins weaken are not fully understood.
Note: the above description describes primary varicose veins, but there is also a secondary type of varicose veins.  This occurs when a clot blocks the blood vessel so that the blood flow is disturbed, such as in the case of deep vein thrombosis.

The following factors can all influence your likelihood of developing varicose veins:

• Family history
• Personal medical history of blood clots
• Obesity
• Gender (women are more likely to develop the condition than men)
• Older age
• Long periods of standing or sitting
• Hormonal changes, e.g.  pregnancy, birth control medication, or hormone replacement therapy

 

Venous Leg Ulcers

Chronic venous diseases are quite common.  If the disease progresses, varicose veins and symptoms of chronic venous insufficiency occur which already associated with considerable impairment in quality of life.  However, chronic venous leg ulcer, an open wound on the leg, is the most severe manifestation of this disorder.
With impaired blood transport in the leg, blood is not transported back to the heart quickly enough.  It accumulates in the veins of the lower leg and exerts pressure on the venous walls.  Fluid collects in the surrounding tissue, which makes the legs swell.  This also compromises the supply of oxygen and nutrients to the skin and underlying tissue.  This deficiency can lead to poorly healing wounds in the long run, which are known by several names, such as leg ulcer, venous leg ulcer, or open leg (ulcus cruris).  

Venous insufficiency is the most significant cause of leg ulcers.  In addition, deep vein thrombosis, arterial insufficiency, diabetes mellitus, infections, and other less frequent causes are involved in the development of venous leg ulcers.  You should consult your doctor and seek treatment as soon as possible if you experience any of the following leg ulcer symptoms:

• An open wound
• Swelling, cramping, heaviness and general discomfort in the legs or ankles
• Varicose veins
• Reddish, dry, and itchy skin
• Discolored skin (red, purple, brown) that may feel slightly hard around the ulcer
• In the event of infection: increased pain, unpleasant odor, discharge emitting from the ulcer, redness and swelling in the affected area

The following factors contribute to a higher risk of developing a venous ulcer:

• Older age
• Smoking
• Obesity
• Previous injuries, such as broken bones, or surgery to the leg
• Varicose veins or deep vein thrombosis
• Immobility, difficulty walking

Compression therapy is an important part of treatment for venous leg ulcers, alongside the latest wound care options such as the Cutimed product range. Wearing compression bandages or compression stockings improves the ability of the blood to flow towards the heart and significantly increases the chances of healing. If you suffer from venous leg ulcers, you should also do plenty of exercise to stimulate blood circulation by activating the calf muscle pump. If you are overweight, reducing your body weight is also advisable to aid the healing process.

 

Thrombosis Prophylaxis

Thrombosis prevention is also known as thrombosis prophylaxis. It comprises treatments that are designed to counteract the formation of blood clots inside blood vessels. These prevention measures often begin just after someone has had surgery, as this puts them at higher risk of having deep vein thrombosis, largely due to lack of movement afterward.  Additionally, DVT (deep vein thrombosis) is often linked to air travel as sitting in confined spaces without moving for long periods of time negatively influences the blood flow in the vessels.

Being aware of these common risk factors, and taking steps to avoid them, is an important part of helping to prevent thrombosis:

• Lack of exercise
• Taking oral contraceptives
• Being overweight/obese
• Smoking
• Dehydration
• Long periods of inactivity, lying or sitting down, such as on long journeys (especially long-haul flights) or while in hospital.

A risk assessment is a helpful way to begin DVT prophylaxis begin with a risk assessment. The risk assessment considers risk factors related to exposure (type of surgical procedure/trauma/acute disease, extent of immobilization) and disposition (individual inherited and acquired factors).  In addition, the health status (diseases such as cancer, the age, dehydration, obesity, the VTE risk and the bleeding risk) influences the personal risk for DVT development. There are several ways to help prevent thrombosis. For example, wearing compression stockings can help reduce swelling in tissues and promote better blood flow. In high-risk patients – such as hospitalized patients at increased risk of thrombosis who are bleeding or are at high risk of major bleeding – medical compression stocking (MCS) (from 15 to 30 mmHg) and anticoagulant thromboprophylaxis are recommended.  Medical compression stockings are especially recommended for thromboprophylaxis if anticoagulants are contraindicated. Their use is also suggested during long-distance travelling, to prevent DVT incidence in patients at risk. This is especially effective when combined with regular exercise during the journey, such as walking down the aisle and doing leg exercises. Drug therapy is also a quite common form of thrombosis prophylaxis. The use of compression stockings and medication can be supplemented with the simple technique of resting with your legs above the level of your heart. This can be done after surgery, for example, which assists in taking pressure off the legs and promotes the flow of blood out of the leg veins and to move throughout the body.

 

Chronic Edema

Chronic edema is a term used to describe a group of conditions characterized by swelling that has been persistent for greater than three months. It is caused by the accumulation of excess fluid within the interstitial space of the affected area(s) and may occur as a result of many disease processes. The terms chronic edema and lymphedema are often used interchangeably. This is because any form of edema results from some degree of lymphatic impairment or overload of the system– either because the lymphatic system is not working properly (primary or secondary), or there is simply too much fluid for a normal lymphatic system to process. Chronic edema can occur due to damage of the normal lymphatic system during surgery, infection, injury or result from an underdeveloped lymphatic system (genetic abnormalities). In the case of chronic venous disease, the poorly functioning veins results in pooling of blood in the legs and higher venous pressures. This leads to an overload of the lymphatic system, which may then lead to lymphatic failure and chronic edema (also called Phleblymphedema).

 

Diagnosis of Lymphatic and Venous Diseases

Lymphatic and venous diseases are a group of conditions characterized by compromised lymphatic or venous systems (or a combination of both), commonly resulting in swelling.  There are many different causes of swelling and successful treatment is dependent on correct diagnosis. 

Diagnosis of lymphatic and venous diseases requires a comprehensive medical assessment, to ensure that the correct underlying issue(s) are identified, and other possible causes are excluded.  This medical assessment will be completed by a doctor or specialist who has expertise in lymphatic and venous diseases.  Diagnosis is made based on medical history and physical examination.  Family history may also be explored, when investigating possible inherited lymphatic or venous diseases. Specialist imaging may be requested at this time, should further information be required. This may include:

• Magnetic Resonance Imaging (MRI)
• Computed Tomography (CT)
• Ultrasound (US)
• Lymphoscintigraphy
• Indocyanine Green (ICG)

Other specialist investigations may include genetic testing (if primary lymphedema is suspected), specialist vascular imaging or blood tests (to exclude other conditions). Once the cause of the swelling has been identified, treatment options will be explored. If an underlying lymphatic or venous disease is confirmed, referral to a lymphedema practitioner or experienced health professional may be suggested for the commencement of treatment as required.