Digital Volumetric Measurements Based on 3D Scans of the Lower Limb: A Valid and Reproducible Method for Evaluation in Lymphedema Therapy

BACKGROUND

Exact quantification of volumetric changes of the extremities is difficult and often error-prone. The aim of this study was to establish a standardized method based on 3-dimensional (3D) scans. Furthermore, this study tests the method in terms of reproducibility and evaluates volume changes after surgical therapy in patients suffering from lymphedema on the lower extremity.

METHODS

3D scans of the lower limb were performed with a mobile 3D scanner; "repeatability" and "interobserver reliability" of digital volumetry were tested. Furthermore, the method was applied on 31 patients suffering from chronic lymphedema.

RESULTS

Calculations of repeatability of the volume based on 20 3D scans of the same lower leg showed a mean volume of 2.488 ± 0.011 liters (range: 2.470-2.510). The mean volume of the different examiners did not differ significantly (F(2,18) = 1.579, P = 0.233). The paired t-test showed a significant mean volume decrease of 375 mL (95% confidence interval = 245/505 mL) between pretreatment and post-treatment (t (30) = 5.892, P < 0.001).

CONCLUSIONS

3D volumetry is a noninvasive, easy, and quick method to assess volume changes of the lower leg. Other than the low costs, it is reproducible and precise and therefore ideal for evolution of therapy in lymphedema.

Segmental differences in daytime changes of leg volume

BACKGROUND

The aim of our study was to comparatively assess volume changes related to daily occupation of the whole leg (WLv), of the lower leg (LLv) and of the upper leg (ULv) in subject with no venous and lymphatic disorders.

METHOD

WLv, LLv, and Ulv were evaluated by water displacement volumetry (WDV) in the morning and in the evening in 20 healthy subjects.

RESULTS

In the legs with occupational edema (OE), WLv increased by 7.07%, LLv by 5.25%, and ULv by 9.80%. In legs without clear OE, WLv increased by 2.41%, LLv by 1.35, and ULv by 3.38%.

CONCLUSIONS

Surprisingly, the increase of ULv was greater than that of LLv. An evening increase in the leg volume also occurred in legs with no clear OE. In our series, a clinically evident OE was related to an increase of the WLv, LLv, and ULv greater than 5.83%, 8.68%, and 1.88%, respectively.

Performance of an adjustable compression wrap in occupational leg swelling

BACKGROUND

Edema in some subjects worsens over time and wraps help to reduce the leg volume.

MATERIAL AND METHODS

An adjustable compression wrap was tried on volunteers for 5 h and volumes measured in each limb before and after wrapping using a 3D surface scanner (HandySCAN 3D®) to estimate the volume of the leg. The contralateral leg was used as control.

RESULTS

We observed a significant decrease in volume in the wrap legs and an increase in the control legs (p < .001), both in the lower part of leg (p = .001) and in the upper part (p = .001).

CONCLUSIONS

Using the Readywrap® for 5 hours significantly reduces the leg volume. This study enables Readywrap to be studied in a population that is easy to observe in the context of a research program. The Handyscan3D® was shown accurate and reproducible to assess leg volume in future studies.

Ultrasonographic study of the effects of compressive stockings on legs with venous edema

OBJECTIVES

The occurrence of leg edema in patients with chronic venous disease (CVD) is currently evaluated by visual inspection, palpation, and measurement of limb circumference. The changes of soft tissues morphology in swollen legs have been poorly investigated by ultrasonography (US) in the past. The purpose of this study was to evaluate the effects of medical compression stockings (MCS) on the US morphology of the cutaneous and subcutaneous layers (CL and SCL, respectively) in legs with venous edema.

METHODS

The morphology of the cutaneous and subcutaneous layers (CL and SCL) was evaluated by US in 18 swollen legs with chronic venous disorders (CVD), before and after 4 weeks of treatment with MCS. Skin morphology was evaluated by using an 8-14 MHz probe with a dedicated setting, 5 cm above the medial malleolus.

RESULTS

MCS provoked both quantitative and qualitative changes. A reduction of CL/SCL thickness greater than 20% was observed in 16/18 legs. A reduction of the SCL echogenicity was observed in 14/18 legs. Nine out of 12 legs which showed abnormalities of the CL before treatment showed a structural rearrangement of the dermis and the reappearing of the dermo-hypodermic junction.

CONCLUSIONS

The reduction of the SCL thickness is to be ascribed to the increase of veno-lymphatic drainage promoted by MCS. The reduction of tissue echogenicity by MCS is a quite innovative concept and it is suggestive for an anti-inflammatory action of MCS on skin tissues.

Reduction of lower-limb edema in patients with chronic venous disease by micronized purified flavonoid fraction: a systematic literature review and meta-analysis

INTRODUCTION

The prevalence of lower limb edema is high among patients with chronic venous disease (CVD). Several clinical studies with various designs have assessed the effect of micronized purified flavonoid fraction (MPFF) on edema. The aim of this work was to provide a comprehensive and accurate evaluation of the reduction in ankle and calf circumference as an indicator of lower limb edema reduction in patients with CVD treated with MPFF by combining studies that use different designs in a single group meta-analysis.

EVIDENCE ACQUISITION

We conducted a systematic literature review in April 2022 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria to identify prospective studies investigating the effect of oral MPFF treatment 1000 mg/day on ankle and calf circumference in patients with CVD. Studies with population including at least one patient with an ulcer were excluded. All prospective studies irrespectively of design (i.e., interventional and non-interventional studies, randomized controlled trials (RCTs), non-randomized studies, studies without a control or reference treatment) were eligible. The Medline, Embase and Cochrane databases were searched. Endpoints were ankle and calf circumference measurements and their overall mean change from baseline estimated with random-effects meta-analysis methods. The evaluation criterion feeling of swelling was also analyzed as a standardized mean change (SMC) with 95% confidence intervals after combination of quantitative scales.

EVIDENCE SYNTHESIS

Among 861 articles identified, eight studies (five RCTs including one placebo-controlled, three non-comparative studies) met the criteria. The overall population consisted of 1635 patients, predominantly female (89% ranging from 64% to 94%) with a mean age of 47 years ranging from 41 to 48 years. Mean reduction in ankle circumference was 6.0 mm (95%CI: 3.6 to 8.4; P<0.001) and 7.0 mm (95%CI: 0.9 to 13.1; P=0.024) after two and at least six months of treatment respectively. The results were similar when considering the study type RCTs and non-RCTs. Mean reduction in calf circumference was 5.7 mm (95%CI: 2.8 to 8.6; P<0.001) and 6.7 mm (95%CI: 5.2 to 8.1; P<0.001), at two months and at the last post-baseline evaluation respectively. Heterogeneity among studies was statistically significant (degree of consistency I2=93.5%; P<0.001 and I2=81.1%, P<0.01 for ankle and calf circumference, respectively). In the three studies reporting the effect on feeling of swelling a significant standardized mean change (SMC) reduction of 2.2 (95%CI: 0.2 to 4.2; P=0.028) on a quantitative scale was observed after two months of treatment with MPFF.

CONCLUSIONS

MPFF appeared to be effective in reducing ankle and calf circumference as well as feeling of swelling irrespective of study design. The circumference reduction is present at short and long term, suggesting that benefit occurs early and is maintained overtime. Despite the observed heterogeneity among included studies, this meta-analysis supports the significant therapeutic efficacy of MPFF in reducing lower-limb edema in patients with CVD. The complete video presentation of the work is available online at www.minervamedica.it (Supplementary Digital Material 1: Supplementary Video 1, 5 min, 192 MB).

Bioimpedance as a measure of fluids in patients with septic shock. A prospective observational study

BACKGROUND

Septic shock is often treated with aggressive fluid resuscitation leading to profound fluid overload. The assessment of fluid status relies on suboptimal measures making treatment difficult. Bioelectrical impedance analysis is an alternative but the validity is unclear. The aim of this study was to determine the validity of bioelectrical impedance analysis for fluid measures in patients with septic shock.

METHODS

Single-center, prospective observational cohort study. We included adult ICU patients with septic shock. We evaluated the agreement between measures on the left and right side of the patient and measures 1 h apart by two bioelectrical impedance devices. Results are presented as Bland Altman plots with 95% Limits of Agreements (LoA) and as correlations between bioelectrical impedance analysis results and clinical markers of fluids.

RESULTS

Forty-nine patients were included. The agreement between measures on the left and the right side of the patient and after 1 h was overall without bias, but with wide LoA's. Fluid overload 1 h apart showed the most narrow 95% LoA (-2.4-2.9 L). The same wide limits of agreements were observed when comparing devices. For example, total body water with 95% LoA of -14.8 -16.7 L. Correlations between bioelectrical impedance analysis and clinical measures were low but statistically significant.

CONCLUSIONS

In patients with septic shock bioelectrical impedance analysis had no systematic errors or bias, but wide limits of agreement, indicating that the devices have a large and uncorrectable random error. Fluid status by bioelectrical impedance analysis is not sufficiently accurate to guide treatment in this group of patients.

Three-dimensional laser scanner as a new tool for measuring lower limb volume in patients with chronic venous diseases

OBJECTIVE

Measurement of lower limb volume in patients with chronic venous disease (CVD) is necessary for assessing severity at the time of diagnosis and evaluating response to therapy administered. Existing methods have some limitations in clinical application and accuracy. The study aimed to investigate the reliability and validity of a three-dimensional laser scanner (3DLS) in measuring the lower limb volume of patients with CVD.

METHODS

A total of 30 patients with CVD (mean age, 55.6 ± 8.07 years; mean body mass index, 24.61 ± 1.87) were recruited in a vascular surgery clinic. The lower limb volumes of all participants were measured using the 3DLS and circumferential method (CM). Statistical analysis was conducted to compare the 3DLS and CM.

RESULTS

There was a strong correlation between the CM and 3DLS method (r² = 0.9065). The 3DLS had a high intraoperator and interoperator reliability. A Bland-Altman plot showed satisfactory agreement between the two methods. The 3DLS demonstrated greater bilateral limb differences than CM.

CONCLUSIONS

There was satisfactory agreement between the two investigated methods. The 3DLS method was confirmed to be accurate, repeatable, and rapid in measuring the lower limb volume in patients with CVD and is, therefore, suitable for clinical use.

Clinical Perspectives and Management of Edema in Chronic Venous Disease—What about Ruscus?

Background: Edema is highly prevalent in patients with cardiovascular disease and is associated with various underlying pathologic conditions, making it challenging for physicians to diagnose and manage. Methods: We report on presentations from a virtual symposium at the Annual Meeting of the European Venous Forum (25 June 2021), which examined edema classification within clinical practice, provided guidance on making differential diagnoses and reviewed evidence for the use of the treatment combination of Ruscus extract, hesperidin methyl chalcone and vitamin C. Results: The understanding of the pathophysiologic mechanisms underlying fluid build-up in chronic venous disease (CVD) is limited. Despite amendments to the classic Starling Principle, discrepancies exist between the theories proposed and real-world evidence. Given the varied disease presentations seen in edema patients, thorough clinical examinations are recommended in order to make a differential diagnosis. The recent CEAP classification update states that edema should be considered a sign of CVD. The combination of Ruscus extract, hesperidin methyl chalcone and vitamin C improves venous tone and lymph contractility and reduces macromolecule permeability and inflammation. Conclusions: Data from randomized controlled trials support guideline recommendations for the use of Ruscus extract, hesperidin methyl chalcone and vitamin C to relieve major CVD-related symptoms and edema.

Time Course of Leg Edema after Endovenous Radiofrequency Ablation for Saphenous Varicose Veins

BACKGROUND

The objectives of the study were to quantitatively evaluate leg edema in patients undergoing endovenous radiofrequency ablation (RFA) for saphenous varicose veins using bioelectrical impedance analysis (BIA) and to elucidate the time course of leg edema after RFA.

METHODS

The data of 87 patients with 128 limbs undergoing RFA for saphenous varicose veins in Eniwa Midorino Clinic from April 2018 to November 2019 were retrospectively analyzed. Saphenous vein reflux was evaluated by duplex scan. Extracellular water/total body water ratio (ECW/TBW) of the leg was measured by BIA. Moderate to severe leg edema (ECW/TBW ≥ 0.400) was defined as significant leg edema. Venous reflux was evaluated as a venous filling index (VFI) using air plethysmography.

RESULTS

BIA revealed that 26 legs (20.3%) had significant edema and 102 legs (79.7%) did not before RFA. The proportion of patients with significant leg edema increased significantly from preoperative to 1 week after RFA (P < 0.05) and decreased 1 month after RFA (P < 0.01). The ECW/TBW increased significantly from preoperative (0.393 ± 0.008) to 1 week after RFA (0.394 ± 0.008, P < 0.05), whereas it decreased significantly before or 1 week to 1 month after RFA (0.391 ± 0.008, P < 0.05). There was a significant, moderate correlation between the decrease of the VFI and that of ECW/TBW (r = 0.34, P < 0.001).

CONCLUSIONS

This is the first study to quantitatively elucidate the time course of leg edema after RFA. Leg edema worsens one week after RFA, but it is improved one month after RFA, compared with that preoperatively.

The effects of water immersion and walking on leg volume, ankle circumference and epifascial thickness in healthy subjects with occupational edema

BACKGROUND

Balneotherapy has been considered beneficial in patients with chronic venous disease due to patient-reported positive outcomes on improvement of symptoms and quality of life.Study aim: Assessing the effects of prolonged water immersion (WI) on leg edema and epifascial thickness and to compare these data with those achieved after continuous walking on ground.

MATERIAL AND METHODS

On three consecutive days, 14 otherwise healthy volunteers (9 females, 5 males, mean age 53 ± 10 years) affected by occupational edema (OE), defined as the edema developing during the time period of the working day and disappearing overnight, stayed standing immobile in a swimming pool for 30 minutes (30'), continuously walking again for 30' in the same pool and walking on ground for 30' without interruptions in a randomized sequence. Leg volume, ankle circumference and epifascial thickness of both legs were assessed each day before and after each intervention.

RESULTS

Leg volume showed a median reduction by 4.20% (IQR 5-3.6) (p = 0.0002) after 30' of immobile standing immersion and by 6.50% (IQR 7.30-5.61) (P < 0.0001) when the patients walked in the pool. Ankle circumference showed a median reduction by 2.89% (IQR 4.23-2.03) (p = 0.02) with the subjects staying standing still in water and by 5.98% (IQR 7.47-4.14) (p = 0.0002) after 30' walking in the pool. Epifascial thickness showed a median reduction by 24.35% (IQR 35.26-22.5) (P < 0.0001) when the volunteers remained standing still and by 32.66% (IQR 36.91-28-84) (P < 0.0001), when walking in water. Leg volumetry showed a median reduction by 0.20% (IQR-0.44-0.29) (p = 0.375) after walking on ground for 30'. Ankle circumference and epifascial thickness did not show any difference walking on ground compared to baseline situation.

CONCLUSIONS

This study showed that 30' of WI, especially when associated with walking, reduced leg volume in otherwise heathy subjects with OE and that walking outside the water did not.

Swollen Lower Limbs in Patients with Negative Pitting Test Leg Oedema: Prediction of Water Displacement Changes by Anthropometry and Bioimpedance Spectroscopy

The assessment of lower limb oedema almost always involves measuring leg volume, and the gold-standard for this is the water displacement technique. As it is not very practical to use in a clinical routine, physicians prefer indirect methods such as anthropometric or bioimpedance measurements. In the case of "non-pitting" leg oedema, i.e. where the presence of oedema is not obvious, it may be challenging to estimate changes in leg volume using these methods separately. The combination of these two methods, however, gives interesting results, such as a new composite parameter that is much more robust and efficient than commonly used parameters.Clinical Relevance- This study demonstrates the benefit of using a composite anthropometric-impedimetric parameter to predict water displacement variations in the leg over the course of a day, rather than using parameters based solely on anthropometry or impedance. Our new parameter (C²-A²)/R₀ showed a robust r² value of 61%, which is more than twice the r² values obtained using other simple or composite parameters.

Comparison between bioelectrical impedance spectroscopy measurements and water volume displacement of ankle oedema variations during the course of a day

OBJECTIVE

The purpose of this study was to find relationships between variations in bioelectrical impedance spectroscopy (BIS) measurements and those obtained by water displacement (WD) and calf (C) and ankle (A) perimetry on legs of patients with venous insufficiency and lower limb oedema, some with positive pitting test (PPT), others with negative pitting test (NPT).

APPROACH

Twenty-nine (29) female subjects were clinically examined prior to inclusion in the trial. Measurements were taken once in the morning and then 6 h later, using perimetry, WD, and then BIS; subjects were standing. Leg volume was assessed using two WD volumeters, one 'Tall' (TWD) and one 'Short' (SWD). BIS was performed using a SFB7 impedance meter device (Impedimed^®).

MAIN RESULTS

Forty-three (43) legs with oedema were included. The results showed that 61% of the TWD variations variance was explained by SWD variations; less than 30% of the TWD variations variance was explained using BIS or perimetry alone, and 45% at best when used in combination. R₀, related to extracellular water, was the key BIS parameter. For NPT subpopulation (32 legs), the composite parameter (C² - A²)/R₀ explained more than 60% of the TWD variations variance. For PPT subpopulation (11 legs), small or statistically non-significant variance explanations were found.

SIGNIFICANCE

Combination of anthropometric and BIS parameters gave a better forecast of WD results than using only one or other. A novel composite parameter, (C² - A²)/R₀, better predicted TWD changes than other parameters hitherto used in literature, with improved estimates for the NPT subpopulation. Study n°ANSM 2017-A01063-50.

[Efficacy of micronized purified flavonoid fraction in treatment of chronic venous oedema]

AIM

The purpose of the study was to assess efficacy and safety of using in real clinical practice micronized purified flavonoid fraction (Detralex) in patients with chronic venous oedema.

PATIENTS AND METHODS

The study enrolled a total of 708 patients presenting with chronic venous disease, belonging to C3EpAsPr according to the CEAP classification (chronic venous oedema), who. depending on the accepted clinical practice by expert physicians were prescribed compression and phlebotropic therapy, as well as undergoing surgical interventions. The main criteria for efficacy of the micronized purified flavonoid fraction included the dynamics of chronic venous oedema, vein-specific symptoms, as well as the main parameters of quality of life. Assessment was made using visual analogue scales, the vein-specific questionnaire CIVIQ-14, and the method of discs for measuring the volume of the crus.

RESULTS

The obtained findings demonstrated significant positive dynamics of the main vein-specific symptoms assessed by a visual analogue scale. When comparing between the visits of recruitment into the study and its termination the feeling of heaviness in calves decreased form 5.38±2.19 cm to 1.56±1.56 cm (p<0.001), pain in the calf diminished from 4.24±3.39 cm to 1.12±1.37 cm (p<0.001), feeling of oedema dropped from 5.68±2.44 cm to 1.38±1.59 cm (p<0.001), severity of nocturnal cramps fell from 2.46±2.30 cm to 0.43±1.01 cm (p<0.001), and intensity of skin inching from 1.46±2.06 cm to 0.43±1.01 cm (p<0.001). Positive dynamics of venous-specific symptoms appeared to be accompanied by significant improvement of all dimensions of quality of life according to the CIVIQ-14 scale: by the pain scale from 41.0±19.1% to 12.8±11.6% (p<0.001), by the physical condition scale - from 31.6±23.8% to 11.1±15.4% (p<0.001), by the psychological state scale - from 24.5±21.1% to 5.7±9.0% (p<0.001). The global index of quality of life also improved significantly from 32.4±18.5% to 9.9±9.9% (p<0.001). The results of the intervention along all the examined parameters (external appearance, possibility of wearing various clothes and increasing the quality of the self-performed work, to improve both interactions with surrounding people and the social activity and rest) turned out better than expectations form an intervention. The volume of the crus as the main criterion over the period of follow up averagely by the group decreased from 3.07±0.84 to 2.78±0.80 litres (p<0.001). A significant decrease in the calf volume from 3.03±0.87 to 2.77±0.85 litres was observed in 288 patients who during the follow up period were not subjected to surgical interventions, with no significant differences in the dynamics of chronic venous oedema revealed between the operated patients and those having received conservative treatment alone.

DISCUSSION

According to a meta-analysis, the micronized purified flavonoid fraction (Detralex) turned out to possess better parameters in relation to therapy of chronic venous oedema as compared with other phlebotropic agents. Therefore, it appears absolutely logical to predominantly use the micronized purified flavonoid fraction in real clinical practice in patients with the CEAP C3 clinical class, which was registered in our study. An important result was also the fact that within the specified terms of follow up surgical intervention demonstrated no significant advantage over conservative therapy alone in treatment of chronic venous oedema. Moreover, conservative treatment in the form of a combination of compression and phlebotropic therapy demonstrated a dynamic decrease in the volume of the affected extremity with a probable transition of the CEAP C3 clinical class to C2.

CONCLUSION

The micronized purified flavonoid fraction (Detralex) at a standard daily dose of 1000 mg in a combination with compression therapy irrespective of the surgical intervention performed resulted in a significant dynamic decrease in the volume of the calf in patients with chronic diseases of lower limb veins (C3EpAsPr according to the CEAP classification). An anti-oedematous effect of the micronized purified flavonoid fraction (Detralex) in a combination with compression manifests itself during the entire period of treatment.

Single Blind, Randomised Study Regarding the Treatment of the Telangiectasia of the Lower Limbs (C1EAP) Using Polidocanol 0,5%, 1%, and Nd:YAG Laser

The treatment of leg telangiectasias could be done with liquid sclerotherapy or Nd:YAG laser. We evaluated randomly, in a simple blind, the efficacy of the treatment with 0,5% polidocanol (POL-0,5), 1% polidocanol (POL-1) and Nd:YAG laser (LAS) on 132 patient (264 limbs) with telangiectasia of the lower limbs with less than 2mm diameter (C1EAP). The main objective was to evaluate the efficacy of the sclerotherapy (chemical compared with Nd:YAG-LAS). Secondary objectives were: possible major complications (deep thrombosis, severe burns, ischemic complications, etc.), the percentage of the local complications, the cosmetic aspect-evaluated by both the patient and the doctor and the grade of discomfort of the patient during and after the procedure. Comparing the treatment with Nd:YAG laser (LAS), polidecanol-0.5% (POL-0.5), polidecanol 1% (POL-1), it was noticed that telangiectasias smaller than 1mm led to good and very good results in all the cases treated with Nd:YAG laser and the same outcome was obtained in one third of the subjects treated with POL-0.5, vs. 47.81% of patients treated with POL-1. When telangiectasias were larger than 1mm diameter, good and very good results occurred in 86.36% of patients treated with LAS and 100% of the cases treated with POL-0.5 and POL-1. In conclusion, we consider that leg telangiectasias can be treated with good results using Nd:YAG laser or sclerotherapy with polidocanol, Nd:YAG laser being reccomended for telangiectasia under than 1 mm diameter while sclerotherapy in larger vessels.