Lurie F, Malgor RD, Carman T, Dean SM, Iafrati MD, Khilnani NM, Labropoulos N, Maldonado TS, Mortimer P, O'Donnell TF Jr, Raffetto JD, Rockson SG, Gasparis AP, et al.
Phlebology. Date of publication 2022 May 1;volume 37(4):252-266.
1. Phlebology. 2022 May;37(4):252-266. doi: 10.1177/02683555211053532. Epub 2022 Mar
8.
The American Venous Forum, American Vein and Lymphatic Society and the Society
for Vascular Medicine expert opinion consensus on lymphedema diagnosis and
treatment.
Lurie F(1)(2), Malgor RD(3), Carman T(4), Dean SM(5), Iafrati MD(6), Khilnani
NM(7), Labropoulos N(8), Maldonado TS(9), Mortimer P(10), O'Donnell TF Jr(6),
Raffetto JD(11)(12)(13), Rockson SG(14), Gasparis AP(8).
Author information:
(1)92661Jobst Vascular Institute of Promedica, Toledo, OH, USA.
(2)University of Michigan at Ann Arbor, Ann Arbor, MI, USA.
(3)296427The University of Colorado, Anschutz Medical Center.
(4)5718Vanderbilt University Medical Center, Nashville, TN, USA.
(5)12306The Ohio State University Wexner Medical Center, Columbus, OH, USA.
(6)1867Tufts University School of Medicine, Boston, MA, USA.
(7)12295Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA.
(8)480303Stony Brook Medicine, Stony Brook, NY, USA.
(9)5894NYU School of Medicine, New York, NY, USA.
(10)4915St George's, University of London, UK.
(11)VA Boston Healthcare System, Boston, USA.
(12)Harvard Medical School, Boston, USA.
(13)Brigham and Women's Hospital, Boston, USA.
(14)10624Stanford University School of Medicine, Stanford, CA, USA.
BACKGROUND: Lymphedema imposes a significant economic and social burden in modern
societies. Controversies about its risk factors, diagnosis, and treatment
permeate the literature. The goal of this study was to assess experts' opinions
on the available literature on lymphedema while following the Delphi methodology.
METHODS: In December of 2019, the American Venous Forum created a working group
tasked to develop a consensus statement regarding current practices for the
diagnosis and treatment of lymphedema. A panel of experts was identified by the
working group. The working group then compiled a list of clinical questions, risk
factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions
that met the criteria for consensus were included in the list. Using a modified
Delphi methodology, six questions that received between 60% and 80% of the votes
were included in the list for the second round of analysis. Consensus was reached
whenever >70% agreement was achieved.
RESULTS: The panel of experts reached consensus that cancer, infection, chronic
venous disease, and surgery are risk factors for secondary lymphedema. Consensus
was also reached that clinical examination is adequate for diagnosing lymphedema
and that all patients with chronic venous insufficiency (C3-C6) should be treated
as lymphedema patients. No consensus was reached regarding routine clinical
practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool.
However, the panel came to consensus regarding the importance of quantifying
edema in all patients (93.6% in favor). In terms of treatment, consensus was
reached favoring the regular use of compression garments to reduce lymphedema
progression (89.4% in favor, 10.6% against; mean score of 79), but the use of
Velcro devices as the first line of compression therapy did not reach consensus
(59.6% in favor vs 40.4% against; total score of 15). There was agreement that
sequential pneumatic compression should be considered as adjuvant therapy in the
maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of
85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean
score of 27). Most of the panel agreed that manual lymphatic drainage should be a
mandatory treatment modality (70.2% in favor), but the panel was split in half
regarding the proposal that reductive surgery should be considered for patients
with failed conservative treatment.
CONCLUSION: This consensus process demonstrated that lymphedema experts agree on
the majority of the statements related to risk factors for lymphedema, and the
diagnostic workup for lymphedema patients. Less agreement was demonstrated on
statements related to treatment of lymphedema. This consensus suggests that
variability in lymphedema care is high even among the experts. Developers of
future practice guidelines for lymphedema should consider this information,
especially in cases of low-level evidence that supports practice patterns with
which the majority of experts disagree.
DOI: 10.1177/02683555211053532
PMCID: PMC9069652
PMID: 35258350 [Indexed for MEDLINE]
