lymphnet.org / Lymphedema FAQs / Question Corner / July-September 2004

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LymphLink Question Corner

July-September 2004
Paula J.B. Stewart, MS, MD

Q:  I am a 39-year-old female smoker who was told recently by my doctor that I have Buerger's Disease. My symptoms are red, painful feet and mild-to-moderate swelling. I also suffer from Raynaud's syndrome and have blue painful fingers in the cold. Are these conditions related and can I treat the swelling like lymphedema?

A:  Buerger's smoking disease is related to smoking or chewing tobacco, which causes vaso-constriction of the smaller arteries of the hands and feet. The constriction can progress to the point of causing ulcers and gangrene. The condition most often affects young men 20-40 years of age. It is curable by discontinuing smoking. Sadly, many of those with Buerger's continue to smoke and ultimately end up with an amputation.

Other treatment options include the use of calcium channel blockers to reduce vaso-constriction. These can cause increased edema as a side effect of the medication and must be used with caution. This edema is primarily inflammatory and can respond to anti-inflammatory medications, however the COX-II inhibitors (such as Vioxx and Celebrex) can cause additional swelling and must be used cautiously. Finally, low compression stockings can be of benefit. However, it would be important to obtain an ABI or ankle-brachial index to measure arterial compromise. If the ABI is less than .5, no compression should be initiated. If more than .5, compression of 8-15 mmHg can be safely used for the patient's comfort.

Raynaud's is associated with Buerger's syndrome in 50% of the cases. It is thought that some component of tobacco–either nicotine and/or carbon monoxide–sensitizes the vasculature to constrict excessively, given a stimulus such as cold or stress.

Q:  I have venous stasis ulcers on both legs and a lot of swelling with thickened rough skin on my feet. My doctor says I can't wear stockings because my circulation is bad. He says my ABI is only .6. What does that mean and how can I treat the swelling and my ulcer?

A:  The ABI less than .9 indicates that your arterial circulation is compromised. Your doctor is worried that application of compressive wraps or garments may further compromise the blood flow to your legs. The stasis ulcers are indicative of venous compromise and usually respond best to compression such as an Unna boot or low-stretch bandages. In addition, your symptoms of fibrosis are suggestive of a secondary LE, which also responds best to low-stretch bandages. When the ABI is greater than .5, it is safe to apply compression lower than the capillary refill pressure of 32 mm/Hg. I typically do not apply more than 25 mm/Hg. There are, in fact, elegant studies demonstrating that arterial compromise in the setting of edema improves with mild compression. The edema seems to cause slightly worse arterial flow due to a "compartment" effect. Thus, I would suggest treating your legs with meticulous skin and wound care, manual lymph drainage, low-stretch bandages with no more than 25 mm/Hg and, eventually, be fitted for compression stockings of 15-25 mm/Hg. Hope this is helpful.

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