Indocyanine Green Demonstrating Positive Anatomical Changes 1 Year After Initiation of Conservative Therapy for Lymphedema: A Case Report

Abstract

Introduction: Lymphedema is the abnormal accumulation of protein-rich fluid due to a damaged or insufficient lymphatic system. Lymphatic vessels can be mapped using indocyanine green (ICG). The purpose of this case report is to demonstrate anatomical changes after 1 year of conservative care as demonstrated through ICG for the first time to the authors' knowledge. Case Description: The patient was a 53-year-old woman who reported a 7-year history of left lower extremity swelling. She completed a short course of physical therapy elsewhere and wore a thigh-high compression garment of 20 to 30 mm Hg. She noted worsening of swelling over time and no longer got resolution of swelling with elevation. She presented to a multidisciplinary clinic for further evaluation and treatment. Objective Findings: The patient completed ICG lymphography demonstrating bilateral disease states in her lower extremities: Campisi stage II with lymphographic stage IV in the right lower extremity and lymphographic stage V in the left lower extremity. Bioimpedance scores, body mass index (BMI), and circumferential measurements were documented as well. Interventions: The patient underwent physical therapy including manual lymphatic drainage (MLD), increasing compression garment to 30 to 40 mm Hg, beginning use of a compression pump at home, exercise, and instructing the patient in self-MLD. There were 6 treatment sessions over a 3-month period. Assessment: At 1-year follow-up, the patient had positive changes in her bioimpedance scores, circumferential measurements, BMI, and ICG lymphography studies. Her ICG lymphography demonstrated increased “linear” patterns instead of diffuse or stardust patterns, suggesting improved lymphographic staging. Discussion: These findings imply that conservative therapies positively affect anatomy and physiology in a compromised lymphatic system after 1 year, allowing the system to work more effectively. These changes indicate lymphangiogensis, recanalization, or tissue recovery, but a causal relationship cannot be drawn at this time. These conservative therapies include complex decongestive therapy (MLD, compression, exercise) and weight loss.