When are lymphedema pumps the answer?

The importance of activating the calf muscle pump in the treatment of lower extremity lymphedema came to the fore during the 2024 International Vein Congress (IVC) in Miami, Florida (April 18–20).

“There are a whole host of non-proffered approaches you can take,” said Brajesh Lal, MD, from Baltimore, Maryland, giving a presentation focused on when he believes is the best time to use lymphedema pumps and nonsurgical interventions. “Most important and primary are elevation of the limb, exercise if you’re dealing with lower extremity edema, which is what most of us will be dealing with, and activating the calf muscle pump.”

Lal pondered where pumps fit into a treatment paradigm that includes massage, exercise, and compression garments. There are numerous options for pumps on the market, including nonsequential pumps and those that provide both sequential and segmental compression, he said. One of the more recent to be introduced are non-pneumatic pumps. One of the biggest issues with pumps currently is that there are numerous guidelines that all claim to promote best practice, Lal continued, which he said are “limited by a lack of standard descriptions, a standard way of providing their recommendations, and, of course, a limited quality of the evidence available.”

“I want to be very careful separating out where there is evidence and where there isn’t, and where there is opinion,” he said. “All guidelines recommend initial decongestive therapy followed by maintenance decongestive therapy. Though the recommendation was strong, evidence for this approach has not been tested in any highly-quantitative manner.”

All guidelines also recommend elevation, exercise and compression garments, though they vary in how they express their recommendations, Lal explained, referencing the guidelines created by the American Venous Forum (AVF), “which is essentially a strong recommendation based on either moderate, moderate-good, and very good quality data.

“Manual lymphatic draining or massage has been given various grades even when the level of evidence is modest,” Lal said. “Pump-assisted compression, however, generally gets a low-moderate grade recommendation in view of the evidence available.”

There is another new form of lymphedema treatment arriving soon in the form of non-pneumatic compression devices, he added.

Ultimately, Lal said he uses pumps, as an adjunct to elevation, exercise and compression. “I use [them] in patients who have severe edema and very large limb volumes, those who have limited ambulation, and those who cannot apply compression devices when they go into the maintenance phase.”