ICG imaging - A decade of learning and progress
By Jane Wigg, Director/ Clinical Nurse Consultant Lymphoedema Training Academy/ LymphVision
Back in 2011 I was fortunate enough to attend a conference that started to introduce the concept of ICG imaging, a year later things were moving fast and in 2013 Prof Belgrado presented on FG-MLD (Fluoroscopy Guided MLD) and ‘Fill and Flush’ at several conferences. In 2014, following training, the Lymphoedema Training Academy changed its MLD technique to reflect this knowledge and commenced FG-MLD training in October 2014.
When your eyes are opened they cannot go back but in reality as Prof. Belgrado says ‘we are at the stage with this technology of still only having one eye open’- we have so much more to learn and technology is advancing to allow us to see more better.
I knew that I needed to bring this technology to patients and I bought my Photodynamic Eye (PDE) camera in 2014 and set up LymphVision.
It’s not been an easy journey as many of you may know but it has been worth it, it has changed and continues to change the lives of many.
ICG imaging has changed everything, forever. For the first time we could see lymphatics moving in real time, but that’s old news now!
What is ICG imaging?
A very small amount of a reflective dye (Indocyanine Green) is injected just under the surface of the skin (intradermal). Using a PDE camera, the image is reflected to a screen, and images are similar to a moving x ray. In normal anatomy, the dye gets absorbed by the lymphatics and is taken into the system to drain.
We see the normal route that the lymph will take when it leaves the microcirculation and drains back. Where there are abnormalities, we see congestion or redirection of the lymphatic drainage. We can see valves in the lymphangions and if they are functioning and continent. With this information, we can diagnose, confirm or exclude lymphoedema, some of its types and causes; we can instruct on treatment, and improvement of care and, of course, specific manual lymphatic drainage pathways for individuals.
How does it help patients?
What we now understand is that our bodies choose the route which lymph drains, usually the most direct and with that, we have little choice to manipulate that route. Now that thousands of people living with lymphoedema have been mapped, we have a better understanding of where the most common routes may be.
However, we have discovered alternative and interesting routes and ways the body copes that we would never have expected. This is allowed for us to recommend bespoke drainage programmes for manual lymphatic drainage and treatment plans. Some of these examples are the ‘Belgrado pathway’ where we see that drainage of lymph from one foot, will drain up, and drain across the abdomen, and down the opposite leg. We also see drainage pathways from the foot, exit at the hip region, deep into the trochanter region. We have identified that the smaller lymphedema leg is filling the larger leg, we have identified that some breast oedema is caused due to the failure of the arm and filling the breast but sometimes the arm does not fill the breast and it is caused due to, for e.g. radiotherapy scarring.
We have been able to identify the presence of oedema where people have been informed it is not present. This gives reassurance to the person who has the lymphoedema when they have been previously misinformed although their body felt to them like they had an oedema.
We have given reassurance that lymphoedema is not present and someone may have been wearing garment for years when they did not need to and were misdiagnosed. We have been able to provide more accurate diagnosis instead of a generic ‘primary lymphoedema’.
We have informed on insurance claims for clients for ongoing support and treatment. We've been able to advise people undergoing surgery of which lymph nodes or pathways to avoid, if possible, which can assist for improved outcomes following surgery. We've been very fortunate in surgeons accepting advice and trying to work with solutions wherever possible.
We also provide ICG imaging pre surgical for people undergoing liposuction for lipoedema. This is often a prerequisite for surgery particularly those travelling abroad for liposuction.
Our extensive knowledge has allowed for us to support people with unusual diagnosis and unusual presentations of lymphoedema or sensations of swelling. At LymphVision, our expert team also go above and beyond with differential diagnosis which is outside of lymphoedema, lipoedema and vascular abnormalities. This supports changes in treatment and increase confidence in diagnosis. For some we continue to hit brick walls in trying to secure that diagnosis with medical teams and referral onto correct departments.
Our extensive work has allowed for us to publish new lymphatic pathways, it is allowed for us to change myths and concepts of manual lymphatic drainage, the main one being “not to waste anymore life carrying out lymphatic drainage that is not necessary to areas that are fully functioning”. Our publication ‘LTA compendium of best practice’ includes some of our studies https://www.lymph.org.uk/shop-products
The drainage pathways published here and with further work from The team at Macquarie university (Australia), demonstrate that there is no need to drain the leg to the axilla, unless you are the 3% who drain there. Presuming that most of the lymphoedema population fit in the 97% who don’t drain their foot to the axilla, gives back time, times and alters self management.
Some of the information gained is not rocket science we have been able to understand that if we empty lymph nodes, we need to empty them well. At LTA we do this with the use of a softball into the axilla, groin or other nodal areas in order to ensure that the lymph nodes are emptied appropriately. We also understand the more frequently the nodes are emptied, the more the lymph has the ability to drain into them and allow forward drainage.
ICG imaging has allowed for the investigation into products including electro-stimulant devices and effects of compression. You will have noted changes to garments over the last decade since understanding what happens with compression on Dermal Rerouting and how top bands can cause obstruction. When the above is cascaded into training, change is happening and treatment and care improving.
ICG imaging has not only opened my eyes, it's open the eyes of our patients who when they see where their lymphatics are blocked or obstructed or where they are draining too, they can change their own self-management accordingly. This can be life changing for lifestyle and saves time.
What hasn't happened over the last 10 years is the uptake of ICG imaging on a larger scale. Although there are many benefits to it, it isn't been seen as a priority and therefore is still sits under private care. Unfortunately that means it's out of the reach for many but on that note, I'd like to say that those who do have further investigation, receive time back in their lives from understanding their diagnosis and how to manage it better and are building evidence for others.
My job will be done when I see ICG imagining paid for to the NHS.
In summary, I would never change this process, it allows for so many advantages which have taken place to not only individuals lives but added to the bigger picture of training healthcare professionals with open eyes and that has a cascade effect into other patient care, and for that every single hurdle has been worth its weight in gold.
Jane Wigg
Director/ Clinical Nurse Consultant
Lymphoedema Training Academy/ LymphVision
www.lymph.org.uk Office +44 300 180 0122
www.lymphvision.com +44 300 180 0112
Winner; World Union Wound Healing Society (WUWHS), Compression and MLD award, 2021
Winner; British Journal of Nursing (BJN), Chronic Oedema Nurse of the Year, 2020
Winner; Journal of Wound care (JWC), Professional Education Award, 2019
Winner; British Lymphology Society (BLS), Innovation in Practice Award, 2017
Finalist; British Journal of Nursing (BJN), Chronic Oedema Award 2017, 2018
Finalist; Royal Collage of Nursing (RCN), Innovation In Nursing Award, 2017
