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Lower-extremity edema is often encountered in clinical practice, and represents a manifestation of a variety of possible disease processes. Edema, especially when it is related to chronic venous disease, worsens after prolonged standing and improves after rest. Evaluation of the edema associated with chronic venous disease and the expected benefit of therapy with daflon® 500 mg has been evidenced in randomized, controlled studies as well as in open prospective trials. Ankle and calf circumference measurement was used in the two double-blind, randomized, placebo-controlled studies with daflon® 500 mg.
In the multicenter RELIEF study14 in which 5052 patients assigned C0s to C4 according to the clinical CEAP classification, edema was assessed by the Leg-O-Meter®. In 20 patients with CVD stage I-II of the Widmer’s classification, the optoelectronic method was used for assessing edema.15 Nine patients had post-thrombotic syndrome and 11 had varicose veins. Cospite compared daflon® 500 mg with diosmin and evaluated edema with a simple tape measure.16 The measurements of ankle and calf circumferences revealed significantly better efficacy in the daflon® 500 mg group (PFigure 6). In recent guidelines17,18 or extensive reviews19 on the treatment of chronic venous disease, daflon® 500 mg has been quoted as a better-established and well-tolerated anti-edema drug.
Edema results from fluid accumulation in the interstitial compartment of the extravascular space.1 This fluid retention clinically is shown by the “pitting” test. The etiology is multifactorial, revolving around the intricate balance of capillary blood and oncotic pressures, tissue pressures, lymphatic flow, and capillary permeability. Physical examination and diagnostic evaluation are mandatory to differentiate between different types of lower-extremity edema. Primary lymphedema which may occur as a hereditary (eg, Milroy’s disease) or a sporadic disease starts frequently in the distal part of the extremity.
The thrombosis often damages the valves with subsequent development of chronic venous disease. The cyst compresses the popliteal vein and subsequently the venous return, which can result in an acute DVT. Also this type of edema may form due to warmth, the summertime season, hot baths, and floor-based heating systems, and improve in winter and with cold temperatures. Acute glomerulonephritis, due to damage to the renal glomerulus, results in altered renal function.

These include corticosteroids, contraceptive pills, nonsteroidal anti-inflammatory drugs, certain antibiotics, etc.
Sudden onset suggests an acute process such as deep vein thrombosis (DVT), trauma, or infection. Redistribution of the extracellular fluid occurs after rest or sleeping in a horizontal position. The patient stands up and is requested to place her (his) lower limb in a plexiglas container filled in with water. The leg passes through a four-sided rigid frame which can be moved along a rail in the long axis of the limb.
The tape is pulled out of the box, put around the limb to measure and the end of the tape hooked to the box.
This device takes into account the height at which the measurement is taken, which greatly increases the precision and the reproducibility of the measurement.
In the study by Chassignolle et al,12 a significant decrease in ankle and calf circumferences was observed (P13 included the measurements of the calf (maximum circumferences) and ankle (minimum supramalleolar circumference) on each affected leg using a spring tape measure. Daflon® 500 mg is indicated as the firstline treatment of edema and the associated chronic venous disease-related symptoms (eg, edema, fatigue, nocturnal cramps, and heaviness) at any stage of the disease.
The causes for secondary lymphedema are related to traumatic or surgical disruption of the lymphatic system, or lymphatic obstruction (eg, filaria invasion). The incompetent valves result in transmission to capillaries of high venous pressure, promoting both fluid and protein loss into the interstitial tissues.
The CVD related edema is characterized by its diurnal variation, mainly worsened at the end of the day and relieved in the morning, after rest or elevation of the legs. The edema is non-pitting and not relieved by leg elevation, contrary to chronic venous disease- related edema. Whereas the gradual appearance of edema over weeks or months suggests chronic causes such as chronic venous disease, medications, or a progressive systemic process. Usually the dimension of the container, around 50 cm in height, allows the measurement of a volume of 2500 to 4000 mL including foot, ankle, and calf. The frame is equipped with infrared-detecting diodes emitting an infrared beam which allows precise measurement of the lower limb volume.

The tape is automatically tightened by a spring mechanism, guaranteeing that the tightening force is similar with all measurements. Limb circumference measurements for recording edema volume in patients with filarial lymphedema. Evaluation of a new vasoactive micronized flavonoid fraction (S 5682) in symptomatic disturbances of the venolymphatic circulation of the lower limb: a doubleblind, placebo-controlled study. Quantification of oedema using the volometer technique: therapeutic application of Daflon® 500 mg in chronic venous insufficiency. Advantage of micronisation of Daflon® 500 mg compared with a simple diosmin in the treatment of venous insufficiency. Hormonal impregnation, plasma and interstitial protein concentration, as well as leukocyte activation, play a role in edema formation. The venous, lymphatic, and capillary networks are often intricate and involved in the appearance of such an edema. Intermittent episodes of edema often occur with recurring erysipelas (cellulitis) or lymphangitis. All sorts of lower-limb edema including those related to CVD and lymphedema can be assessed using this method. Markers placed on the leg allow the identification of the upper and the lower reference point. There is increasing evidence that the leukocyte is a key cell in the chronic inflammation which leads to valve damage.
A classification has been proposed depending on which system is at the origin of edema formation7 (Table III). This might subsequently increase venous hypertension, which has direct consequences on increased capillary permeability and edema formation.
The history and investigations should focus especially on the cardiac, hepatic, and renal functions.

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