Lymphatic Venous Anastomosis (LVA): pre- and postoperative protocols for improving patient outcomesBy: Lindsay Davey, MScPT, MSc, CDT
April 20, 2021
Editors: Ryan Davey, PhD and Lindsay Davey, MScPT, MSc, CDT
Have you recently undergone lymphatic venous anastomosis (LVA) surgery for lymphedema, or are considering it? As with other forms of surgery, appropriate preoperative preparation and postoperative care is necessary to achieve optimal results.
LVA is a relatively new surgical approach for treating lymphedema, and so pre- and postoperative protocols are not yet standardized. Through helpful discussions with LVA surgeon Dr. Siba Haykal and her group at the University Health Network in Toronto, here we describe our current understanding of what could be done before and after LVA surgery to enhance patient outcomes.
What is lymphatic venous anastomosis (LVA)?
In recent years surgeons have begun exploring lymphatic venous anastomosis (also known as ‘lymphaticovenular anastomosis’) surgery for treating early-stage lymphedema. Rather than a cure for lymphedema, LVA is intended to help patients reduce baseline swelling and make ongoing symptom management easier. In other words, for some patients LVA surgery may be a viable complement to the current ‘gold-standard’ approach to lymphedema treatment which consists of managing symptoms and preventing progression using Combined (or ‘complex’) Decongestive Therapy (CDT).
Lymphedema arises due to a fluid imbalance caused by damage or malformation of lymphatic structures (lymph vessels and nodes) in the affected tissue. The result is an accumulation of excess fluid (‘lymph’) which if left unmanaged will worsen and cause additional tissue changes such as chronic inflammation, tissue fibrosis (scarring) and localized immune system dysfunction. The goal of LVA is to connect (or ‘anastomose’) still functional lymphatic vessels to a nearby small vein, thereby enhancing the drainage of stagnant fluid out of the tissue. To learn more about LVA surgery and its effectiveness, please see our article: Lymphatic Venous Anastomosis (LVA) Surgery for Lymphedema.
Although the available clinical data on LVA is relatively small, and best practices are still being formulated, there is a strong theoretical and clinical rationale for robust preoperative and postoperative surgical protocols.
Preoperative preparations for lymphatic venous anastomosis (LVA)
Preoperative protocols are steps performed before surgery that can help increase the likelihood of an optimal surgical outcome. In the case of LVA surgery for lymphedema the following preparations should be made, typically with the assistance of a CDT therapist:
- Set realistic expectations through discussion with your surgeon. As with every medical procedure, patient satisfaction is immutably linked to patient expectation. LVA surgery does not cure lymphedema, nor is it likely to eliminate the requirement for ongoing symptom management. In some cases, patients do not report a significant improvement in their symptoms. Learn more about what you should expect from LVA surgery.
- Achieve maximum limb volume reduction prior to surgery through conservative approaches (CDT). Reducing your swelling (both volume and tissue density, if present) as much as possible in advance of surgery will encourage more rapid post-surgical healing and decrease the risk of infection. This is likely to require increased compliance with self-massage, massage by a CDT practitioner, and/or compression bandaging. Maximal limb volume reduction in advance of surgery will also allow you to establish more accurate baseline measurements.
- Establish symptom baseline measurements. This includes having a CDT therapist take circumferential measurements (standardized measurements every 4 cm on both arms); document tissue quality of the limb including pitting, density, and fibrosis; and recording subjective experiences as it relates to the affected limb (both sensory and functional).
- Establish a plan for immediate postoperative symptom control which should include traditional compression bandaging (it is important to make sure the necessary bandaging supplies are on-hand, or available from your CDT practitioner). Learning and employing self-management CDT techniques, and/or ensuring that adequate follow-up care with a certified CDT therapist is booked and ready to go. See more below.
Postoperative care following lymphatic venous anastomosis (LVA)
Postoperative protocols are steps performed after a surgery to assist healing and increase the likelihood of an optimal outcome for the patient. In the case of LVA surgery for lymphedema the following postsurgical steps are vital for ensuring the best possible results:
- Follow-up with a CDT therapist within a few days of surgery is ideal, to examine any acute stage changes, to record objective and subjective measurements, and to ensure an adequate management plan is in place. Learning when and how self-massage should be re-initiated post-op is essential.
- Concerted CDT management twice a week for 4-6 weeks consisting of regular lymphatic drainage massage and bandaging. The style of lymphatic massage differs from classic lymphatic massage in that it promotes flow in the direction of the newly created lymphatic-venous junctions. Both the massage and bandaging can be performed by the patient if trained and able, or by a certified CDT practitioner.
- Regular reporting on outcome measures including circumferential measurements taken every 2 weeks, any tissue quality changes and changes in the patient’s subjective experience.
- Follow-up with compression garment fitter to accommodate changes in limb volume or shape.
- Continue with routine lymphedema self-management moving forward.
Achieving an optimal outcome
LVA surgery will hopefully offer you concrete symptom relief while making ongoing symptom management easier, but it is not a cure. Equally important to understand is that LVA surgery will not in itself prevent further disease progression since the underlying lymphatic dysfunction remains. Poor post-surgical management of the remaining swelling is likely to lead to a gradual worsening of symptoms and progression of the condition, even beyond pre-surgical levels.
Appropriate pre- and postsurgical care is essential not only in order to achieve the greatest volume reduction and symptom improvement possible, but also in order to ensure that you keep any of the gains you have made.
Hi Lindsay, I have a leg that is larger than the other by 3 1/2 inches at the thigh. It is 1/2 an inch larger below the thigh. I had a total knee replacement in December and I’m trying to figure out if my thigh is larger due to my knee replacement and all the inflammation it caused or if I have developed Lymphedema. My PT team for my knee therapy said i could be larger due to inflammation and said it could be larger sometimes up to 2 inches due to swelling but did say it is larger than they would expect it to be which is why I’m seeing a vascular specialist. I have no lower limb swelling except I seem to have a response to heat that can make my ankles swell from time to time, but it goes down later in the day after I have rested them by putting them up above the heart. I am considered obese at 238 with a BMI above 30, trying to reduce it but I have a difficult time losing weight added that i am 59. I had 2 tests to see if my arteries were working ok and to rule out a clot, I got the assurance immediately that there is no clot and waiting results from doc but you could hear them during the test loud and clear during the test. A lot of my fat is below the belly. I do have a urinary incontinence issue that I had the band surgery back in 2008 for but then in 2015 I had to have it removed as it had gotten loose and and was causing pain from moving around trying to get out. Now its a constant battle to when I need to wear incontinence pads. Not sure if a incontinence issue could make one leg swell. I also developed a inner thigh fat pocket that I have been trying to get rid of but its a tough area. I just don’t know what I have going on. Sound anything like you have heard? Are there other things that could make my thigh swell?
Thank you so much for sharing your story. I am so sorry to hear of the struggles you’ve had with your thigh since your knee replacement in December, and the pre-existing incontinence issues and weight challenges. I can say up front, that water retention or anything urinary would be unlikely to be the cause for your thigh swelling, namely because we would expect to see the issue affect both legs more or less equally if that was the case (same goes for congestive heart failure, other kidney function issue, etc). I am very happy to hear they did a Doppler and have ruled out a blood clot, given that this can (albeit rarely) be a complication of a surgery and given it mainly affects the upper leg. The vascular surgeon is an excellent next step in terms of physicians to consult, and will likely be able to comment on the lymphedema front as well. My guess is, that it’s a combination of things that has contributed to the swelling. Given you have a high BMI, the lymphatic system is already under a certain degree of challenge, as we hold our fat tissue in the same area under the tissue that many of our lymphatic vessels run. This would explain the swelling you experience with heat, affecting the ankles, for example. With a surgery as involved as a knee replacement, this produces quite a bit of post-surgical swelling, which would rely on both the venous and lymphatic system to drain out from the leg. If your leg is already challenged by the weight in terms of optimal venous and lymphatic return, then yes, I could see how some of the swelling persisting now could be lymphatic in nature. The good news is, if it is indeed swelling, compression and massage to help it drain could certainly be tried and might be quite effective. If there is a CDT therapist near you, they could readily assist with this and you might find improvement in short order. The vascular surgeon may suggest the same thing, and given you will have been cleared for any other vascular issues, clots, etc, I would suggest it would definitely be worth trying. I hope you find relief soon Lisa. Best wishes to you! Lindsay Davey