Lymphatic Venous Anastomosis (LVA) Surgery for Lymphedema

There is no cure for lymphedema, either surgical, pharmacological or otherwise. Instead, the symptoms of lymphedema which include chronic swelling, tissue hardening, and infection are normally managed through Combined (or ‘complex’) Decongestive Therapy (CDT). CDT is a combination of manual lymphatic drainage massage, compressive bandages and garments, exercise, and education.

Although CDT is generally highly effective at reducing the symptoms of lymphedema and preventing disease progression, it requires sustained self-care and vigilance. For patients who cannot achieve the level of symptom relief they desire through CDT, surgical approaches like lymphatic venous anastomosis (LVA) (also known as ‘lymphaticovenular anastomosis’) may hold promise.

The heart of the problem: inadequate fluid transport

Before discussing surgical options for lymphedema, it is necessary to understand the core issue underlying it: a fluid transport problem.

The cells of the body are continuously bathed in life-sustaining oxygen, nutrients, vitamins, and electrolytes (among other substances) delivered by the blood stream. This continuous flow of fluid throughout the body delivers the necessities of life while clearing out toxic cellular waste products. Unbeknownst to many, this enormously complex task is not accomplished by the blood circulatory system (arteries and veins) alone but requires the lymphatic system as well.

The lymphatic system is an extensive fluid transport system that along with the venous system (the veins) is responsible for draining the fluid delivered by the arteries to the cells of the body and returning it back to the blood stream.

When components of the lymphatic system such as the lymph vessels and lymph nodes are damaged or missing due to cancer treatment, or malformed at birth, the venous system can struggle to keep up with the demand to properly drain the affected area. The result is the accumulation of lymph fluid, swelling, and the onset of lymphedema: a condition that if left unchecked will progressively worsen culminating in irreversible swelling, tissue hardening, infection risk, and other changes.

While we cannot (yet?) coax the body to regenerate damaged or absent lymphatic structures, we can attempt to address the problem with targeted fluid reduction strategies such as CDT, and in appropriate cases, perhaps surgery as well.

Surgical options for lymphedema

Surgery is considered an invasive branch of medicine, and so is typically considered the treatment of last resort after available ‘conservative’ (read: non-surgical) options have been exhausted. This treatment hierarchy applies to lymphedema as well; most lymphedema patients have never seriously discussed surgical options. Rightfully so, most lymphedema patients would agree that judicious symptom management using the principles of CDT is sufficient to manage their symptoms. As a result, the surgical treatment of lymphedema has been commonly reserved for only the most advanced cases where CDT has failed to sufficiently help patients manage their condition, and where significant infection risk, limb disfunction, and quality-of-life concerns have arisen.

Perhaps the most successful example of a surgical intervention for lymphedema is specialized lymphatics-sparing lymphedema liposuction. Specialized liposuction has been shown to dramatically reduce limb volume in patients who are considerably swollen (compared to the unaffected limb) and whose excess limb volume predominantly consists of adipose tissue (a late-stage development of lymphedema). This procedure can successfully help these advanced-case patients ‘reset’ to a state that is more easily managed through CDT, and immensely improve quality of life (ref 1,2). However, Lymphedema liposuction is only appropriate as a last resort for the most advanced cases of lymphedema.

More recently this “surgery-as-a-last-resort” paradigm for lymphedema has been challenged. Surgical procedures are being investigated as potentially earlier interventions for lymphedema, and for patients who have less advanced disease. Rather than removing excess bulk through liposuction, these new surgical approaches attempt to improve the body’s reduced capacity to drain lymph fluid. The two best examples may be lymph node transfer (LNT), which aims to repair damaged lymphatic transport by transplanting lymph nodes from a donor site (typically the groin); and lymphatic venous anastomosis (LVA) which aims to circumvent lymphatic damage by delivering lymphatic fluid back into circulation through the venous system instead of the lymphatic system. We will discuss how exactly LVA is accomplished below.

What is lymphatic venous anastomosis (LVA)?

LVA may be the most promising surgical option for treating less advanced cases of lymphedema where patients feel dissatisfied with their current level of symptom management despite the judicious application of CDT. It is the most common surgical procedure attempted under these circumstances, and there is even some early evidence to suggest that it might also offer preventative protection in patients at high-risk of developing lymphedema (ref 3).

Here’s how LVA works:

Lymphatic venous anastomosis (LVA) is a microsurgical intervention where multiple lymphatic vessels are connected (‘anastomosed’) to a small nearby vein. By connecting still functional lymphatic vessels that are downstream of a region of lymphatic damage to a small vein, LVA attempts to bypass the lymphatic damage (not to mention the remaining lymphatic system as a whole). The goal of LVA is to encourage some of the excess lymph fluid accumulating in the tissue to rejoin the circulatory system in the arm itself, rather than closer to the heart where it would normally take place. A related microvascular technique known as ‘lymphatico-lymphatic bypass’ where stranded lymphatic vessels are attached to still-functional lymphatic vessels may also be a viable surgical option, although much less common.

Is lymphatic venous anastomosis effective?

Studies of LVA performed to date offer early and encouraging results, however, the small number and size of the studies, along with procedural differences between them, limits drawing strong conclusions (ref 4, 5, 6).

Clinical investigations of microsurgical approaches like LVA are inherently difficult to draw conclusions from. This is due in large part to the small number and size of the studies, less-than-optimal experimental designs (in the real world compromises must always be made), differences between patients and how they manage their condition before and after surgery, and the challenge and variability of microsurgery itself.

During LVA procedures specialized dyes can be used to help find and ‘map out’ lymphatic vessels that are still healthy, and to confirm an open connection between anastomosed vessels. But even when good connections are made between healthy lymphatic vessels and adjacent veins, the functional end-result will depend on a variety of other factors. These include the choice and location of the lymphatic vessels and veins used (ref 7), the number of connections made (more is likely better (ref 5)), the limb involved (arms appear to work much better than legs (ref 5)), the stage of lymphedema (patients with earlier stage I/II lymphedema tend to show better results (ref 4,5)), and other patient differences including lymphedema self-care behaviour and compliance to CDT principles both before and after surgery.

With all the above in mind, surgical results still do show promise. One of the research teams that helped pioneer this form of surgery for breast cancer related lymphedema published a paper in 2006 on their (extensive) clinical experiences over the years (ref 4). The authors reported that LVA offered 83% of their lymphedema patients significant symptom improvement with an average reduction of 67% in excess limb volume (swelling). Unfortunately, this paper was more a discussion of clinical observations than a proper clinical study, so it is hard to know how to interpret their findings.

A more recent and much more rigorously designed prospective clinical study by Chang et al. (ref 5) offers a similar, if more modest, endorsement. The authors enrolled 89 patients with arm lymphedema secondary to breast cancer in their study and found quantifiable improvement in arm volume for 74% of their patients, with an average reduction in the excess volume (swelling) of the affected arm (compared to the normal arm) of 42% at 12 months post-surgery. Unfortunately, no statistics were offered to help us understand the variability in this result between patients, so it is unclear how many patients might have experienced a much greater or much lesser improvement. Interestingly, the authors did report that the effects of the surgery appeared to be long lasting; ten patients who were followed for at least two years showed a 35% reduction in the excess volume at year two.

A more recent study of 29 women with breast cancer related lymphedema supports the results of Chang et al., demonstrating a 33% reduction in excess arm volume at one year following LVA (ref 6). 28 of 29 patients in this study experienced a decrease in arm volume, while one exhibited an increase in arm volume.

Importantly, in each of these above reports the authors stated that the patients who were enrolled had demonstrated good adherence to CDT management practices before surgery and were therefore starting from a state of maximal lymphedema symptom management. Immediately following surgery, they also resumed their lymphedema management practices.

Should we expect LVA to cure lymphedema or remove the necessity for ongoing management and self-care?

Not likely. While any reduction in limb volume could be beneficial for increasing patient satisfaction and easing the burden of ongoing management, anecdotal reports suggest that only a small minority of patients might be able to fully discontinue their ongoing management practices for some period of time following surgery.

So how would you fare if you had LVA surgery?

Very roughly speaking, if you have early (stage I/II) arm lymphedema secondary to breast cancer and had an LVA surgery performed in the manner of Chang et al. (ref 5), your best guess might be that you would have a 75% chance of experiencing a measurable improvement, which on average might be around a 35% decrease in excess arm volume (swelling) by year two.

Physiology gets in the way

Unfortunately, LVA suffers from an intrinsic physiological limitation: the venous system alone is normally insufficient to clear the excess fluid from a limb – hence the existence of the lymphatic system in the first place. Unlike much more passively acting veins, lymph vessels are comprised of very small contractile units that actively suck in fluid and pump it towards the heart. Altering these lymphatic vessels to instead propel fluid into small nearby veins will certainly help relieve fluid build-up, but in most circumstances is not likely to entirely replace the lost capacity of the compromised lymphatic system.

Is lymphatic venous anastomosis surgery for me?

If you have early-stage arm lymphedema (stage I/II) secondary to breast cancer and have judiciously applied conservative methods (CDT) to the best of your abilities but remain dissatisfied with your level of symptom management, this surgery could be worth discussing with your health team. While LVA is not a cure for lymphedema, it is probable that your symptoms could improve with treatment. However, this improvement is unlikely to eliminate your need for ongoing symptom management via traditional lymphatic massage and compression strategies. In order to ensure the best possible surgical outcome, it is important to follow pre- and postoperative LVA protocols.

References

1. Brorson H. Liposuction in Lymphedema Treatment. J Reconstr Microsurg. 2016 Jan; 32(1):56-65. abstract
2. Schaverien MV, Munro KJ, Baker PA, Munnoch DA. Liposuction for chronic lymphoedema of the upper limb: 5 years of experience. J Plast Reconstr Aesthet Surg. 2012; 65(7):935–942. https://doi.org/10.1016/j.bjps.2012.01.021
3. Markkula SP, Leung N, Allen VB, Furniss D. Surgical interventions for the prevention or treatment of lymphoedema after breast cancer treatment. Chochrane Database Syst Rev. 2019 Feb 19;2(2). https://pubmed.ncbi.nlm.nih.gov/30779124/
4. Campisi C, Davini D, Bellini G, et al. Lymphatic microsurgery for the treatment of lymphedema. Microsurgery. 2006 26(1):65-9. https://pubmed.ncbi.nlm.nih.gov/16444753/
5. Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plas Reconstr Surg. 2013 Nov;132(5):1305-1314. https://pubmed.ncbi.nlm.nih.gov/24165613/
6. Winters H, Tielemans HJP, Hameeteman M, et al. The efficacy of lymphaticovenular anastomosis in breast cancer-related lymphedema. Breast Cancer Res Treat. 2017 Sep;165(2):321-327. https://pubmed.ncbi.nlm.nih.gov/28608029/
7. Seki Y, Kajikawa A, Yamamoto T, et al. The dynamic-lymphaticovenular anastomosis method for breast cancer treatment-related lymphedema: Creation of functional lymphaticovenular anastomoses with use of preoperative dynamic ultrasonography. J Plast Reconstr Aesthet Surg. 2019 Jan:72(1):62-70. https://pubmed.ncbi.nlm.nih.gov/30292697/