Changing the Paradigm: Lymphovenous Anastomosis in Advanced Stage Lower Extremity Lymphedema

Abstract

Background: Traditionally, lymphovenous anastomosis is not routinely performed in patients with advanced stage lymphedema because of difficulty with identifying functioning lymphatics. This study presents the use of duplex ultrasound and magnetic resonance lymphangiography to identify functional lymphatics and reports the clinical outcome of lymphovenous anastomosis in advanced stage lower extremity lymphedema patients. Methods: This was a retrospective study of 42 patients (50 lower limbs) with advanced lymphedema (late stage 2 or 3) that underwent functional lymphovenous anastomoses. Functional lymphatic vessels were identified preoperatively using magnetic resonance lymphangiography and duplex ultrasound. Results: An average of 4.64 lymphovenous anastomoses were performed per limb using the lymphatics located in the deep fat underneath the superficial fascia. The average diameter of lymphatic vessels was 0.61 mm (range, 0.35 to 1 mm). The average limb volume was reduced 14.0 percent postoperatively, followed by 15.2 percent after 3 months, and 15.5 percent after 6 months and 1 year (p < 0.001). For patients with unilateral lymphedema, 32.4 percent had less than 10 percent volume excess compared to the contralateral side postoperatively, whereas 20.5 percent had more than 20 percent volume excess. The incidence of cellulitis decreased from 0.84 per year to 0.07 per year after surgery (p < 0.001). Conclusion: This study shows that functioning lymphatic vessels can be identified preoperatively using ultrasound and magnetic resonance lymphangiography; thus, lymphovenous anastomoses can effectively reduce the volume of the limb and improve subjective symptoms in patients with advanced stage lymphedema of the lower extremity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Surgical treatment of carpal tunnel syndrome in advanced-stage upper extremity lymphedema

“…Traditionally, LVA was considered for early-stage lymphedema but functional LVA may effectively reduce the volume of the limb and improve the subjective symptoms of patients with advanced-stage lymphedema. [ 9 ] LVA may benefit patients with advanced-stage upper extremity lymphedema when functional lymphatic vessels are identified. Recently, magnetic resonance lymphangiography and supermicrosurgery techniques have become available to successfully identify functioning lymphatic vessels and achieve favorable LVA results to improve lymphedema.…”

“…The volume of the unaffected extremity was also measured and the volume difference ratio was ultimately calculated according to the formula: (volume of affected extremity – volume of unaffected extremity)/volume of unaffected contralateral extremity × 100. [ 9 ]…”

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