Lymphovenous Anastomosis (LVA)

Say Goodbye to Compression Garments after Dr. Cheng’s Lymphedema Microsurgery

The most common problem faced by these cancer survivors is post-operative lymphedema. Symptoms include swollen limbs due to impaired lymphatic circulation, which cannot necessarily be improved with non-surgical rehabilitation. Some patients may also experience skin problems (eczema, rough skin, unidentified protrusion), repeated cellulitis or toe mold infection. Dr. Cheng’s LVA technique is a minimally-invasive microsurgery procedure that can address the symptoms of lymphedema.

LVA Animation

LVA Animation - Lymphedema Grading Systems
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How Does LVA Surgery Work?

An individualized treatment plan is determined based on subsequent imaging studies for patients with grade I to IV lymphedema. Grade I and early II lymphedema patients will undergo lymphodynamic evaluation by indocyanine green (ICG) lymphography. This is performed via subdermal injections into the dorsal skin of the second and fourth web spaces of the fingers or toes. Images are obtained at 5 minutes, and then again after 20 hours. Indocyanine green injection allows the evaluation of the presence and location of open, functioning lymphatic channels or dermal backflow (obstruction of lymphatic flow).

If the LVA is chosen for a patient, Dr. Cheng’s preference is to perform 1 or 2 Side-To-End (lymph-to-vein) anastomosis to allow for lymph to drain into the vein from both proximal and distal directions (supermicrosurgery techniques). Patent blue injected distal to the planned incision allows for easier detection of lymphatic channels which can then be seen draining from the lymphatic channel into the vein, confirming patency of the LVA. ICG fluorescence may also be used to verify a patent anastomosis.

Case 1
Lymphedema - Before Treatment photo - hands, patient 1 Lymphedema - Before Treatment photo - hands, patient 1
BEFOREAFTER

Before Surgery:

This is a 57-year-old female with left upper limb lymphedema for 12- months after left mastectomy and radiation.

After Surgery:

At a 15- months of follow-up, the circumferential reduction rates of the affected limb without the use of compression garments were 86% and 100% above the elbow and below the elbow, respectively.

Case 2
Lymphedema - Before Treatment photo - hands, patient 2 Lymphedema - Before Treatment photo - hands, patient 2
BEFOREAFTER

Before Surgery:

This is a 56-year-old female with right upper limb lymphedema for 10- months after right mastectomy and axillary 31 lymph nodes dissection and radiation.

After Surgery:

At a 36- months of follow-up, the circumferential reduction rates of the affected limb without the use of compression garments were 100% and 100% above the elbow and below the elbow, respectively.

Case 3
Lymphedema - Before Treatment photo - hands, patient 3 Lymphedema - Before Treatment photo - hands, patient 3
BEFOREAFTER

Before Surgery:

This is a 64-year-old female with left upper limb lymphedema for 12- months after right mastectomy and axillary lymph nodes dissection and radiation.

After Surgery:

At a 36- months of follow-up, the circumferential reduction rates of the affected limb without the use of compression garments were 100% and 100% above the elbow and below the elbow, respectively.

Case 4
Lymphedema - Before Treatment photo - hands, patient 4 Lymphedema - Before Treatment photo - hands, patient 4
BEFOREAFTER

Before Surgery:

This is a 39-year-old female with left upper limb lymphedema for 6- months after left mastectomy and axillary 31 lymph nodes dissection and radiation.

After Surgery:

At a 3- months of follow-up, the circumferential reduction rates of the affected limb without the use of compression garments were 35% and 60% above the elbow and below the elbow, respectively.

Lymphovenous Anastomosis - Side-to-end (Cheng’s Technique)Side-to-end (Cheng’s Technique)
Lymphovenous Anastomosis - End-to-end (Koshima’s Technique)End-to-end (Koshima’s Technique)

 

Patency test of the side-to-end lymphovenous anastomosisPatency test of the side-to-end lymphovenous anastomosis using indocyanine green lymphography (right) and patent blue (left)

Candidates for Lymphovenous Anatomosis

  • Cancer patients that have had lymph nodes removed due to the disease
  • Patients who have not experienced relief from non-surgical therapies
  • Cheng’s Grading 1, and early Greade 2 lymphedema
  • Partial obstruction on lymphoscintigraphy
  • Patent lymphatic ducts on indocyanine green(ICG) lymphography

What To Expect After Surgery

The most advanced minimally invasive supermicrosurgical techniques relieve lymphoedema through small incisions (around 3cm) which expose lymphatic channels and small veins just beneath the skin. Preoperatively, indocyanine green lymphography is used to map the lymphatic system on the skin and locate the incisions. Once the lymphatic channel and a suitable vein have been identified and prepared, a connection between the system is created to give the lymphatic fluid an alternative route to escape from the affected area, effectively bypassing the area of damage to the lymphatics.

Contact Dr. Cheng for A Consultation

Dr. Cheng is a member of the American Society of Reconstructive Microsurgery is internationally known for his microsurgery techniques. If you would like to know more about lymphovenous anatomosis and cutting-edge treatments for lymphedema, contact Dr. Cheng. Based on your individual case, Dr. Cheng will recommend the best treatment to reduce swelling and improve your quality of life.

 

Lymphedema FAQ
▲The flow diagram represents the impact of both physiologic and nonphysiologic methods of surgical treatment on the lymphatic system.

Data source: Principles and Practice of Lymphedema Surgery. Cheng MH, Chang DW, Patel KM (Editors). Elsevier Inc, Oxford, United Kingdom. ISBN: 978-0-323-29897-1. July 2015, page 218.

Recommended reading:

  1. Successful treatment of early-stage lower extremity lymphedema with side-to-end lymphovenous anastomosis with indocyanine green lymphography assisted.
    Ito R, Wu CT, Lin MC, Cheng MH.
    Microsurgery. 2016 May;36(4):310-5.
    https://www.ncbi.nlm.nih.gov/pubmed/26666982
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