Lymphaticovenous anastomosis (LVA) describes a method of directly connecting the lymphatic vessels in the affected area of the body to the tiny veins nearby. This allows the excess lymphatic fluid to drain directly into the vein and be returned to the body’s natural circulation.
LVA carries the least risk of any of the modern lymphedema surgeries. It can usually be performed as an outpatient procedure with the patient returning home the day of the surgery.
Previously thought to be ineffective, new approaches to LVA surgery have shown to be an effective and long-term solution for the lymphedema in many patients. A goal of the procedure is to decrease swelling, pain and discomfort in the extremity and eliminate the need for further use of compression garments. In our experience, most patients have results that range from a moderate to significant improvement of their extremity swelling.
Appearance Before Surgery
3 Months After LVA
2 1/2 Years After LVA
Patient with lymphedema of the right leg following treatment for cancer. Prior to LVA surgery, she required about 60 hours of manual lymphatic drainage massage (MLD) per month and one or more layered 30-40mm Hg compression stockings. After surgery and healing, she requires to 2 or 3 hours of MLD per month and a single 20-30 mm mercury compression stocking. When she does have swelling the compression and therapy to reduce this is much more effective and brings the swelling down quite rapidly. She is able to exercise 30-35 minutes per session 3 times a week.
Several small incisions in the affected arm or leg are all that is required for surgical access for the procedure. The technique relies on the use of superfine microsurgery to connect the lymphatic channels directly to the nearby veins. The diameter of the lymphatic channels is tiny, on the order of 0.1 mm to 0.9 mm in diameter, with most lymphatic vessels used in the procedure ranging from 0.3 mm to 0.6 mm wide. In comparison, the lead from a standard mechanical pencil is several times as broad. Specialized techniques are employed in which surgeons use superfine surgical suture and a high-powered microscope.
LVA surgery, like lymph node transfer surgery, is effective in removing fluid from an extremity. A limb that has become larger and swollen due to the deposition of fat or fibrotic tissue is better treated with the Suction-Assisted Protein Lipectomy (SAPL) technique.
AN IMPROVED SURGICAL TECHNIQUE
Dr. Granzow had adapted his surgical method for this procedure from Dr. Isao Koshima, one of the fathers of microsurgery. Dr. Koshima pioneered the techniques of superfine microsurgery and has applied his methods to improving the outcomes of lymphaticovenous anastomosis surgery. Dr. Granzow studied with Dr. Koshima in Japan and maintains close professional contact with him. Current results show much greater success rates than were reported previously by other surgeons who attempted to perform the LVA technique.
Dr.Jay Granzow and Dr. Isao Koshima performing
lymphaticovenous anastomoses in Japan in 2005
It is thought that not all of the lympaticovenous connections remain open after the surgery, which may account for the mixed results sometimes seen in the surgery. Dr. Granzow seeks to make multiple lymphatic to venous connections during a typical series of short procedures, with the goal of achieving several connections that remain open in the long term.
The procedure appears to offer a moderate to significant improvement in the symptoms of lymphedema. While no outcomes in any medical procedure can be guaranteed, the great advantage of this surgical method is that the direct medical risks associated with the small incisions and tiny procedures appear to be quite low compared with the possibility of a moderate to significant improvement in the affected limb.