Lymphaticovenous Anastomosis (LVA)

What is Lymphaticovenular Anastomosis - (LVA)?

In lymphoedema, fluid accumulates in the affected arm or leg due to its inability to return to the bloodstream. Lymphaticovenular Anastomosis (LVA) is a surgical procedure that directly links the obstructed lymphatic vessels in the arm or leg to nearby veins, allowing the fluid to bypass the blockage and enhancing its return to the bloodstream.

LVA was first described by Koshima in 1996. It is a specialist super-microsurgery technique using a high-resolution microscope, super-fine microsurgical instruments and very fine sutures. The lymphatic vessels are tiny and only 0.8 mm in diameter, making them difficult to identify with the naked eye. The PDE video fluoroscopy camera uses dye to identify the vessels, and they are prepared using the microscope and sutured end to end onto a local vein.

The operation is minimally invasive and performed using small incisions on the limb. Several LVAs are performed to maximise the amount of fluid passing back into the circulation.

It is usually performed under general anaesthetic (when you are fully unconscious) as a day case procedure so you can go home the same day.

It is essential to continue to wear your compression garments and be managed by a lymphoedema nurse/physiotherapist as you recover.

Small transverse incisions are made in the skin over the lymphatics in order that the lymph nodes are identified in the harvest site with their supplying blood vessels.

A video fluoroscopy camera is used to identify the relevant lymph nodes to harvest whilst protecting the lymph nodes that drain the donor limb. Thus, minimising the risk of developing lymphoedema at the donor site.

Any scarring that may be present at the recipient site is released, to try to prevent lymphoedema, as well as creating a pocket for your new lymph nodes and identifying the blood vessels to be used.

The donor nodes are elevated carefully, ensuring they remain attached to their supplying blood vessels. The tissue is then completely removed, and the artery and vein are reattached to small vessels in the recipient site. Once the lymph node flap is in place, it should turn pink and have its own blood supply. This can be checked using the video fluoroscopy camera.

Having surgery should be a very positive experience. Complications are infrequent and usually minor. However, all surgery has risk, and it is important that you are aware of the possible complications. All the risks will be discussed in detail with you at your consultation. However, if you have further questions or concerns, please do not hesitate to discuss them with me. Decisions about surgery must never be rushed and requires personal research.

These risks can be divided into those specific to the surgery and those that relate to the anaesthesia.

General Anaesthetic risks: An anaesthetic is very safe, however, should a complication arise, the relevant medical expertise is immediately available to deal with this.

The risks increase if you have certain medical problems, which will be discussed at length during the consultation. The risks include:

  • Unintended intraoperative awareness, which is very rare.
  • Dizziness and nausea.
  • Sore throat.
  • Damage to teeth or mouth.
  • Nerve injury due to body positioning.
  • Allergic reaction or anaphylaxis.
  • Malignant hyperthermia, which is a rare life-threatening condition.

The anaesthetist will go through these risks in more detail prior to your surgery.

Scars: Scars tend to settle remarkably well. However, some people heal with thickened scars, and this can make them more noticeable.

Bruising and swelling: This is very common and may take approximately 3 weeks to resolve.

Haematoma: This is clotted blood that collects under the skin. If a haematoma develops, it is likely to do so within 4 to 6 hours post-surgery. Any increase in swelling or pain should be reported immediately so that timely treatment can be given. Sometimes patients need to have this collection of blood removed with another short operation. This does not normally delay your recovery or change the cosmetic result.

Infection: Lymphoedema patients are at a higher risk of developing an infection after surgery, therefore, I prescribe you a course of antibiotics to take for 2 weeks, whilst everything is healing.

Numbness, reduced sensation or oversensitivity:  A reduction in sensation occurs in most patients around the abdomen and possibly the upper thigh. This is usually temporary, but occasionally these changes can remain to some degree.

Lymphocele: This is a collection of clear fluid under the skin, at the donor site, which sits in a pocket. It is because of cutting some of the lymphatics from where the nodes are harvested. This normally reabsorbs spontaneously over the course of a couple of weeks, although it can be drained with a needle if it feels tight. Vary rarely a surgical procedure may be required if it does not reabsorb.

Wound healing problems: These are rare but can range from minor problems, such as small areas of wound separation, to major issues, such as skin loss. Although very rare, skin grafting to close the wound may be required thus resulting in further surgery.

People who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.

Dog-ears: These are soft tissue prominences where the scar stops. In most cases these settle over the course of 3 months. A small local anaesthetic procedure may be required to remove any excess that remains.

Indentation: You may develop a slight depression where the lymph node flap has been removed. The majority of this will correct naturally but any remaining indentation can be corrected with a fat transfer.

Lymphoedema of the donor limb: In theory this should not happen, as we do not harvest the lymph nodes that drain the limb. However, there is a small risk that this could occur.

Flap failure: As the flap relies on small blood vessels to keep it alive, there is a possibility that the flap will fail. At a 2% risk, this is very unlikely.

No improvement: Whilst a lymph node transfer is normally successful in most patients, it is possible that there is only minimal improvement, resulting in a further surgical procedure being considered.

Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE): Following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and travel to your lungs. If the blood clot is large enough, it could prove fatal.

The overall risk for surgery is less than 1%, but to reduce any risks of a DVT/PE, you will be provided with special stockings to wear in bed together with a blood thinning injection, if you are not mobile or have previously had a DVT or PE.

All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, do not hesitate to discuss these with me.

Your incisions will be closed with a dissolvable suture that does not need removing. You will have waterproof glue-based dressing, which will gradually dissolve at about 3 weeks. You can shower as soon as you want and do not need any dressing changes.

Your incisions will be closed with a dissolvable suture that does not need to be removed. You will have a Prineo waterproof glue-based dressing applied, which will be removed at approximately 3 weeks post-surgery. You can shower as soon as you want and do not need any dressing changes.

A tube (called a drain) will channel away any excess blood or body fluid from your donor site. This is removed as soon as the fluid is less than 30ml/24 hours, which is normally about 3 days post-surgery.

You can go home with the drain, and we will show you how to manage it. As soon as it is ready to be removed, we will see you in clinic to remove it.

You will need to wear your normal lymphoedema garment during the day. After 2 weeks you should gradually be able to reduce the strength of the compression and the amount of time you are wearing it over the following months whilst the amount of fluid reduces.

I recommend that you commence manual lymphatic drainage with the physiotherapist to encourage the swelling to settle and the limb to drain in the initial post-surgery period.

Before you leave the hospital, you will be given a follow up appointment to see the nurses at one week to check your incisions and an appointment to see me in 2 weeks. You will not be able to drive yourself home from hospital and, ideally, you should have someone to stay with you for a few days to assist you. If you have any concerns during this period, do contact the clinic for advice.

When you return home, you should take it easy for the first week or so. Most people take around 1 to 2 weeks off from work. You should be able to drive from 2 weeks, commence gentle exercise at around 2 weeks and return to the gym or equivalent activities at around 4 weeks.

Surgical fees are a combination of the hospital costs, the surgeon and anaesthetic fees and any consumables such as implants. For lymphoedema surgery the fees are normally cover by your health insurance, however most patients have a co-pay of 20% and this means you are likely to have to pay towards the cost of your surgery. Any fees will be calculated, and you will be informed of the potential fees at your consultation.

Lymphoedema Case Study