Lymphatic Venous Anastomosis

Lymphatic Venous Anastomosis

PEP Topic 
Lymphedema
Description 

One of the surgical techniques being examined for its effect on lymphedema development is lymphatic venous anastomosis.  This involves the surgical creation of a local connection between the lymphatic vessels and veins in an attempt to facilitate drainage of lymphatic fluid into the circulatory system, thereby reducing lymphedema development.

Effectiveness Not Established

Research Evidence Summaries

Boccardo, F.M., Casabona, F., Friedman, D., Puglisi, M., De Cian, F., Ansaldi, F., & Campisi, C. (2011). Surgical prevention of arm lymphedema after breast cancer treatment. Annals of Surgical Oncology, 18, 2500–2505.

doi: 10.1245/s10434-011-1624-4
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Study Purpose:

To assess the efficacy of lymphactic venous anastomosis (LVA) during surgery for prevention of lymphedema in women having surgery for breast cancer

Intervention Characteristics/Basic Study Process:

Patients who consented to participation prior to surgery were randomly assigned to the intervention group or usual care.  Those in the intervention group underwent the LVA microsurgical technique. Specifics of the surgery were described. In the treatment group, 16 patients had lymph node metastasis and underwent the LVA during primary surgery and axillary dissection. In those patients assigned to the intervention who did not have lymph node metastasis with intraoperative frozen section, the procedure was planned after finding micrometastasis after immunohistochemical analysis, and the LVA could be done during lymph node dissection at a second surgery. All patients had volume measurement done by the Kuhnke method and by lymphoscintigraphy. Follow-up included these measures at 1, 3, 6, 12, and 18 months after surgery.

Sample Characteristics:

  • The study reported on 46 patients with breast cancer.
  • Mean age was 67.5 years with a range of 52–74 years.
  • The sample was 100% female.

Setting:

The study was conducted in Italy. The site was not specified.

Phase of Care and Clinical Applications:

  • Patients were undergoing the transition phase after initial treatment.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

This was a randomized clinical trial.

Measurement Instruments/Methods:

  • Limb volume was measured.    
  • Lymphoscintigraphy (LS) was used.

Results:

Beginning at month three, the proportion of patients with lymphedema was higher in the control group (p = 0.047). No significant differences were reported between volume measures at baseline, one, and six months in the intervention group. By comparison, a significantly higher arm volume was reported at one and six months in the control group (p < 0.01). Postoperatively, LS demonstrated a patency rate of 95.6% for LVAs. 

Conclusions:

This trial demonstrated that intraoperative LVA microsurgery was effective in reducing arm lymphedema during the first six months after surgery in women with breast cancer.

Limitations:

  • The sample size was small with fewer than 100 patients.
  • No information was provided regarding any other interventions during the study period to combat development of lymphedema. 
  • Although the mean follow-up time for the study was reported to be 18 months, only analysis of 6 months was provided. 
  • No information was provided regarding use of adjuvant treatment during the study follow-up period or differences in body mass index (BMI) that could have influenced findings.

Nursing Implications:

Study findings suggested that operative LVA with breast surgery can be effective in reducing development of secondary lymphedema. More research in this area is needed to further strengthen these findings. Nurses can advocate for patients to ask about the availability and potential use of this surgical technique.

Damstra, R.J., Voesten, H.G., van Schelven, W.D., & van der Lei, B. (2009). Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema. A prospective study of 11 LVA procedures in 10 patients with breast cancer related lymphedema and a critical review of the literature. Breast Cancer Research and Treatment, 113(2), 199–206.

doi: 10.1007%2Fs10549-008-9932-5
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Study Purpose:

To evaluate the effectiveness of lymphatic venous anastomosis (LVA) in the treatment of one-sided, breast cancer-related lymphedema

Intervention Characteristics/Basic Study Process:

Unilateral lymphoscintigraphy was done with attention to liver uptake, and methylene blue was used to outline the lymphatic system. An experienced microvascular surgeon did the LVA procedures doing end-to-side anastomoses with micro instruments. Antibitoitics were used preoperatively, and the extremity was bandaged and elevated at night. Patients were followed at three months, six months, one year, and beyond. The mean final follow up was eight years.

Sample Characteristics:

  • The study sample was comprised of 10 female patients.
  • Mean age was 58.7 years, with a range of 46-68 years.
  • All patients were postmastectomy and had persistent lymphedema that had not responded to more conservative interventions.
  • Lymphedema was present for a mean of 5.3 years before LVA.

Setting:

The study took place at a single site in the Netherlands.

Study Design:

The study used a prospective descriptive design.

Measurement Instruments/Methods:

  • Arm volume was measured using inverse water volumetry method.
  • The SF-36 measured quality of life. 
  • Indirect circumferential measurement of limbs was taken.
  • Patients underwent lymphoscintigraphy. 

Results:

After six months, 5 of 10 patients had subjective relief according to SF-36 results. After one year, the mean volume difference between limbs was 1,075 cc, with a range of 500-1856, and the circumferential measurement demonstrated improvement of 4.8%. An initial postoperative volume reduction seen at 16% was lost in one year, at which time no more than a 2% difference between limbs was observed.

Conclusions:

No significant improvements were found over the long term after an initial period of symptom relief and volume reduction.

Limitations:

  • The study sample was small, with less than 30 patients.
  • The study did not have a comparison or control group. 

Nursing Implications:

The small prospective study suggests there is no long-term benefit of LVA surgery for management of lymphedema associated with breast cancer.

Gennaro, P., Gabriele, G., Mihara, M., Kikuchi, K., Salini, C., Aboh, I., . . . Ungari, C. (2016). Supramicrosurgical lymphatico-venular anastomosis (LVA) in treating lymphoedema: 36-months preliminary report. European Review for Medical and Pharmacological Sciences, 20, 4642–4653. 

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Study Purpose:

To evaluate the effects of lymphaticovenular anastomosis (LVA) on patients with lymphedema

Intervention Characteristics/Basic Study Process:

A retrospective research study of 36-months of follow-up of 69 patients with lymphedema after LVA surgery. Each had a preoperative ultrasound with an echo-color doppler. Results were not discussed in the study, neither did it state why these were done.
 
Each patient was measured bilaterally with 5 circumferential measurement points. Sums were compared pre- and postoperatively and then at multiple intervals throughout 36 months.
Upper extremity: hand, wrist, elbow, 5 cm distal and 5 cm proximal to the elbow
Lower extremity: dorsum of the foot, ankle, the knee, 10 cm distal and 10 cm proximal to the knee
 
Pre- and postoperative indocyanine green dye (ICG) lymphography: Each patient had an ICG lymphography, which is injected into the distal extremity, involving an infrared light issues to visualize the lymphatics. After the intervention, patients evaluated their quality of life and lymphedema. They were evaluated again at two weeks, one month, and every six months after surgery. Patients started lymph drainage postoperatively. Patients wore compression for one year after the surgery.

Sample Characteristics:

  • N = 69   
  • MEAN AGE = 55 years (range = 16–76 years)
  • MALES: 7%, FEMALES: 93%
  • CURRENT TREATMENT: Other
  • KEY DISEASE CHARACTERISTICS: Unilateral upper or lower extremity lymphedema with or without a history of cancer diagnosis; of the 69 patients, 42 had upper extremity lymphedema and 27 had lower extremity edema; of the patients with cancer, 40 had a history of breast cancer, 9 had a history of endometial cancer, 3 had a history of melanoma with lymphadenectomy, 2 a history of ovarian cancer, 2 had cervical cancer, 1 had sarcoma, and 1 had bladder cancer with lymphadenectomy; 9 patients had primary lymphedema, and 1 had traumatic lymphedema; of the patients with cancer, 39 had radiation therapy.
  • OTHER KEY SAMPLE CHARACTERISTICS: Patients with at least a one-year follow-up were included in the study.

Setting:

  • SITE: Single site  
  • SETTING TYPE: Not specified    
  • LOCATION: Italy

Phase of Care and Clinical Applications:

APPLICATIONS: Pediatrics, elder care

Study Design:

Retrospective

Measurement Instruments/Methods:

Measuring tape

Results:

All patients lost volume with an average reduction of 50%. None of the study patients reported an event of cellulitis during the follow-up. Patients with histories of cellulitis had less reduction. A 49% reduction was seen in patients who had reported one to two events, and a 33% reduction was seen in those with more than two events.  
  • Postoperative ICG: Three hundred thirty-seven of the 366 anastomosis remained patent. 
  • Subjective reporting: Sixty-seven reported satisfaction: lighter limbs, softer tissue, less pain, and improved function.

Conclusions:

The LVA appears to successfully establish alternate lymphatic drainage pathways in the lymph damaged limb. It is minimally invasive requiring considerably less surgery than the lymph node transplantation procedures and potentially better outcomes. The patients tolerate it well and recovery quickly. It is unclear whether patients no longer needed to use compression garments, but the study reported that all had a reduction in compression class. The researchers reported outcomes that did reflect disease progression: Stage IV limbs did not improve, as well as stage II.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)

Nursing Implications:

The findings suggest that LVA may be helpful for patients to reduce lymphedema. Nurses need to be aware of patient education needs if this procedure is used.

Systematic Review/Meta-Analysis

Cormier, J.N., Rourke, L., Crosby, M., Chang, D., & Armer, J. (2012). The surgical treatment of lymphedema: A systematic review of the contemporary literature (2004-2010). Annals of Surgical Oncology, 19(2), 642–651.

doi: 10.1245/s10434-011-2017-4
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Purpose:

To examine peer-reviewed literature evaluating the surgical treatment of lymphedema

Search Strategy:

  • Databases searched were MEDLINE, CINAHL, Cochrane Library, PapersFirst, ProceedingsFirst, Worldcat, PEDro, National Guidelines Clearing House, ACP Journal Club and Dare (2004–2010).
  • Search keywords were not stated.
  • Studies were included in the review if they were related to lymphedema and involved eight or more patients.
  • Studies were excluded if they were not refereed articles.

Literature Evaluated:

  • The total number of references retrieved was not stated.
  • Studies were evaluated using an adapted checklist using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) scale. 

Sample Characteristics:

  • The final number of studies was 19.
  • Sample range across all studies was 9–1,800, with larger samples in retrospective descriptive studies
  • Key sample characteristics were not provided.

Results:

Findings were grouped according to the type of procedure: excisional (8 studies, 4 involving liposuction), lymphatic reconstruction (8 studies of  lymphatic venous anastomosis [LVA]), and tissue transfer (4 studies involving lymph node transfer, stromal cell transplant, lymphatic tissue transplant, and lymph node transplant). Reduction in lymphedema volume was greatest after excisional procedures (91.1%). Lymphatic reconstruction was associated with 54.9% reduction, and tissue transfer with 47.6% reduction. Overall, surgical procedures did not appear to eliminate the need for compression therapy. Follow-up duration and methods of lymphedema measurement varied substantially across studies. Quality scores for studies ranged from 2–12 across all procedure types and tended to vary considerably within surgery type grouping as well. Studies were done in both upper and lower extremities, though most LVAs were done in lower extremities. The majority of studies did not comment on postoperative complications. Authors noted that a growing body of evidence supports the use of surgical procedures for prevention of lymphedema.

Conclusions:

Evidence related to the effectiveness of various surgical procedures for lymphedema is somewhat limited, and the ability to generalize findings also is limited given the wide variation in study quality, sample sizes, measurement methods, and lack of long-term follow up information. Surgical procedures have not been shown to eliminate the need for ongoing conventional therapies for lymphedema.

Limitations:

This review is limited by a lack of full information on search results, with consort type of flow charting, lack of information about disease types, and patient characteristics.

Nursing Implications:

Results of surgical procedures appear to show some promise for reducing lymphedema volumes. However, current evidence is too limited to generalize and more information is needed regarding postoperative complications or long-term results. Surgical intervention has not been shown to eliminate the need for ongoing conservative and conventional interventions as well.

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