Outcomes of Lymphovenous Anastomosis for Upper Extremity Lymphedema: A Systematic Review

Abstract

Background: Lymphovenous anastomosis (LVA) is an accepted microsurgical treatment for lymphedema of the upper extremity (UE). This study summarizes and analyzes recent data on the outcomes associated with LVA for UE lymphedema at varying degrees of severity.

Methods: A literature search was conducted in the PubMed database to extract articles published through June 19, 2020. Studies reporting data on postoperative improvement in limb circumference/volume or subjective improvement in quality of life for patients with primary or secondary lymphedema of the UE were included. Extracted data consisted of demographic data, number of patients and upper limbs, duration of symptoms before LVA, surgical technique, follow-up, and objective and subjective outcomes.

Results: A total of 92 articles were identified, of which 16 studies were eligible for final inclusion comprising a total of 349 patients and 244 upper limbs. The average age of patients ranged from 38.4 to 64 years. The duration of lymphedema before LVA ranged from 9 months to 7 years. The mean length of follow-up ranged from 6 months to 8 years. Fourteen studies reported an objective improvement in limb circumference or volume measurements following LVA, ranging from 0% to 100%. Patients included had varying severity of lymphedema, ranging from Campisi stage I to IV. The maximal improvement in objective measurements was found in patients with lower stage lymphedema.

Conclusion: LVA is a safe, effective technique for the treatment of UE lymphedema refractory to decompressive treatment. Results of LVA indicate greater efficacy in earlier stages of lymphedema before advanced lymphatic sclerosis.

Conflict of interest statement

Disclosures: The authors have no financial interest to declare in relation to the content of this article.

Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.

Figures

Fig. 1.

Surgical techniques for lymphedema. A, LVA is a microsurgical technique to anastomose subdermal distal lymphatics with the adjacent venules. B, VLNT has its primary objective to transfer healthy lymph nodes to the affected site. C, SAPL is a reductive technique that seeks to remove the fibrofatty tissue by liposuction, generated secondary to a long period of lymph stasis in the limb. Created with BioRender.com.

Fig. 2.

PRISMA flow diagram.

Fig. 3.

Campisi staging. A, No swelling or skin changes are present even though there is impaired lymphatic circulation. The distinctive characteristic between stage Ib and II is the persistence of edema (1) after elevation of the extremity (2). B, Stage Ib has partial improvement with the extremity’s elevation; (C) stage II has persistent edema even with the maneuver. D, Persistent edema with lymphangitis. E, Fibrotic lymphedema and column-like extremity with the presence of warts. F, Elephantiasis with deformity of the extremity is present.

Fig. 4.

Lymphatic vessels in patients with different Campisi stages. Patients with higher Campisi stages might not be candidates for LVA due to sclerosed lymphatic vessels. Since LVA relies on a healthy lymphatic vessel architecture, patients with lower Campisi stages might be better candidates for this procedure. A, Cross-section of a healthy lymphatic vessel (valves are not displayed). B, Cross-section of a sclerotic lymphatic vessel, with an increased collagen deposition between the endothelium basement membrane and the adventitia and a reduced vessel lumen. *Collecting lymphatics have a thin layer of smooth muscle cells, whereas initial lymphatics lack one completely. **Collecting lymphatics have a basement membrane, whereas initial lymphatics do not, or have a scarce amount. ***Collecting lymphatics have an adventitia, whereas the endothelium of initial lymphatics is in direct contact with connective tissue. Created with BioRender.com.

Fig. 5.

Cheng et al improved outcomes using VLNT over LVA for patients with advanced lymphedema. According to Cheng et al results, patients with higher Campisi stages showed a better treatment response to VLNT than to LVA. A, Choosing an LVA to treat patients with high Campisi stages might lead to suboptimal long-term vessel patency. The progressive increase in lymphatic sclerosis decreases the vessel’s lumen diameter, increasing the lymphatic system’s pressure. The low numbers of healthy lymphatic vessels cannot compensate, leading to treatment failure or worsening of lymphedema. B, VLNT might be a better option for these patients since it does not rely on the existing local lymphatic vessels. Created with BioRender.com.