Lymphovenous Shunts Research Articles

Lymphangiogenesis after nonvascularized lymph node transplantation: Lymphangiographic findings in mice and minipigs

The establishment of new connections after NVLNT (non-vascularized lymph node transplantation) is still poorly understood. The purpose of this study was to investigate lymphatic connections after NVLNT using lymphangiography. In a mice model, 40 mice were allocated to undergo NVLNT or sham surgery. On day 21 after NVLNT, the lymphatic vessels were observed on near-infrared fluorescence imaging with indocyanine green. In a minipig model, 12 minipigs underwent NVLNT. On day 14 after NVLNT, the transplanted lymph node and donor site were checked by ultrasound, and minipigs with viable transplanted LNs were allocated to lipiodol lymphangiography or MR lymphangiography groups. Transplanted LN engraftment was examined with immunohistochemical staining. After NVLNT in mice, the signal intensities in the popliteal region at 3 minutes and 5 minutes were higher in the transplanted side than the control side (21.3 ± 8.1 vs. 11.0 ± 4.6 at 3 minutes, 26.7 ± 6.8 vs. 19.7 ± 5.9 at 5 minutes), while in the sham group, there were no significant differences between sides. In minipigs, lipiodol lymphangiography (n = 5) showed Lipiodol accumulation in transplanted LNs with innumerable newly formed lymphatic vessels and lymphovenous shunts. MR lymphangiography (n = 5) showed higher enhancement on the transplanted side compared to the control side. Histology showed successful engraftment of transplanted LNs in 16 out of 20 (80%) mice and 9 out of 12 (75%) minipigs. Omnidirectional lymphangiogenesis forming a dense lymphatic network and spontaneous formation of lymphovenous shunts were shown after NVLNT.

Abstract No. 36 Incidence of lymphovenous shunting during nodal lymphangiography

The lymphatic system returns fluid predominantly through the thoracic duct to the venous circulation at the left venous angle. Lymphovenous shunts (LVS) have been described at various other levels and during lymphangiography have resulted in complications from non-target ethiodized oil embolization (NTE) in the pulmonary circulation, brain, liver, and kidneys among other areas (1-6). NTE has been noted occur in patients who have lymphatic leaks below the diaphragm or due to non-traumatic lymphatic disorders (4-6).

Lymphovenous shunts: from development to clinical applications.

The lymphatic system is a vast network of vessels that functions to return excess fluid from the interstitial space to the blood stream. Lymphovenous shunts are anastomoses, either natural or surgical, that connect the lymphatic and venous systems. Connections between the thoracic duct and venous system or between the right lymphatic duct and venous system are prime examples of anatomic lymphovenous shunts. Lymphovenous shunts are also present peripherally in tissues such as lymph nodes. Furthermore, pathologic lymphovenous shunts are observed in conditions such as lymphedema, malignancy, and lymphovenous malformations. Surgically, lymphovenous shunts may be constructed as an approach to treat lymphedema. Here, we discuss anatomic and surgical lymphovenous shunts in the context of normal development and disease. This perspective is intended to give an understanding of the role of lymphovenous shunts in health and disease and to show how they can be leveraged to treat disease surgically.

Edema Fluid Can Be Successfully Evacuated from the Lymphedematous Limbs by Implantation of Silicone Tubings Bypassing the Site of Flow Obstruction Long-Term Observations.

Background: Lymphedema of limbs is caused by partial or total obstruction of lymphatic collectors. In advanced cases all main lymphatics are obstructed and tissue fluid accumulates in the interstitial spaces. The microsurgical lympho-venous shunts cannot be performed. We propose in such cases drainage of fluid accumulations by creating artificial flow pathways to the nonobstructed regions by implantation of silicone tubes. Aim: To present the 3 to over 6 year follow-up results of therapy by subcutaneous implantation of silicone tubes. Methods: In 150 patients with obstructive limb lymphedema after pelvic or axillary lymphadenectomy and irradiation in uterine or breast cancer or following soft tissue inflammation silicone tubes were implanted subcutaneously. Results: There was (1) immediate decrease of limb circumference within days after implantation; (2) in lower limbs in a 3-year follow-up a decrease in mid-calf circumference by a mean -8.7% (p < 0.05) with range of -3.2% to -31.0% corresponding to 90-900 mL volume and in the mid-thigh a mean -1.8% (p < 0.05) with range of -9.3% to +3% equal to 0-900 mL. In the upper limb in the 2-year follow-up the decrease in the mid-forearm was -8.5% (p < 0.01) with a range of -3.0% to -22.0% and in the mid-arm a mean -12% (p < 0.05) with a range of -7% to -22%. That corresponded to 180-700 mL volume for the limb; (3) decreased tissue stiffness; (4) maintenance of tubes patency on control lymphoscintigraphy, contrast opacification, and ultrasonography; and (5) lack of reaction to foreign body and effective control of inflammation at the site of implantation using low doses of benzathine penicillin. Conclusions: The technical simplicity of the surgical procedure, fast decrease of limb edema, and lack of tissue reaction to the implant make the method worth applying in advanced stages of lymphedema.

Liposuction Treatment of Lymphedema.

In the Western world, lymphedema most commonly occurs following treatment of cancer. Limb reductions have been reported utilizing various conservative therapies including manual lymph and pressure therapy, as well as by microsurgical reconstruction involving lymphovenous shunts and transplantation of lymph vessels or nodes. Failure of these conservative and surgical treatments to provide complete reduction in patients with long-standing pronounced lymphedema is due to the persistence of excess newly formed subcutaneous adipose tissue in response to slow or absent lymph flow, which is not removed in patients with chronic non-pitting lymphedema. Traditional surgical regimes utilizing bridging procedures, total excision with skin grafting, or reduction plasty seldom achieved acceptable cosmetic and functional results. Liposuction removes the hypertrophied adipose tissue and is a prerequisite to achieve complete reduction, and this reduction is maintained long-term through constant (24 h) use of compression garments postoperatively. This article describes the techniques and evidence basis for the use of liposuction for treatment of lymphedema.

A New Method for Treatment of Lymphedema of Limbs: Standardized Manual Massage with a New Device Linforoll in Conservative and Surgical Therapy Protocols.

Edema fluid in lymphedematous limbs should be evacuated to sites where it can be absorbed. It should be moved either to the hypogastrium or arm/scapular regions along tissue channels or implanted silicon channels or through lymphovenous anastomoses. For that purpose, the manual lymphatic drainage of limb is an effective method. Standardization of manual massage applied force and timing becomes necessary. A device with known pressing area and continuously showing the applied force while moving it toward the root of the limb is needed. Moreover, force could be adjusted to the stiffness of the massaged tissues that varies at different levels of the limb. Results from such a device would be repeatable and reproducible by others. In this study we present data on tissue fluid hydromechanics obtained from 20 patients with obstructive limb lymphedema during massage with a massaging roller called Linforoll. Linforoll is composed of a hand piece with roller and pressure sensor connected wireless to the computer displaying the pressure curve of the applied force. Electron microscopy studies for checking eventual tissue changes were done. Linforoll provides the possibilities of: 1) regulating the applied force according to the hydromechanic conditions of the massaged tissues; 2) standardization of massage repeatable in the same patient; 3) decrease of limb volume; 4) evident increase in tissue elasticity; 5) application as a driving force for fluid flow along the surgically implanted tubing and vessels running to the lymphovenous shunts.

Transnodal ultrasound-guided lymphangiography for thoracic duct embolization in chylothorax

To evaluate the feasibility of ultrasound-guided transnodal lymphangiography as an modified technique for visualization of the abdomino-thoracic lymphatic system for thoracic duct embolization in patients with chylothorax after thoracic surgery. 10 patients (six men and four women, mean age 53 y [range, 22-72 y]) with chylothorax after thoracic surgery underwent ultrasound-guided transnodal lymphangiography. An inguinal lymph node was accessed under ultrasound guidance with a 25-gauge spinal needle and lipiodol was injected. Opacification of the lymphatic system was intermittently controlled by fluoroscopy. The thoracic duct was percutaneously accessed and embolization was performed. Following mean times were assessed: for the procedure of inguinal puncture, number of inguinal punctures, time from start of lipiodol injection until inguinal lymphangiogram, volume of injected contrast media, duration of opacification of target lymphatics, number of percutaneous punctions and time for thoracic duct access, time for thoracic duct embolization and complications. Procedure times until initial lymphangiogram were compared with times of a control group (n=10) in patients who had undergone pedal lymphangiography. The procedure of ultrasound guided lymph node puncture was successful in all cases (10 /10). Mean procedure times from inguinal access to initial lymphangiogram were 12.3 ± 2 minutes (pedal lymphangiography : 30.4 ± 5 minutes). Average of inguinal punctions was 1.3 (1-3). Small extravasation occurred in 4 of 10 patients. In 2 patients a contralateral inguinal punction was necessary because of lymphovenous shunts. In 10 /10 patients the lymphatic systems was opacified about 24.5 ± 9 minutes for thoracic duct embolization without required additional injection. Average of thoracic duct punctions were 1.5 (1-3). Procedure times until catheterization of the target lymphatics and until embolization of the thoracic duct were 19.3 ± 9 minutes and 14.5 ± 2 minutes respectively. Ultrasound-guided transnodal lymphangiography is a less technically challenging technique for opacification of the abdomino-thoracal lymphatic system for subsequent thoracic duct embolization.

Lymphovenous Microsurgical Shunts in Treatment of Lymphedema of Lower Limbs: A 45-year Experience of One Surgeon/One Center

RationaleThe use of microsurgical lymphovenous shunts is one of the generally accepted treatments for limb lymphedema. AimThe 45-year personal experience of one surgeon in indications, technique and results of lymphovenous shunt operations in lower limb lymphedema of varying etiology is presented. MaterialOne thousand three hundred patients were followed up in the period 1966–2011. Patients were classified into groups according to the etiology of lymphedema as postinflammatory/posttraumatic, postsurgical, idiopathic and hyperplastic. Decrease in limb circumference, heaviness and pain, and increase in joint flexing were evaluated. ResultsThe most satisfactory results, reaching 80–100% improvement, were obtained in the congenital non-hereditary hyperplastic lymphedema group, with large lymphatics not previously damaged by infection. Results were also satisfactory in the group of cancer patients after iliac lymphadenectomy, reaching 80%. A less satisfactory outcome was observed in the postinflammatory group, not exceeding 30–40%. In idiopathic lymphedema results were satisfactory in only a few cases. ConclusionsPatients with lymphedema with local segmental obstruction but still partly patent distal lymphatics and without an active inflammatory process in the skin, subcutaneous tissue and lymph vessels present satisfactory results.

Lymphovenöse Shunts und Thromboide bei Harnstauungsniere

This case of urinary obstruction with short anamnesis illuminates the early tissue reaction to urine extravasation, especially the Tamm-Horsfall protein. The latter becomes organized in the manner of a foreign body substance and drains via ectatic renal lymph vessels and reopened lymphovenous shunts into the intrarenal venous system. Polypoid formations (thromboids) with or without vessel obliteration appear to result in a clinical course of severe renal impairment.

Liposuction in arm lymphedema treatment.

Breast cancer is the most common disease in women, and up to 38% develop lymphedema of the arm following mastectomy, standard axillary node dissection and postoperative irradiation. Limb reductions have been reported utilizing various conservative therapies such as manual lymph and pressure therapy. Some patients with long-standing pronounced lymphedema do not respond to these conservative treatments because slow or absent lymph flow causes the formation of excess subcutaneous adipose tissue. Previous surgical regimes utilizing bridging procedures, total excision with skin grafting or reduction plasty seldom achieved acceptable cosmetic and functional results. Microsurgical reconstruction involving lympho-venous shunts or transplantation of lymph vessels has also been investigated. Although attractive in concept, the common failure of microsurgery to provide complete reduction is due to the persistence of newly formed subcutaneous adipose tissue, which is not removed in patients with chronic non-pitting lymphedema. Liposuction removes the hypertrophied adipose tissue and is a prerequisite to achieve complete reduction. The new equilibrium is maintained through constant (24-hour) use of compression garments postoperatively. Long-term follow up (7 years) does not show any recurrence of the edema.

The use of vein grafts in the treatment of peripheral lymphedemas: long-term results.

This study evaluates long-term results of the treatment of peripheral lymphedemas by the microsurgical reconstructive technique of interposed vein grafts. The technique consists of the use of autologous vein grafts to reconstruct lymphatic pathways where there is a block to the lymphatic circulation of the limb, whether of congenital or acquired etiology. The venous segment represents a sort of "bridge" between afferent and efferent lymphatic collectors (lymphatic-venous-lymphatic plasty [LVLA]). The results also proved to have positive long-term effects after microsurgical operation. Follow-up evaluation was performed clinically by water volumetry and instrumentally by lymphangioscintigraphy. With this LVLA technique, peripheral lymphedemas can be treated when derivative lymphovenous shunts cannot be used because of impaired venous circulation in the same lymphedematous limb. The new aspect of the study is that we report long-term clinical and instrumental results.

Frontiers in lymphatic microsurgery.

The Authors report an overview on the modern surgical treatment of peripheral lymphoedema. The aim of lymphatic microsurgical operations is to drain the lymph either toward the venous circulation (lympho-venous shunts) or the lymphatic collectors above the obstacle to the lymph flow, with the interposition of lymphatic or venous grafts (lymphatic-venous-lymphatic plasty). Selection of candidate patients for lymphatic microsurgery is based on an adequate diagnostic investigation, which includes above all lymphoscintigraphy, conventional oil contrast lymphangiography, Doppler venous flowmetry and manometry, and, if necessary (angiodysplasias), an accurate study also of the artery circulation. The clinical outcome of lymphatic microsurgery, assessed by water volumetry and lymphangioscintigraphy, performed at variable distance of time from operations till over 5 years after surgery, shows a significant reduction of edema volume and improvement of lymph flow in all patients and that the more precocious the microsurgical treatment the better the results.

Possible Implications of Neck Lymphovenous Shunts

Recently we read the article by Robbins and coworkers'¹entitled "Standardizing Neck Dissection Terminology." According to the classic anatomic description, the linear and continued progression of metastasis along the lymphatic chains of the neck toward the jugulosubclavian angle is a rare event, even in those patients who may reach a terminal state without any treatment. In the context of adipose tissue, small lymphoid aggregates are seen. Venous vessels linked by vascular capillary structures (interpretable as lymphovenous shunts) are isolated in the jugulodigastric region. To investigate this apparent anatomic-functional discrepancy we are now observing the ways of drainage with lymphoscintigraphy, without any diagnostic aim. We always observed a fast drainage and a distribution of the tracer similar to the N + anatomic distribution in the clinical cases; similar results were obtained with a marker of neoplastic involvement (gallium 67 citrate). The study was performed on both sides of the neck, ie,

Experimental Model of Lymphedema

The authors describe a new exper imental model for lymphedema of rabbit ear. The method proved to be reliable and easily reproducible. The dilatation of lymph vessels after ex perimental provocation of lymphe dema permits study of the physio pathologic basis of lymphovenous shunts created by means of micro surgery and proves to be helpful for the microsurgeon's practice.

Postlymphographic cerebral lipid embolization in the vena cava superior syndrome

A recent case of Lipiodol Ultrafluid embolism to the brain is reported. Pathogenetic concepts involving right-to-left shunts, and lympho-venous shunts with pulmonary capillary overloading are reviewed. In addition, it is suggested that a local disturbance in cerebral circulation due to a cava superior syndrome may contribute to the severe cerebral symptoms.

Neurologic complications following lymphangiography. Possible mechanisms and a case of blindness.

A four-day postpartum patient with oat cell carcinoma of the lungs and mediastinum developed blindness, right hemiparesis, and was comatose shortly after undergoing lymphangiography. She made a full recovery from the effects of the procedure over the next week. Only 19 cases of cerebral complications following lymphangiography have been recorded in the world literature, and this is the second case of blindness reported. Ethiodized oil (Ethiodol) could reach the cerebral circulation (1) during compression or obstruction of the caval system, (2) through lymphovenous shunts, either congenital or tumor-induced, (3) through a right-to-left intracardiac shunt, or (4) via intrapulmonary arteriovenous shunts which can occur with acute and chronic pulmonary disease—probably the mechanism of cerebral embolization of dye in our patient.

A study of retroperitoneal fibrosis

This is a case report of retroperitoneal fibrosis in a female patient of 42 years. The lymphogram showed evidence of total lymph block with lymphovenous shunts to the branches of the portal vein. Earl

Lympho-venous shunts after obstruction of the lymph drainage from the heart

Lympho-venous shunts after obstruction of the lymph drainage from the heart

The clinical siginifcance of lymphaticovenous communications.

Editorial Notes1 June 1970The Clinical Significance of Lymphaticovenous CommunicationsSAM A. THREEFOOT, M.D. F.A.C.P.SAM A. THREEFOOT, M.D. F.A.C.P.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-72-6-957 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThe clinical significance of lymphaticovenous communications has not been fully appreciated, in part because of the technical difficulties in detecting and in studying the function of the communications in living human subjects. Edwards and Kinmonth, who is responsible for the promotion of lymphography as a clinical procedure, have recently reviewed the radiological criteria for the identification of lymphovenous shunts and discussed aspects of their clinical significance (1). They observed, as have other lymphographers (2-7), that most lymphovenous shunts are detected in subjects with neoplastic or inflammatory obstruction of lymph vessels or nodes. Since visualization of small globules of radiopaque oil...

Lymphovenous shunts in man.

Lymphovenous shunts have been detected in patients by lymphography with Ultrafluid Lipiodol. No shunts were found in patients with normal lymphatic systems. They were found in patients with lymphoedema, with lymph nodes involved by malignant disease, and in patients who had had surgical interruption of lymphatic pathways, either vessels or nodes. The total incidence of lymphovenous shunts in 700 lymphographic studies was 2.3%. The incidence in the various pathological groups was highest in those with obvious lymph node involvement.In certain situations, particularly primary lymphoedema, the role of a lymphovenous shunt appears favourable to prognosis. In other situations a deleterious effect may be produced.