Lymphatic-venous anastomosis (LVA) for lymphoedema

Lymphatic-venous anastomosis, known as LVA, is a microsurgical procedure that creates small connections between lymphatic vessels and nearby veins. Its purpose is to provide the lymph with an alternative route back into the bloodstream when the lymphatic system is unable to drain it properly.

The procedure is carried out via small incisions and with the aid of a surgical microscope, as the vessels being worked on may measure less than one millimetre. Before considering the procedure, the team assesses how the lymphatic system functions and what changes have occurred in the tissues, as both the indication for the procedure and the expected benefits depend on this assessment.

Lymphatic-venous anastomosis: what it involves

The lymphatic system functions as a collection and transport network. It recovers some of the fluid and proteins left between the cells and returns them to the bloodstream. When this capacity diminishes, lymph begins to accumulate in the tissues and the characteristic swelling of lymphoedema appears.

Over time, the problem may cease to be merely a matter of fluid retention. The tissues may become inflamed, hardened and increase in fat content, meaning that two limbs of similar volume do not necessarily present the same condition or respond equally to treatment.

LVA is based precisely on this reality. In people who still have lymphatic vessels capable of transporting lymph, the surgeon can connect them to small nearby veins, thereby creating an alternative drainage route into the bloodstream.

The term ‘anastomosis’ refers to a surgical connection between two ducts. In this case, this connection makes it possible to utilise the residual function of the lymphatic system to facilitate the drainage of accumulated lymph.

Aim of the treatment

The aim of LVA is to improve lymphatic drainage and reduce the consequences of its impairment, but the response is not assessed solely by how much the size of the arm or leg decreases.

For some people, the most significant change may be a reduction in heaviness or tension; for others, it may be fewer infections, greater ease of movement or a reduced need for compression. Volume remains important, but it does not always change at the same rate as symptoms or function.

For this reason, before the procedure, the objectives considered clinically relevant in each case are established, along with how they will be assessed afterwards. This approach to evaluating the outcome avoids reducing the entire course of lymphoedema to a single measurement.

When it may be indicated

LVA may be considered when there are lymphatic vessels that still retain their drainage capacity and can be used to create useful connections with small veins.

The decision does not depend solely on the extent of the swelling in the limb or the duration of the condition. The cause of the lymphoedema, the symptoms, previous infections, the response to treatments already undertaken and the impact the condition has on daily life are also taken into account.

The condition of the tissues is equally important. When lymphoedema has been developing for some time, part of the increase in volume may be due not only to retained fluid, but also to an increase in fatty tissue and changes involving fibrosis or hardening. This composition influences which procedure may be most beneficial.

LVA may be considered for some cases of secondary lymphoedema — for example, following certain cancer treatments — as well as for certain forms of primary lymphoedema. The selection criteria are not the same in all cases and require an individualised assessment.

Pre-operative assessment and tests

The assessment begins by piecing together the history of the lymphoedema: when it first appeared, how it has progressed, what symptoms it causes, whether it has led to infections, and how the patient has responded to treatments received to date.

Next, the lymphatic system itself is examined. The aim is to determine which vessels are still functioning, how the lymph flows and which areas could be used to create new connections.

One of the tests used is indocyanine green lymphography. A fluorescent tracer is administered via small superficial injections, allowing the path of the lymph through the vessels close to the skin to be observed using a special camera.

This information helps to identify functional pathways and plan where anastomoses might be performed. Depending on the characteristics of the case, other investigations may be added, such as specialised ultrasound or complementary imaging studies.

Not everyone requires exactly the same tests. The choice of investigations depends on the information the team needs to decide whether LVA is likely to be beneficial and how it should be planned.

How the procedure is carried out

Once the lymphatic system has been examined, the surgeon selects the points where connections can be created. Through small incisions, the surgeon identifies a lymphatic vessel and a nearby vein. Under a surgical microscope, both structures are prepared and joined using extremely fine sutures.

The size of these vessels explains why the technique falls within the field of supermicrosurgery, a form of microsurgery designed to work with structures smaller than one millimetre.

Several connections can be made during a single operation. Their number and location depend on the anatomy, the available vessels and the characteristics of each individual case. Where possible, the team checks during the operation itself that lymph is flowing into the vein via the new pathway.

Anaesthesia may be local or general, depending on the procedure and the pre-operative assessment. The duration of the surgery may also vary. The number of anastomoses alone does not determine the extent to which a person’s condition will improve; what matters is that they are functional and that this new drainage pathway subsequently results in a clinically significant improvement.

What results can it deliver?

The response to LVA can manifest in different ways, and not all of these necessarily appear at the same time.

In women with arm lymphoedema following breast cancer, a trial published in Scientific Reports observed improvement in certain physical aspects at the six-month mark. However, it did not demonstrate a significant reduction in arm volume or a clear improvement across the range of problems assessed.

This type of result helps to explain why a person may feel better even if there is little change in the size of the limb.

The effect on infections has also been studied. In people with secondary lymphoedema of the legs, a trial published in the BJS found fewer episodes of infectious cellulitis when LVA was added to decongestive therapy. In this context, cellulitis refers to an infection of the skin and soft tissues, not the cosmetic condition known by the same name.

In that study, no significant differences were observed in limb circumference or pain during the period analysed.

There is also data from long-term follow-up. A series published in 2026 described sustained improvements in symptoms and quality of life several years after the intervention. As it came from a single centre and lacked a comparison group, its results provide information on the course of the condition but do not guarantee the same response for all individuals.

Overall, the available evidence suggests that LVA may offer benefits in selected patients, although the extent of improvement varies and there is no single success rate applicable to all types of lymphoedema.

Compression, rehabilitation and other forms of care

LVA forms part of the overall treatment for lymphoedema and does not automatically replace other forms of care.

Compression, adapted exercise, skin care and certain physiotherapy techniques may still be necessary following the procedure. The need to continue or modify these is assessed as the patient’s response becomes clear.

A study published in 2026 on the use of compression garments following VLS described a partial reduction or discontinuation of these garments in some selected patients with secondary upper-limb lymphoedema. The sample size was small, and the changes were made after a favourable and stable clinical course had been confirmed.

Therefore, compression sleeves or stockings are not automatically discontinued after surgery. In some people, their use may be reduced; in others, they remain important for managing lymphoedema.

Furthermore, the guidelines for the first few days following the operation may differ from the long-term recommendations. The use of compression, exercise and physical therapies are adjusted according to the procedure performed and the patient’s clinical progress.

Alternatives and combination with other techniques

Lymphoedema surgery includes procedures that address different problems. LVA uses existing lymphatic vessels to create new drainage pathways. Vascularised lymphatic tissue transfer, on the other hand, involves moving lymphatic tissue from another part of the body, together with its blood supply, to promote new circulation pathways.

Where excess fatty tissue contributes significantly to the increase in volume, reduction surgery, such as liposuction specifically for lymphoedema, may be considered.

The choice depends on the residual function of the lymphatic system, the composition of the tissues and the degree of fibrosis or hardening. In certain patients, several procedures may be combined or carried out in different stages.

The Barcelona surgical algorithm uses precisely this lymphatic function and the characteristics of the tissues to guide this selection.

Risks and potential complications

Although it is carried out via small incisions, LVA remains a surgical procedure and requires a proper assessment of its risks.

Local discomfort, bruising, problems with healing or wound infection may occur, in addition to the risks associated with the type of anaesthesia used. There is also a possibility that one of the new connections may close or fail to function as expected.

Studies evaluating the patency of anastomoses show that verifying that a connection remains open and assessing clinical improvement are two related but distinct aspects. An anastomosis may function technically correctly and yet produce a lesser benefit than expected.

There may also be a partial response. For example, heaviness or infections may improve whilst significant swelling persists.

These possibilities form part of the pre-operative assessment, so that expectations are realistic and other options can be considered when necessary.

Follow-up and assessment of the response

Monitoring allows progress to be compared with the situation prior to the intervention. Limb measurements, discomfort, infections, daily activities and compression requirements are reviewed. In certain cases, imaging tests may be used again to assess the functioning of the connections or lymphatic circulation.

This assessment helps to determine which objectives are being met, identify any potential difficulties and adapt care in line with the response observed.

The Barcelona Consensus on Reconstructive Surgery for Lymphoedema emphasises pre-operative assessment and specialised follow-up as fundamental elements of surgical treatment.

The onset of fever, progressive redness, localised warmth or increasing pain requires medical assessment, as it may indicate an infection and should not automatically be attributed to the lymphoedema itself or to the normal recovery process.

Team expertise and surgical planning

LVA requires expertise in microsurgery and specific knowledge of lymphoedema. Planning begins well before entering the operating theatre. The team must interpret the tests, locate suitable vessels, assess tissue changes and determine what objectives are reasonable for each individual.

Experience also enables the team to recognise when another technique may offer better outcomes or when it is useful to combine different procedures.

The international consensus on reconstructive surgery for lymphoedema identifies individual assessment, preparation and coordination between professionals as essential elements of this type of treatment.

Specialists involved and the care pathway

At the Publio Cordón Memorial Hospital, the surgical assessment of lymphoedema is carried out by the Advanced Breast Reconstruction and Lymphoedema Unit, which forms part of the Department of Plastic and Reconstructive Surgery.

The unit is headed by Dr Jaume Masià Ayala and includes lymphatic-venous anastomoses as part of its programme of microsurgery and supermicrosurgery for lymphoedema.

The pathway begins with an assessment of the patient’s medical history, symptoms, previous treatments and the impact of lymphoedema on daily life. The functioning of the lymphatic system and the condition of the tissues are then examined to determine which options are likely to be beneficial.

When a lymphatic-venous anastomosis (LVA) is considered, the team explains the aims of the procedure, the alternatives and the aftercare required. In cases of lymphoedema related to cancer treatments, care may require coordination with other specialist departments.

Subsequent follow-up allows the response to be assessed and the care plan to be adapted, whilst maintaining coordination with the professionals responsible for rehabilitation and conservative treatment of lymphoedema.

Preguntas frecuentes

Can LVA be assessed even if I have had lymphoedema for many years?

Yes. The duration of the condition is important, but it is not the only criterion. We also investigate whether there are any lymphatic vessels that still have drainage capacity and what changes have occurred in the tissues.

Will I be able to take off the compression sleeve or stocking?

It depends on the response. Some people may be able to reduce their use, whilst others need to continue using it. Any changes should be made after assessing how things are progressing and in accordance with the team’s instructions.

Does LVA involve the transplantation of lymph nodes?

No. LVA connects lymphatic vessels to nearby small veins. The transfer of vascularised lymphatic tissue involves moving lymphatic tissue from another part of the body, together with its blood supply.

Can the feeling of heaviness improve even if the arm or leg is still swollen?

Yes. Symptoms, breast size and function do not always change to the same extent. There may be an improvement in the feeling of heaviness, in the incidence of infections or in comfort when carrying out activities, even if the reduction in size is only slight.

How long does it take to find out whether the LVA has worked?

Wound healing occurs before a full assessment of the lymphoedema can be carried out. The response is monitored over the following months by comparing symptoms, volume, infections and compression requirements with the previous situation.

Is treating existing lymphoedema the same as trying to prevent it during cancer surgery?

No. This factsheet concerns the management of established lymphoedema. Techniques designed to prevent its onset during certain cancer operations have specific indications and evidence.

Medical information for general guidance

This factsheet explains what lymphatic-venous anastomosis involves, what its aims may be, and how its inclusion in the treatment of lymphoedema is assessed. The information has been compiled from up-to-date scientific literature and reflects the commitment of the Publio Cordón Memorial Hospital to providing rigorous, comprehensible and up-to-date medical information.

Surgical indications, expected benefits and guidelines on compression, activity and follow-up require specialist assessment. This content is not a substitute for an individual clinical assessment.