Efficacy of Microsurgical Venous Couplers in Lymphovenous Anastomosis of the Thoracic Duct: An Examination of Outcomes and Patency at Follow-Up

Abstract

Background

Central lymphatic disruption can result in devastating lymphedema, chylothorax, chylous ascites, metabolic deficiencies, and death. Literature from our institution has previously demonstrated the technical feasibility of lymphovenous anastomosis (LVA) for thoracic duct (TD) bypass. Here, we present our complete patient series with expanded follow-up utilizing a microsurgical venous coupler to facilitate LVA.

Methods

A single-institution, retrospective review was conducted for adult patients who underwent LVA for TD bypass between 2019 and 2024. Demographic, etiological, and perioperative information was collected. Symptomatic resolution with or without radiographically confirmed patency was considered a successful bypass at follow-up.

Results

A total of 23 patients underwent LVA of the TD. The mean age was 49.7 years. Median postoperative follow-up was 395 days (interquartile range [IQR]: 150.5–554.5). Anastomotic targets included the EJV (n = 15), IJV (n = 4), AJV (n = 2), or another regional vein (n = 3). The technical success of the venous coupler was 100%. Three patients experienced a surgical site complication (13.0%). At follow-up, 13 patients (56.5%) had a patent TD anastomosis with symptomatic resolution. One patient (4.3%) had a patent anastomosis confirmed on imaging but experienced mild symptomatic recrudescence. The remaining patients (39.1%) had nonpatent anastomoses. The median venous coupler size was 3.0 mm for both the patent cohort and the nonpatent cohort.

Conclusion

LVA for TD bypass with an anastomotic coupler is well tolerated and provided durable relief of symptoms in over half of our cohort. This data supports venous coupler utilization in LVA for thoracic TD occlusion. Patient accrual is ongoing to further evaluate and optimize outcomes.

Keywords

thoracic duct occlusion - lymphovenous anastomosis - central lymphatic bypass outcomes

Ethical Approval

This study was approved by the Institutional Review Board (IRB) and adheres to ethical standards.

Previous Presentation

This work has been accepted as a poster at the American Association of Plastic Surgeons (AAPS) May 18 to May 21, 2024.

Publication History

Received: 03 January 2025

Accepted: 17 April 2025

Accepted Manuscript online:
29 April 2025

Article published online:
22 May 2025

• References

• 1 Oliver G, Alitalo K. The lymphatic vasculature: recent progress and paradigms. Annu Rev Cell Dev Biol 2005; 21: 457-483
• 2 Bhardwaj R, Vaziri H, Gautam A, Ballesteros E, Karimeddini D, Wu GY. Chylous ascites: a review of pathogenesis, diagnosis and treatment. J Clin Transl Hepatol 2018; 6 (01) 105-113
• 3 Karakousi T, Mudianto T, Lund AW. Lymphatic vessels in the age of cancer immunotherapy. Nat Rev Cancer 2024; 24 (06) 363-381
• 4 Kiyonaga M, Mori H, Matsumoto S, Yamada Y, Sai M, Okada F. Thoracic duct and cisterna chyli: evaluation with multidetector row CT. Br J Radiol 2012; 85 (1016) 1052-1058
• 5 O'Hagan LA, Windsor JA, Phillips ARJ, Itkin M, Russell PS, Mirjalili SA. Anatomy of the lymphovenous valve of the thoracic duct in humans. J Anat 2020; 236 (06) 1146-1153
• 6 Moore Jr JE, Bertram CD. Lymphatic system flows. Annu Rev Fluid Mech 2018; 50: 459-482
• 7 Parmeggiani D, Gualtieri G, Terracciano G. et al. Prolonged iatrogenic thoracic duct chylous fistula in neck surgery: conservative management or surgery? A literature review. Scand J Surg 2021; 110 (04) 550-556
• 8 Derakhshan A, Lubelski D, Steinmetz MP. et al. Thoracic duct injury following cervical spine surgery: a multicenter retrospective review. Global Spine J 2017; 7 (Suppl. 01) 115S-119S
• 9 Ruiz Pier JL, Rashid MA. Thoracic duct injury: an up to date. J Cardiothorac Trauma 2021; 6 (01)
• 10 Hematti H, Mehran RJ. Anatomy of the thoracic duct. Thorac Surg Clin 2011; 21 (02) 229-238 , ix
• 11 Rochefort MM. Review of chylopericardium. Mediastinum 2022; 6: 3
• 12 Lopez-Gutierrez JC, Tovar JA. Chylothorax and chylous ascites: management and pitfalls. Semin Pediatr Surg 2014; 23 (05) 298-302
• 13 Weniger M, D'Haese JG, Angele MK, Kleespies A, Werner J, Hartwig W. Treatment options for chylous ascites after major abdominal surgery: a systematic review. Am J Surg 2016; 211 (01) 206-213
• 14 McGrath EE, Blades Z, Anderson PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med 2010; 104 (01) 1-8
• 15 Wemyss-Holden SA, Launois B, Maddern GJ. Management of thoracic duct injuries after oesophagectomy. Br J Surg 2001; 88 (11) 1442-1448
• 16 Duletzke NT, Kiraly LN, Martindale RG. Chylothorax and chylous ascites: overview, management, and nutrition. Nutr Clin Pract 2023; 38 (03) 557-563
• 17 Nadolski GJ, Chauhan NR, Itkin M. Lymphangiography and lymphatic embolization for the treatment of refractory chylous ascites. Cardiovasc Intervent Radiol 2018; 41 (03) 415-423
• 18 Beidas OE, Gusenoff JA. Update on liposuction: what all plastic surgeons should know. Plast Reconstr Surg 2021; 147 (04) 658e-668e
• 19 Kung TA, Champaneria MC, Maki JH, Neligan PC. Current concepts in the surgical management of lymphedema. Plast Reconstr Surg 2017; 139 (04) 1003e-1013e
• 20 Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg 2013; 132 (05) 1305-1314
• 21 Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000; 16 (06) 437-442
• 22 Tourani SS, Taylor GI, Ashton MW. Long-term patency of lymphovenous anastomoses: a systematic review. Plast Reconstr Surg 2016; 138 (02) 492-498
• 23 Maegawa J, Yabuki Y, Tomoeda H, Hosono M, Yasumura K. Outcomes of lymphaticovenous side-to-end anastomosis in peripheral lymphedema. J Vasc Surg 2012; 55 (03) 753-760
• 24 Suzuki Y, Sakuma H, Yamazaki S. Evaluation of patency rates of different lymphaticovenous anastomosis techniques and risk factors for obstruction in secondary upper extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2019; 7 (01) 113-117
• 25 Kelly B, Smith CL, Saravanan M, Dori Y, Hjortdal VE. Spontaneous contractions of the human thoracic duct-Important for securing lymphatic return during positive pressure ventilation?. Physiol Rep 2022; 10 (10) e15258
• 26 Taghinia AH, Upton J, Trenor III CC. et al. Lymphaticovenous bypass of the thoracic duct for the treatment of chylous leak in central conducting lymphatic anomalies. J Pediatr Surg 2019; 54 (03) 562-568
• 27 Reisen B, Kovach SJ, Levin LS. et al. Thoracic duct-to-vein anastomosis for the management of thoracic duct outflow obstruction in newborns and infants: a case series. J Pediatr Surg 2020; 55 (02) 234-239
• 28 Toyoda Y, Fowler C, Mazzaferro DM. et al. Thoracic duct lymphovenous bypass: a preliminary case series, surgical techniques, and expected physiologic outcomes. Plast Reconstr Surg Glob Open 2022; 10 (12) e4695
• 29 Jandali S, Wu LC, Vega SJ, Kovach SJ, Serletti JM. 1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction. Plast Reconstr Surg 2010; 125 (03) 792-798
• 30 Medina ND, Fischer JP, Fosnot J, Serletti JM, Wu LC, Kovach III SJ. Lower extremity free flap outcomes using an anastomotic venous coupler device. Ann Plast Surg 2014; 72 (02) 176-179
• 31 Othman S, Azoury SC, Klifto K, Toyoda Y, Itkin M, Kovach SJ. Microsurgical thoracic duct lymphovenous bypass in the adult population. Plast Reconstr Surg Glob Open 2021; 9 (10) e3875
• 32 Laje P, Dori Y, Smith C, Pinto E, Taha D, Maeda K. Surgical management of central lymphatic conduction disorders: a review. J Pediatr Surg 2024; 59 (02) 281-289
• 33 Ozen A, Lenardo MJ. Protein-losing enteropathy. N Engl J Med 2023; 389 (08) 733-748
• 34 Umar SB, DiBaise JK. Protein-losing enteropathy: case illustrations and clinical review. Am J Gastroenterol 2010; 105 (01) 43-49 , quiz 50
• 35 Lopez M, Roberson ML, Strassle PD, Ogunleye A. Epidemiology of lymphedema-related admissions in the United States: 2012-2017. Surg Oncol 2020; 35: 249-253
• 36 Garza RM, Wong D, Chang DW. Optimizing outcomes in lymphedema reconstruction. Plast Reconstr Surg 2023; 152 (06) 1131e-1142e
• 37 Kulkarni AR, Mehrara BJ, Pusic AL. et al. Venous thrombosis in handsewn versus coupled venous anastomoses in 857 consecutive breast free flaps. J Reconstr Microsurg 2016; 32 (03) 178-182
• 38 Wolfs JAGN, de Joode LGEH, van der Hulst RRWJ, Qiu SS. Correlation between patency and clinical improvement after lymphaticovenous anastomosis (LVA) in breast cancer-related lymphedema: 12-month follow-up. Breast Cancer Res Treat 2020; 179 (01) 131-138
• 39 Boccardo F, Santori G, Villa G, Accogli S, Dessalvi S. Long-term patency of multiple lymphatic-venous anastomoses in cancer-related lymphedema: a single center observational study. Microsurgery 2022; 42 (07) 668-676