What is Lymphedema?

Lymphedema is a condition during which lymphatic fluid cannot normally circulate, typically from the arms or legs, towards the main veins of the central body where the fluid is typically absorbed.

Lymphedema is typically divided into two separate groups, primary and secondary.

Primary lymphedema is congenital in nature, and can be due to malformations, or syndromic causes. This type of lymphedema is present from birth, and is exceedingly rare, but often worsens throughout life.

Secondary lymphedema is caused by a variety of factors, and causes are largely specific to geographic areas.

In developed countries such as the USA or most of Europe, the vast majority of lymphedema is caused by tissue damage due to surgery or radiation, or it coexists with congenital venous problems.

When lymphedema is caused by tissue damage, it typically arises months to years after surgery or radiation. In the United States, this is a common complication caused by damage to the axillary (armpit) area during breast cancer surgery and/or radiation. It can however happen in any area where lymph nodes were removed, such as the groin area (affecting the leg) as well. It is quite important to understand lymph nodes are typically intimately associated with veins (as depicted in the diagram below). This means that damage to a major vein is a potential risk during any surgery that involves the removal of lymph nodes.

nyc-surgical-associates-axillary-vein-min

In developing countries, typically sub-tropical countries such as Brazil or south East Asia, other causes such as parasitic infections must be considered as a causal factor.

How do vein problems cause lymphedema?

Lymphatic vessels are typically located between arteries (source of oxygen rich blood from the heart) and veins that carry oxygen poor blood back to the heart. Normal arterial pressure is very high (approximately 100mmHg), while vein pressure is very low (approximately 5mmHg, or 5 percent of arterial pressure). Lymphatic pressure is thus affected dramatically by small increases in venous pressure, as the lymphatic fluid needs to make the transition from artery to vein.

nycsa-lymph-capiliaries-in-tissue-spaces-min

arm lymphedema caused by radiation surgery
A typical example of arm lymphedema caused by radiation surgery
A typical example of lymphedema with a significant venous component:
A typical example of lymphedema with a significant venous component

What kinds of problems does lymphedema cause?

Initially, lymphedema presents simply as swelling of the affected limb (typically including the hand/foot). Often the limb is cool and pale, relative to the limb of the patient’s unaffected side.

Over time, swelling can progress to a point where it significantly limits mobility, and commonly causes pain, heaviness and clumsiness of the limb.

Towards the more severe end of the spectrum, spontaneous, life threatening infections called “lymphangitis” can occur. This is because one of the functions of our lymphatic system is to clear infectious particles, and return our white blood cells that fight infection from the limb to the central part of the body to be processed. When the lymphatic vessels are obstructed to a large degree, the immune system may become compromised in its ability to remove infectious particles from our bodies. The stagnation of these infectious particles then leads to a vastly increased chance of infection.

How can I be checked for lymphedema?

A screening examination for lymphedema is performed by a skilled clinician who is experienced with this problem. Typically, as part of the examination, your blood vessels (arteries and veins) will be checked with duplex ultrasound as well. This is because concomitant problems with blood vessels are a common, but (typically) easily-treatable complication of lymphedema.

In very rare cases, we may order a test called lymphscintigraphy, but in most cases this is not needed.

Can other blood vessels contribute to my symptoms of lymphedema?

Absolutely, and very commonly. This occurs most often with concomitant vein problems.

To understand this phenomenon, it’s important to understand 3 principles of veins and lymphatic vessels.

  1. Anatomically, they are closely intertwined. Meaning, lymph nodes are typically located
    intimately involved with veins. This means if damage to lymphatics has occurred due to surgery or radiation, it is likely that some damage to veins occurred as well.
  2. Veins and lymphatic vessels are both very low-pressure systems, unlike arteries. This means
    that they are obstructed at a very similar pressure; when one is affected, the other is also affected as a result.
  3. Congenital problems with venous circulation, which are exponentially more common than
    congenital lymphatic problems, will eventually cause problems with the lymphatic system if the venous pressure builds up to a significant extent, due to principle #2.

breast-lymphedema

How do you ensure that other blood vessels are not involved?

We start with a noninvasive test called duplex ultrasonography, which gives us a basic idea of what is going on with your veins and arteries. While this test is noninvasive, and very helpful if positive, the test being negative does not reliably rule out venous disease.

A detailed history in terms of symptoms as well as an examination of the affected limb is crucial in deciding whether further testing is needed after the duplex test.

If further testing is recommended given findings from physical examination and patient history, the next step is to perform a venogram; the diagnostic gold-standard test.

A venogram is a very precise and accurate way of concretely ruling out a venous contribution to your problems, and is done through a small IV with contrast dye and an X-ray machine. There is typically no downtime, pain, or scarring after a venogram, and your surgeon will describe specific details about this test with you if it is indicated.

Does having a venous problem affect my ability to achieve a good outcome from surgery?

Yes, however, not how you would think. We have found that the vast majority of patients who have been diagnosed with lymphedema, and are found to have a significant venous problem, often respond positively and significantly to treatment of the venous problem alone, without specific lymphatic surgery.

Because treatment for venous problems has a very high success and low complication rate, in patients with venous disease as well, we typically start there. Satisfactory results/significant improvement of symptoms is often achieved after this procedure alone.

Lymphedema Treatment with NYC Surgical Associates

What are the treatment options for any venous problems that may be contributing to my lymphedema?

Treatment options always start with medical therapy, which is identical for lymphatic AND venous problems. This consists largely of compression garments, and physical decompressive therapy.

If you have decided you want to proceed with surgical therapy, typically there are two options; angioplasty and stenting.

Angioplasty is using a special balloon to stretch the inside of the vein where it has become narrowed, so that it is closer to its original size. This allows blood to circulate under lower pressure, which improves flow and decreases swelling. Typically, we utilize angioplasty for the arms, as research data suggests that stent placement in this area does not yield the same favorable long-term outcomes that have been achieved by stenting in the legs.

Stenting utilizes a very thin walled metal tube to stretch the vessel and achieve the same outcomes as angioplasty, but with more durable results because the metal tube prevents the vein from shrinking back to the size that limited blood flow and caused swelling. Stenting is typically used for the legs, and has an excellent long-term durability track record, unlike in the arms.

The downside to using angioplasty only as a treatment option is the results are not as durable as stenting, because there is no stent or metal tube left in place to keep the vessel open. Often patients may require a minor touch up procedure in the future, usually 1-2 years after the initial one, for continued clinical improvement. However, because angioplasty requires minimal down-time, minimal scarring, and is a largely painless procedure, the vast majority of patients find that the improvement they experience is very much worth these additional follow up treatments.

What if I have no venous problems?

If you happen to be one of the rare patients that do not have any concomitant venous problems, no venous treatment would be indicated, and the next step would be a lymphatic specific surgery.

Several options exist for lymphatic specific surgery, including:

  1. Therapeutic debulking, lymph sparing liposuction
    Once lymphatic fluid spills into your surrounding tissues, it can cause inflammation and stimulate fat stem cells to grow. Your surgeon removes this extra fat caused by lymphedema with a specialized thin cannula that uses pressurized water jets to gently dissect the tissue while minimizing extra damage to lymphatic vessels. This is typically an outpatient procedure with a very short recovery time.
  2. Vascularized lymph node transplant
    Your surgeon transplants a group of lymph nodes from a healthy part of your body to the affected area, effectively rewiring the lymphatic system. This is an inpatient procedure with a recovery time of a few days before resuming regular activity.
  3. Lymphaticovenous anastomosis
    Your surgeon uses microsurgical techniques and equipment to reroute your lymphatic system, bypassing damaged nodes and connecting lymphatic channels directly into your veins. The lympho-venous bypass is an outpatient surgery. You can return to regular activity within a few days.
  4. Debulking excisions with skin grafts (Charles procedure)
    Affected tissue is removed and your surgeon uses part of it as skin grafts to repair the area. Skin grafts require more extensive care of the surgical site after your procedure, and it can take up to one month to return to normal activity.

Do I have to proceed with surgery?

Absolutely not. The decision to proceed with surgery is one only the patient can make and should only be made when the patient is aware of all options, risks, expected benefits, and a synergy regarding expectations and outcomes is present between the patient and surgeon.

Does insurance cover my surgery?

In most cases, yes. Depending on specific plans, there may or may not be certain exclusions, but a clear discussion of what is covered and what is not will be had with the patient PRIOR to any procedures being scheduled, so that no surprise bills become an issue. This is standard for any patient at NYC Surgical, as we believe in complete transparency.

Lymphedema Treatment Cost New York & New Jersey

NYC Surgical Associates is committed to helping our patients receive the best care possible. That journey always begins with a medical consultation.

No two cases of lymphedema are exactly alike, so consultations enable our doctors to better understand each patient’s situation and determine the best treatment.

Prior to booking a consultation with our surgical practice, our team will collect your insurance information to determine if our providers accept your specific insurance plan.

If we do not accept your medical insurance, we will inform you of any out of pocket costs associated with a consultation and help you weigh your options. Either way, a doctor must see you before we can tell you what treatment for your condition will entail, from both a medical and cost standpoint. Contact us today.