From the American Venous Forum

Lymphorrhea responds to negative pressurewound therapyBabak Abai, MD, Robert W. Zickler, MD, Peter J. Pappas, MD, Brajesh K. Lal, MD,and Frank T. Padberg, Jr, MD, Newark and East Orange, NJ

Lymphoceles and lymph fistulas are common complications of femoral exposure for vascular procedures. Three patientswho required readmission after their vascular interventions were treated with negative pressure wound therapy. Onceadequate control of the drainage was obtained, the patients were discharged home with a portable suction unit. The meantime to stop lymph leak was 14 days, and the mean length of hospital stay was 7.3 days. This method of managementoffers early control of fluid drainage, rapid control of the wound, earlier closure, and the potential for reduced length ofstay. Patient acceptance and convenience may be enhanced by outpatient management and return to work in appropriately

motivated individuals. ( J Vasc Surg 2007;45:610-3.)

Lymphatic injury is a common cause of morbidity in thevascular patient. Lymphatic vessels are usually small and areinfrequently visualized. Despite efforts to meticulously li-gate lymphatic tissue, transection of adjacent lymphaticswill occasionally occur during vascular exposures becausethey are anatomically located close to major vessels, clini-cally appearing as lymphocele or lymph fistula in 1% to 4%of femoral dissections.1

Lymphocele is a cystic collection of lymphatic fluidfrom a disrupted lymphatic channel that forms a pocket inthe soft tissue of the healing wound. Continued fluidaccumulation in fresh wounds may cause wound disruptionand lymphorrhea. Continued leakage constitutes lymphfistula. Lymphoceles and lymph fistulas of the femoralregions have been reported after lymph node biopsy, arte-rial reconstruction, vascular cannulation, saphenous veinharvest, and other procedures.2 Any dissection in the re-gion of the femoral neurovascular bundle can lead to thetransection of the lymphatic channels.

Uncontrolled lymphatic drainage can be the source ofsignificant morbidity for the patient, and wound infectionmay occur in up to 57%.3 Lymph leaks are difficult tomanage and can result in prolonged hospital stays of up toa month.4 Secondary wound infection may be devastat-ing when prosthetic material is present. Exposure ofeither autogenous or synthetic grafts may result in break-down with bleeding, infection, and loss of the vascularreconstruction, life, and/or limb.

Many modes of therapy have been described (Fig 1). A

From the Section of Vascular Surgery, Department of Surgery, New JerseyMedical School, University of Medicine and Dentistry of New Jersey, andVeterans Affairs New Jersey Health Care System.

Funding provided by Sigvaris Traveling Fellowship in Venous Disease.Competition of interest: The authors have no financial ties with the NPWT

product or the corporation manufacturing this product. This undertakingwas not supported by the manufacturers of this product.

Presented at the Eighteenth Annual Meeting of The American VenousForum, Miami, Fla, Feb 20-26, 2006.

Reprint requests: Frank T. Padberg, Jr, MD, Suite 7200, Doctors OfficeCenter, 90 Bergen St, Newark, NJ 07103 (e-mail: PadbergJr@aol.com).

0741-5214/$32.00Copyright © 2007 by The Society for Vascular Surgery.

doi:10.1016/j.jvs.2006.10.043

610

novel mode of therapy is the use of negative pressurewound therapy (NPWT) devices to treat this problem. Wesuccessfully managed three patients with lymphatic leaksusing NPWT.

CASE REPORT

Patient 1. PS is an 88-year-old man who was referred forevaluation of a pulsatile suprapubic mass. An infrarenal abdominalaortic aneurysm had been repaired with an aortoaortic tube graftmore than decade previously. Duplex ultrasound imaging and CTscans demonstrated a 6-cm anastomotic pseudoaneurysm at thedistal anastomosis.

Bilateral longitudinal femoral arteriotomies were performed

Lymphatic Leak

Non-OperativeTherapy

Operative Therapy

Bedrest, Prophylactic Antibiotics, and Compression dresssings

Multiple Aspirations of Lymph Cavity

Instillation of Sclerosing Agents

Radiation Therapy

*NPWT

Intraoperative Lymphatic Mapping and Ligation

Musculocutaneous Flap Closure

*NPWT for failure of surgical therapy

Fig 1. Current modes of therapy for femoral lymph leaks withproposed role of negative pressure wound therapy (NPWT).

and the pseudoaneurysm was successfully excluded with a bifur-

JOURNAL OF VASCULAR SURGERYVolume 45, Number 3 Abai et al 611

cated endovascular graft. On postoperative day (POD) 6, sponta-neous drainage of copious, clear, serous lymphatic fluid was notedfrom the left femoral incision. The patient was placed on bed restwith compression dressings applied to the groin. The lymph leakcontinued.

On POD 11, we explored the wound after injections ofisosulfan blue dye in the distal thigh an hour before the start of theprocedure; however, this failed to localize the leaking lymphaticchannels. Copious, serous drainage continued. The wound wassubsequently treated with NPWT. Lymphatic drainage ceased after19 days of therapy. Although this therapy could have been deliv-ered at his home, he remained in the hospital for social reasons.The lymph leak completely resolved, and the wound has remainedclosed with no ultrasound evidence of lymphocele by 15 months(Fig 2).

Patient 2. RF is 52-year-old man who was treated severalyears previously with abdominoperineal resection and pelvic irra-diation for colon cancer. An acute left iliofemoral venous throm-bosis developed after placement of a prosthetic penile implant. Hereturned to the operating room where the reservoir for the implantwas revised. The thrombosis manifested as diffuse limb edema,pain, cyanosis, and discoloration. Venous thrombectomy through

Fig 2. Patient 1. A, Lymphorrhea left femoral wound. B, Nega-tive pressure wound therapy in place. C, Granulation tissue. D,Wound healed.

a longitudinal infrainguinal incision produced immediate relief of

pain, edema, and cyanosis. Initially managed with intravenousheparin, he was discharged home after achieving appropriate Cou-madin (Bristol-Myers Squibb, New York, NY) anticoagulation.

The patient returned to the clinic on POD 13 with leakage oflymph from the thrombectomy incision. He was subsequentlytaken to the operating room in attempts to ligate the draininglymphatics with the assistance of distal limb isosulfan blue dyeinjections in between the first and second toes and third and fourthtoes. Despite injection 30 minutes before the operation and wait-ing for 30 minutes in the operating room, no clearly draining bluelymphatics were seen. The tissue at the base of the wound wherethe lymph leak was suspected was ligated. A suction drain wasplaced and the wound was closed. He was discharged home, butthe drain was dislodged accidentally at home.

Although these attempts to control the lymph leak wereunsuccessful, a clean, open wound was achieved. NPWT wasapplied to control the drainage and he was discharged home 5 dayslater. This was facilitated by home nurse monitoring of a portableNPWT unit changed every 3 days. This patient was self employedand returned to work while wearing the portable NPWT dressing.His lymph leak ceased after 12 days of NPWT and has not recurred.There was no evidence of lymphocele on ultrasound imaging after

Fig 3. Patient 2. A, Portable negative pressure wound therapyallows ambulatory therapy. B, Granulating wound after treatmentwith portable negative pressure wound therapy.

11 months.

JOURNAL OF VASCULAR SURGERYMarch 2007612 Abai et al

Patient 3. At age 72, JR had an uneventful, elective, endo-vascular repair of an infrarenal 6.2-cm abdominal aortic aneurysmvia bilateral longitudinal femoral incisions. Seven days after dis-charge home, he returned with fever of 102°F and drainage ofclear, serous fluid from left femoral incision. The right femoralincision healed without complications. The left wound was openedat the bedside and was managed locally for 2 days with wet-to-damp dressing changes and intravenous antibiotics. Once the feverresolved and the wound was clean and clear of infection, a NPWTdressing was applied.

He was discharged home again 5 days later. This was facili-tated by home nurse monitoring of a portable NPWT unit changedevery 3 days. His lymph leak stopped after 11 days of NPWT andhas not recurred. There was no evidence of lymphocele on ultra-sound imaging after 12 months.

DISCUSSION

Many modes of therapy have been proposed (Fig 1) fortreatment of this problem. Nonoperative recommenda-tions have included bed rest, prophylactic antibiotics, andpressure dressings. This management resulted in extendedlength of hospital stay, increased cost, patient immobility,and risk of underlying wound or graft infection. Othernonoperative modalities that have been tried with modestsuccess include multiple aspirations of the lymphatic cavity,instillation of sclerosing agents, and administration of radi-ation therapy to the region.3,4

Operative modalities have been advocated by someauthors as an ideal approach to this problem. A few authors

Fig 4. Patient 3. A and B, Duplex ultrasound imaging oand the echolucent lymphocele. C, Resolution of the lymvein.

recommend ligation of leaking lymphatics with the assis-

tance of intraoperative lymphatic mapping.3,5-7 A moreaggressive approach for the exposed synthetic graft is amuscle flap to cover the graft. Although this requires anextensive dissection and another operation, it is the mosteffective treatment, with prevention of infection and anas-tomotic breakdown.8

Fleischmann et al9 described the concept of using con-trolled subatmospheric pressure to treat open or infectedwounds in 1993. The negative pressure wound care systemwas developed using the same principles by Argenta et al10

in 1995 (V.A.C. Therapy System, KCI, San Antonio, Tex).It has been shown to be superior to conventional dressingsin the management of complex wounds.

Initial studies with NPWT dressings in animal labora-tory animals showed that it increased the granulation tissuein the wound by 103.4% � 35.3%. This is postulated to becaused by the effects of suction on increased blood flow tothe wound region, the removal of wound inhibiting factorssuch as metalloproteases from the wound, and finally, thecellular response to increased stress in the wound. TheNPWT system has also been shown to decrease the bacterialcount in the grossly infected wound to �105 organisms pergram of tissue within 4 to 5 days. By removing interstitialfluids that develop with edema around the wound site, italso decreases the distance from blood vessels to the woundand therefore improves oxygen and nutrient delivery anddecreases the distance the white blood cells have to travel toreach the wound site.11

The one disadvantage of the NPWT system is that the

femoral region demonstrates the femoral artery and veincele after negative pressure wound therapy. FV, femoral

f thepho

suction apparatus is usually bulky, and although it is good

JOURNAL OF VASCULAR SURGERYVolume 45, Number 3 Abai et al 613

for immobile patients, it hinders ambulatory patients. Toallay this problem, a portable, battery-powered suction unitis now commercially available (Fig 3). This simplifies thecare of complex wounds in the outpatient setting.

The incidence of femoral wound infection is 1% to 2%in femoral dissections. These infections are potentially di-sastrous. This is especially true in cases where prostheticgrafts are used in the wound. Dosluoglu et al12 appliedNPWT successfully in management of wounds with ex-posed prosthetic material. This was achieved only if theanastomosis was not exposed. Presumably, a number ofthese exposed and infected grafts would have requiredresection and revascularization. Their report demonstratessuccessful NPWT management of graft exposure and infec-tion in the wound.

In this study, the effectiveness of NPWT was demon-strated in three patients by resolution of the lymphoceleand cessation of the lymphatic drainage (Fig 4). Operativetherapy failed to stop lymphatic drainage in the two patientsthat underwent this initial mode of therapy. Mean durationof therapy reported was 47.6 days for nonoperative therapyand 19.8 days for operative therapy. Our mean time forcessation lymphatic drainage was 14 days (Table). Therewere no infections after application of NPWT system, andin all cases, the wounds closed successfully without disrup-tion of vascular repair. Wound infections have been re-ported to ensue in as many as 57% of incisions complicatedby lymph fistula. Two patients were discharged home withthe portable NPWT device, which enabled one patient toresume work.

CONCLUSION

Although many modes of therapy have been describedfor the treatment of lymph fistulas, no one mode has clearlyemerged as the best solution. We successfully treated threepatients with lymph leaks from their femoral dissection withnegative pressure wound therapy. Although we present a

Table. Summary of therapy for patients

I

Procedure Endovascular AAA repairOnset of lymph leak POD 6Side of complication LeftClinical course POD 11NPWT commences Re-op (lymphatic mapping �

ligation)POD 14

Days to stop lymph leak 19LOS† (days) 7 days*Infection None

AAA, Abdominal aortic aneurysm; POD, postoperative day; NPWT, negati*Patient was ready for discharge at 7 days but remained 29 days for social r†Length of hospital stay to care for fistula.

small case series, we have demonstrated that NPWT re-

sulted in rapid resolution of three lymph fistulas, was ame-nable to outpatient management, and decreased the time toclosure compared with existing treatment options andwithout the morbidity of an operative procedure.

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9. Fleischmann W, Strecker W, Bombelli M, Kinzl L. [Vacuum sealing asa treatment of soft tissue damage is open fractures] [Article in German].Unfallchirurg 1993;96:488-92.

10. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method forwound control and treatment: clinical experience. Ann Plast Surg1997;38:563-77.

11. Venturi ML, Attinger CE, Mesbahi AN, Hess CL, Graw KS. Mecha-nisms and clinical applications of the Vacuum-Assisted Closure (VAC)Device. Am J Clin Dermatol 2005;6:185-94.

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Patient

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Submitted Jul 17, 2006; accepted Oct 14, 2006.