A small but growing body of evidence suggests that a minimally invasive surgical procedure called lymphovenous anastomosis (LVA) might be an effective treatment for Alzheimer's disease (AD), according to a special article in the March issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS). The journal is published in the Lippincott portfolio by Wolters Kluwer.

"LVA represents a novel surgical strategy targeting brain lymphatic dysfunction – potentially addressing a key factor involved in the development and progression of AD," according to the paper's lead author, Dr. Chew Khong Yik, Senior Consultant, Department of Plastic, Reconstruction & Aesthetic Surgery, Singapore General Hospital (SGH). "However, much more research will be needed to establish the true benefits of this procedure." The study was led by SGH, together with researchers from Duke-NUS Medical School and the National Neuroscience Institute, both in Singapore.

Sometimes called lymphovenous bypass, LVA is a relatively simple surgical procedure in which lymphatic vessels are connected (anastomosed) to neighboring blood vessels to improve lymphatic flow. The concept of LVA is not new; it is commonly performed to relieve obstructed lymph flow, causing severe swelling (lymphedema), often as a complication of cancer treatment.

In recent years, studies have suggested that impaired lymph flow in the brain – called "glymphatic" flow because it is regulated by brain cells called glia – may contribute to AD-related abnormalities, including amyloid-beta plaques and deposits of tau protein. Damage to glymphatic flow may lead to reduced clearance of neurotoxins, particularly during sleep. Lifestyle changes and medications have been suggested to enhance brain lymphatic flow, but with limited effectiveness.

By creating a direct connection between lymphatic vessels and veins, LVA bypasses blocked or dysfunctional lymphatic pathways – providing "continuous, passive" improvement in glymphatic flow. Plastic surgeons are among the few specialist doctors who are skilled in microsurgery techniques used in LVA, as well as in the anatomy of the head and neck.

Initial studies have supported the benefits of LVA surgery in patients with AD, with improved cognitive test scores and sometimes dramatic gains in mental and physical functioning. Some studies have linked these clinical improvements to evidence of increased lymphatic flow.

"Together, these studies support the safety and potential cognitive benefit of LVA in AD, warranting further validation," said Dr. Chew. The study outlines "lessons learned" for establishing the effectiveness of LVA for AD, including:

• Clear selection criteria, targeting patients with a confirmed diagnosis of mild to moderate AD.
• Standardized surgical approaches, including preoperative testing to map lymph and blood vessel targets.
• Defined approaches to monitoring changes in cognitive function.
• Evidence to confirm the mechanisms by which restoring brain glymphatic flow leads to clinical improvement.
• Data on the risks and potential complications of LVA surgery.

"LVA represents a novel therapeutic strategy that may complement existing treatments, offering new hope for addressing the pathophysiology of AD," Dr. Chew and his coauthors concluded. "Through collaborative, long-term clinical trials, LVA may emerge not only as an adjunct to current AD therapies but also as a potential treatment avenue for other neurodegenerative diseases."

Plastic and Reconstructive Surgery® is published by Wolters Kluwer.

Click here to read "Exploring Lymphovenous Anastomosis for Alzheimer Disease: Addressing Brain Lymphatic Dysfunction, Feasibility, and Outcome Metrics"

Article: "Exploring Lymphovenous Anastomosis for Alzheimer Disease: Addressing Brain Lymphatic Dysfunction, Feasibility, and Outcome Metrics" (doi: 10.1097/PRS.0000000000012364)

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