{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T12:20:59Z","timestamp":1781698859049,"version":"3.54.5"},"reference-count":30,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,2,18]],"date-time":"2026-02-18T00:00:00Z","timestamp":1771372800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Lymphovenous anastomosis (LVA) has become an established microsurgical treatment for lymphedema, yet the hemodynamic basis for its efficacy in the lower extremity has not been rigorously examined. Most assessments of anastomotic function are performed in the supine position, where lymphatic pressure exceeds venous pressure, creating a favorable gradient for drainage. However, adults spend 16\u201318 h daily in upright postures, during which ankle-level venous pressure rises to 80\u2013100 mmHg while lymphatic pressure increases only modestly. This pressure reversal raises questions about whether lower extremity LVA can function during routine daily activities. Several protective mechanisms have been proposed, including careful recipient venule selection, competent venous valves, and calf muscle pump assistance, yet these safeguards are inherently intermittent rather than continuous. Clinical data reveal progressive anastomotic patency decline over time, with some studies reporting 64% occlusion at two years, a pattern consistent with cumulative hemodynamic injury. Notably, clinical improvement sometimes persists despite declining patency, suggesting that concurrent conservative therapy or selection bias may contribute to observed outcomes. This review critically examines the postural hemodynamics relevant to lower extremity LVA, evaluates proposed protective mechanisms, and argues that the fundamental premise of sustained upright-posture drainage remains untested after three decades of clinical practice.<\/jats:p>","DOI":"10.3390\/jcm15041594","type":"journal-article","created":{"date-parts":[[2026,2,18]],"date-time":"2026-02-18T15:28:18Z","timestamp":1771428498000},"page":"1594","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Hemodynamic Challenges of Lower Extremity Lymphovenous Anastomosis: A Critical Reappraisal"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3517-5532","authenticated-orcid":false,"given":"Daihun","family":"Kang","sequence":"first","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, Ewha Womans University Seoul Hospital, Seoul 07804, Republic of Korea"},{"name":"College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e4529","DOI":"10.1097\/GOX.0000000000004529","article-title":"Outcomes of Lymphovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review","volume":"10","author":"Verhey","year":"2022","journal-title":"Plast. 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