Introduction: Lymphaticovenular anastomosis (LVA) and vascularized lymph node transfer (VLNT) are established lymphedema treatments. However, LVA is only effective for early disease and VLNT can cause donor-site lymphedema and contour deformity. Vascularized lymph vessel transfer (VLVT) is free of these limitations. We described our experience of a new VLVT technique. Patients and Methods: Patients with fluid-predominant lymphedema who failed lymphedema therapy were offered surgical intervention. Those with early injury seen on indocyanine green (ICG) lymphography were treated with LVA. Superficial iliac artery perforator (SCIP)-based lymph vessel transfer was offered to those with advanced injury. After lymphographic mapping of the lymph vessels and doppler perforator mapping, thin SCIP flap was harvested. Only the superficial fat layer was included to recruit the lymph vessels while preserving the lymph nodes. The flaps were vascularized with end-toside or perforator-to-perforator anastomosis. Results: The SCIP-based lymph vessel flap was performed in 6 patients with extremity lymphedema. Four had upper and 2 had lower extremity disease. One had partial (< 5%) flap loss which was managed with local wound care. All others had uneventful postoperative course. Follow-up was 13-27 months. All experienced prompt relief of symptoms and circumference reduction. At 1 year out, all demonstrated durable symptomatic improvement with correlating improvement on ICG lymphography. Three of 6 patients achieved minimal compression garment use. None developed donor site lymphedema. Conclusions: Our early experience of the SCIP-based VLVT showed promising result in treating extremity lymphedema and suggested it as a viable alternative treatment to LVA and VLNT. Ethics Approval and Consent to Participate:The study is in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Background: Lymphaticovenular anastomosis (LVA) is an established supermicrosurgical treatment of the lymphedema. However, success rates vary, possibly related to the variation in patient selection, surgical technique, and postoperative care. One of the controversies on postoperative care is whether to apply limb compression. We set out to assess the effect of external limb compression on the LVA. Methods: Following each of the anastomoses of the LVA procedure, the flow across the anastomosis was immediately assessed. A "washout" sign was defined as observing the favorable ante grade, lymph-to-vein flow, whereas a "backflow" sign was defined as observing the unfavorable retrograde, vein-to-lymph flow. After the initial flow pattern was recorded, bandage compression was applied to the leg and the changes to the flow pattern were recorded. Patients were tracked with lymphedema indices as well as lymphedema quality of life (LYMQOL) assessment system at preoperative, within the 3rd and 6th month visits. Results: Five patients were included in the study. 42 LVAs were constructed-26 with the standard, and 16 via the octopus technique. Initially, 25 (60%) demonstrated "washout", with the remaining 17 (40%) showing "backflow". After compression was applied, those entire initially demonstrating washout" maintained the "washout" pattern, while 16 of 17, or 94%, that initially demonstrated "backflow" converted to "washout". In the follow up, all patients had statistically significant edema reduction based on lower extremity lymphedema indices (P = 0.0009) and relief of symptoms based on the LYMQOL assessment (P = 0.0006). Conclusion: Postoperative compression following LVA does not harm the anastomoses created, and can augment the lymphatic flow and convert unfavorable retrograde flow to favorable ante grade flow.
Microsurgical vascularized lymph node transfer (VLNT) and supermicrosurgical lymphaticovenular anastomosis (LVA) are increasingly performed to treat lymphedema. The surgical outcome is commonly assessed by volume-based measurement (VBM), a method that is not consistently reliable. We describe indocyanine green (ICG) lymphography as an alternative postoperative tracking modality after lymphatic reconstruction with VLNT and LVA. VLNT and LVA were performed in patients with therapy-refractory lymphedema. Patients were evaluated qualitatively by clinical assessment, quantitatively with VBM, and lymphographically using ICG lymphography. The evaluation was performed preoperatively, and at 3, 6, and 12-month postoperatively. Overall, 21 patients underwent lymphatic reconstruction with either VLNT or LVA. All reported prompt and durable relief of symptoms during the study period. All experienced disease regression based on the Campisi criteria. Out of the 21 patients, 20 (95%) demonstrated lymphographic down staging of disease severity. Out of the 21 patients, 3 (14%) developed a paradoxical increase in limb volume based on VBM despite clinical improvement. ICG lymphography correlated highly with patient self-assessment and clinical examination, and is an effective postoperative tracking modality after lymphatic reconstruction.
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