Axillary reverse mapping and lymphaticovenous bypass: Lymphedema prevention through enhanced lymphatic visualization and restoration of flow

Abstract

Background A lymphedema (LE) prevention surgery (LPS) paradigm for patients undergoing axillary lymphadenectomy (ALND) was developed to protect against LE through enhanced lymphatic visualization during axillary reverse mapping (ARM) and refinement in decision making during lymphaticovenous bypass (LVB). Methods A retrospective analysis of a prospective database was performed evaluating patients with breast cancer who underwent ALND, ARM, and LVB from September 2016 to December 2018. Patient and tumor characteristics, oncologic and reconstructive operative details, complications and LE development were analyzed. Results LPS was completed in 58 patients with a mean age of 51.7 years. An average of 14 lymph nodes (LN) were removed during ALND. An average of 2.1 blue lymphatic channels were visualized with an average of 1.4 LVBs performed per patient. End to end anastomosis was performed in 37 patients and a multiple lymphatic intussusception technique in 21. Patency was confirmed 96.5% of patients. Adjuvant radiation was administered to 89% of patients. Two patients developed LE with a median follow‐up of 11.8 months. Conclusion We report on our experience using a unique LPS technique. Refinements in ARM and a systematic approach to LVB allows for maximal preservation of lymphatic continuity, identification of transected lymphatics, and reestablishment of upper extremity lymphatic drainage pathways.

Microsurgical techniques in the treatment of breast cancer-related lymphedema: a systematic review of efficacy and patient outcomes

“…To safely harvest a vascularized inguinal lymph node flap, axillary reverse mapping (ARM) should be performed in the donor area, using ICG, LG, lymphazurin, isosulfan blue or methylene blue dye in the knee and foot [ 15 , 51 ]. This method allows for maximal preservation of lymphatic vessels [ 56 , 57 ]. Then, during VLNT, the lymphatics other that the sentinel lymph nodes should be selected for surgical removal to reduce the risk of iatrogenic donor site lymphedema (DSL) [ 5 , 51 ].…”

“…Vascularized gastroepiploic lymph node transfer (VLNT) is a promising novel technique with good early postoperative outcomes in BCRL reduction [ 72 ]. Future work should focus on lymphedema prevention surgery (LPS) by implementing surveillance programs for lymphedema management (SLYM) [ 73 ] and technological advancements [ 56 ], including robot-assisted supermicrosurgical LVA [ 74 ].…”

Systemic blue hue after isosulfan use for lymphatic mapping in a case of metastatic melanoma excision

“…Systemic blue hue after isosulfan use for lymphatic mapping in a case of metastatic melanoma excision Injection of isosulfan blue (lymphazurin) to delineate lymph vessels during lymphaticovenous anastomosis (LVA) is becoming more common as lymphedema surgeries are gaining popularity (Schwarz et al, 2019). Transient discoloration of skin injection sites and urine that may last for several hours to weeks is a well-known side effect of isosulfan blue.…”

“…The patient underwent excision of the back lesion, axillary lymph node dissection, and prophylactic LVA. ARM was performed using isosulfan blue, as previously described by our institution (Schwarz et al, 2019). Initially, a total of 3 ml of indocyanine green was injected-1 ml in three interdigital webspaces, and 2 ml in the upper medial arm.…”

“…Immediately prior to LVA, a total of 5 ml isosulfan blue was injected into the upper medial arm. LVA was performed using the intussusception technique (Schwarz et al, 2019). At the conclusion of the case, the patient was awakened from general anesthesia and it was noticed that there was diffuse blue-green discoloration of the face and shoulders (Figure 1).…”