Lymphaticovenular anastomosis and venous arterialization in coexisting Raynaud's phenomenon and lymphedema: A case report

Abstract

Raynaud's phenomenon is highly prevalent in the general population. The optimal medical management for patients with severe Raynaud's phenomenon remains unclear. Venous arterialization (VA) may be considered as a salvage procedure when no distal vessels are available for vascular reconstruction. Surgical treatments for lymphedema, including lymphovenous anastomosis (LVA), are becoming popular alternatives to conservative therapy. Here, we report on a patient with comorbid primary Raynaud's phenomenon and lymphedema in whom both VA and LVA were performed. The patient was a 60-year-old woman with an edematous right upper limb and pain and cold sensitivity in the middle, ring, and small fingers that was refractory to medication. Indocyanine green lymphography and computed tomography angiography suggested coexistence of lymphedema and primary Raynaud's phenomenon.VA and LVA were performed to reduce the risks of cellulitis and amputation. Computed tomography angiography was performed regularly after surgery to examine the arterialized venous system and Doppler echography to search for developing branches. Five months later, three branches of the arterialized veins that flowed proximally at the level of the hand and wrist were ligated. By around 1 year after surgery, the lymphedema index in the affected upper limb had improved from 116 to 103 and the patient's numerical rating scale score for intractable pain and cold sensitivity had improved from 6-7 to 1-2. We believe that the combination of VA and LVA in the early stages of primary Raynaud's phenomenon and lymphedema was effective in this case.

Simultaneous bilateral distal venous arterialization between redial artery and cephalic vein in dorsal hand for Raynaud's phenomenon in both hands: A case report

“…While several reports have included valvulotomy (Chloros et al, 2008; Kind, 2006; Matarrese & Hammert, 2011), this would not be necessary when venous arterialization is performed around the level of the wrist or distal to the dorsum of the hand (Pederson, 1997; Peters et al, 2020), likely because the valves distal to this level become incompetent when faced with arterial blood flow, as in our present case and in our previously reported case (Yoshida et al, 2019). Venous arterialization as distal as possible is also recommended for minimal invasiveness and to reduce the risk of postoperative complications.…”

“…However, these surgical procedures are accompanied by the problems based on the invasiveness (Thibaudeau et al, 2016), and need to be minimalize those risks (Carrel & Guthrie, 1906;Stolic, 2013). Some reports have highlighted the importance of performing a more distal anastomosis to overcome these disadvantages of venous arterialization (Lengua, 1975;Yoshida et al, 2019).…”

“…However, these surgical procedures are accompanied by the problems based on the invasiveness (Thibaudeau et al, 2016), and need to be minimalize those risks (Carrel & Guthrie, 1906; Stolic, 2013). Some reports have highlighted the importance of performing a more distal anastomosis to overcome these disadvantages of venous arterialization (Lengua, 1975; Yoshida et al, 2019). In the case, arteriovenous fistulas were created in the radial artery running at the level of the anatomical snuff box in order to avoid these problems, although the brachial artery is recommended to establish good reverse flow (Zeng & Hammert, 2016).…”

“…Furthermore, after creating the venous arterialization, ligation as many of the proximally flowing branches of the arterialized vein as possible was performed to avoid the steal phenomenon and excessive edema. In a previous report, it was described how our venous arterialization technique reduced the risk of edema and high‐output cardiac failure and made it possible to improve lymphedema with coexisting RP using simultaneous lymphaticovenular anastomosis and venous arterialization (Yoshida et al, 2019). The present case demonstrates that it is also possible to administer an intravenous infusion into the forearm even when implementing the presented venous arterialization technique.…”

Successful Treatment of Rheumatoid Lymphedema with Lymphatic Venous Anastomosis

“… 3 LVA has recently been indicated as a treatment option for a wider range of illnesses, such as coexisting Raynaud’s phenomenon and lymphedema, morbidly obese patients with lymphedema, and immunosuppressant-induced lymphedema. 8 – 10 Currently, only conservative methods have been used for the treatment of rheumatoid lymphedema. 2 Surgical treatment might be considered in patients that are refractory to conservative treatment.…”