Abstract: Optimal Sites for Supermicrosurgical Lymphaticovenular Anastomosis: An Analysis of 1259 Anastomoses

BACKGROUND: With establishment of supermicrosurgery (microvascular anastomosis of 0.5 mm vessel), supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming a choice of treatment for compression-refractory lymphedema.1,2 It is important to anastomose a lymphatic vessel with abundant lymph flow for effective bypass.2,3 However, optimal site for LVA is yet to be clarified. METHODS: LVA was performed on 264 limbs of 134 lower extremity lymphedema (LEL) patients. Intraoperative lymphatic vessel’s findings were assessed according to characteristics of limbs, and preoperative indocyanine green (ICG) lymphography findings.4,5 Univariate and multivariate analyses were performed to clarify factors associated with lymphatic vessel’s diameter and lymphosclerosis. RESULTS: LVA resulted in 1259 anastomoses using 949 lymphatic vessels at 794 surgical sites. The number of anastomoses per limb ranged from 1 to 16 (median 5). Multivariate analyses revealed that factors associated with larger lymphatic vessel (0.5 mm or larger) were age [65 or older; odds ratio (OR) 1.403], radiation history (OR 1.622), incision in thigh/leg (compared with groin; OR 1.607/1.628), and ICG lymphography of Stardust/Diffuse pattern (compared with Linear pattern; OR 0.529/0.047), and that factors associated with severe lymphosclerosis were body mass index (25 or larger; OR 1.775), radiation history (OR 0.465), incision in thigh/foot (OR 2.378/4.444), and ICG lymphography of Stardust/Diffuse pattern (OR 82.048/1406.174). CONCLUSIONS: Factors associated with lymphatic vessel’s diameter and sclerosis were clarified. It is important to put an incision for LVA in regions with higher probability to find a large lymphatic vessel with less lymphosclerosis. ICG lymphography finding is the most important preoperative indicator to predict lymphatic vessel’s condition, and LVA should not be performed in regions with Diffuse pattern. DISCLOSURE/FINANCIAL SUPPORT:Supported, in part, by Tokyo Metropolitan Clinical Research Grant for Special Research H280402001 (to Dr. Takumi Yamamoto). None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. REFERENCES: 1. Yamamoto T, Narushima M, Yoshimatsu H, Seki Y, Yamamoto N, Oka A, et al. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multi-site lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg. 2014;72(1):67–70. 2. Yamamoto T, Narushima M, Kikuchi K, Yoshimatsu H, Todokoro T, Mihara M, et al. Lambda-shaped anastomosis with intravascular stenting method for safe and effective lymphaticovenular anastomosis. Plast Reconstr Surg 2011;127(5):1987–92. 3. Yamamoto T, Yamamoto N, Azuma S, Yoshimatsu H, Seki Y, Narushima M, et al. Near-infrared illumination system-integrated microscope for supermicrosurgical lymphaticovenular anastomosis. Microsurgery 2014;34(1):23–7. 4. Yamamoto T, Narushima M, Doi K, Oshima A, Ogata F, Mihara M, et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns. Plast Reconstr Surg 2011;127(5):1979–86. 5. Yamamoto T, Matsuda N, Doi K, Oshima A, Yoshimatsu H, Todokoro T, et al. The earliest finding of indocyanine green (ICG) lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow (DB) stage and concept of subclinical lymphedema. Plast Reconstr Surg 2011;128(4):314e-21e.