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

Graham S. Schwarz, Stephen R. Grobmyer, Risal S. Djohan, Cagri Cakmakoglu, Steven L. Bernard, Diane Radford, Zahraa Al‐Hilli, Rebecca Knackstedt, Michelle Djohan, Stephanie A. Valente. J Surg Oncol. 2019 May 29

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

Graham S. Schwarz,  Stephen R. Grobmyer, Risal S. Djohan, Cagri Cakmakoglu, Steven L. Bernard, Diane Radford, Zahraa Al‐Hilli, Rebecca Knackstedt, Michelle Djohan, Stephanie A. Valente. J Surg Oncol. 2019 May 29

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.

Main findings

  • Axillary reverse lymphatic mapping (ARM) has shown promise in identifying upper extremity (UE) lymphatic drainage pathways coursing through the axilla.
  • Lymphaticovenous bypass (LVB) is a microsurgical technique that reroutes lymphatic fluid into the venous system via anastomosis of divided lymphatics with recipient veins proximal to the level of obstruction.
  • The aim was to describe a unique approach to LE preventative surgery in patients with breast cancer undergoing ALND and to report the clinical outcomes. Lymphedema preventative surgery (LPS) combines ARM and LVB to maximally preserve lymphatic continuity and reestablish physiologic UE lymphatic drainage pathways.
  • An average of 1.4 LVBs (range 1‐4) were performed per patient. End to‐end anastomoses was performed in 64% (37/58) of patients and intussusception anastomosis was performed in 36% (21/58) of patients.
  • Intraoperative patency with ICG lymphangiography and/or blue dye was confirmed in96.5%(56/58).
  • Two anastomoses were felt to be insufficient because of excessive venous backflow into the lymphatics. Operative time for immediate lymphatic reconstruction after ALND ranged from 40 to150 minutes and incorporated identification of structures, mobilization, and preparation as well as anastomotic completion.
  • LE occurred in 2/43 (4.6%) of patients with more than 6 months of follow‐up as confirmed by differential CA measurements.
  • The ability to complete successful LVB was not limited by lymphatic identification, rather it was impacted by the availability of recipient veins with the appropriate size, arc of rotation, and valvular competence. Of 60 patients with planned LPS, three (5%) were unable to attain successful LVB for these reasons.
  • Patency is confirmed using both ICG lymphangiography and blue dye allowing the surgeon to reliably demonstrate flow through each anastomotic variation irrespective of vessel wall thickness or admixture of lymphatic fluid and venous blood.
  • Limitations:
    • Short‐term follow up of less than 2 years and the low sample size is not sufficient to clearly demonstrate a durable protective effect against LE.
    • Based on this data set, they are yet not able to specifically evaluate the superiority of varied LVB anastomotic techniques on the preservation of long‐term lymphatic function.
    • Multiple risk factors in addition to ALND are known to contribute to LE development, and indeed, the 2 patients who developed LE in this cohort exhibited certain risks including radiotherapy, chemotherapy, axillary seroma, and high BMI. Because the incidence of LE was so low, meaningful association with these factors could not be made at this time.
    • Long‐term follow‐up and analysis including a control group without lymphatic reconstruction also will help identify which factors are the strongest contributors to the development of LE in the setting of LVB.