Evaluation of patency rates of different lymphaticovenous anastomosis techniques and risk factors for obstruction in secondary upper extremity lymphedema

Yushi Suzuki, MD,a Hisashi Sakuma, MD,b and Shun Yamazaki, MD,c Ichikawa, Yokohama, and Okinawa. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2018

Click to read the abstract

Evaluation of patency rates of different lymphaticovenous  anastomosis techniques and risk factors for obstruction in secondary upper extremity lymphedema

Yushi Suzuki, MD,a Hisashi Sakuma, MD,b and Shun Yamazaki, MD,c Ichikawa, Yokohama, and Okinawa. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2018

Objective: Lymphaticovenous anastomosis (LVA) is one of the surgical treatments for lymphedema. Lymphaticovenous side-to-end anastomosis (LVSEA) and lymphaticovenous end-to-end anastomosis (LVEEA) are the most commonly used procedures; however, only a few reports have evaluated direct anastomosis. We used indocyanine green fluorescence lymphography to evaluate and to compare both techniques.

Methods: Eighteen patients (67 anastomoses) with secondary upper extremity lymphedema were evaluated 6 months postoperatively. After injection of indocyanine green, anastomoses that were obviously patent were considered patent, and the others were considered unpatent. In addition, we evaluated the risk factors for obstruction using the following five points: dyeing of the lymphatic vessel by patent blue, lymphatic flow, venous regurgitation, lymphatic vessel degeneration, and runoff after the anastomosis.

Results: There were 44 LVSEAs and 23 LVEEAs performed, of which 14 (32%) and 8 (35%) were patent, respectively. Risk factors for obstruction in these 67 anastomoses were evaluated. However, no significant difference was found.

Conclusions: Patency of an LVA anastomosis is not high and not different between LVSEA and LVEEA. However, if anastomotic occlusion occurs, lymphatic obstruction is more likely with LVEEA than with LVSEA. Therefore, when LVA is performed, we recommend LVSEA principally and LVEEA only when the potential for consequences and risk of obstruction are low.

Main findings

  • Lymph vascular end to end anastomosis (LVEEA) has high drainage effectiveness as it allows flow of all distal lymph fluid. However, obstruction might worsen lymphedema by disruption of the distal lymphatic flow. Moreover, this method does not allow salvage of the regurgitated peripheral lymph flow if there is valve insufficiency in the collective lymphatic vessel. In contrast, drainage effectiveness decreases in lymph vascular side to end anastomosis (LVSEA) compared with LVEEA if the lymphatic vessel pressure is low and the venous resistance is high, yet LVSEA allows preservation of the existing lymphatic flow even if anastomosis is obstructed.
  • Take Home Message: Six-month patency, determined by indocyanine green fluorescence lymphography, was 32% in 44 side-to-end lymphaticovenous anastomoses and 35% in 23 lymphaticovenous end to-end anastomoses (P¼ .81) in 18 patients with secondary upper extremity lymphedema. Quality of lymphatic flow, reflux at the anastomotic site, lymphatic vessel degeneration, and runoff did not significantly influence patency.
  • Recommendation: The authors recommend use of lymphaticovenous side-to-end anastomosis as a primary option. Lymphaticovenous end-to-end anastomosis is recommended only when the risk and potential for consequences of anastomotic occlusion are low.