Multi-site lymphatic venous anastomosis using echography to detect suitable subcutaneous vein in severe lymphedema patients

Makoto Mihara, Hisako Hara, Yoshihisa Kawakami, Hang Peng Zhou, Shuichi Tange, Kazuki Kikuchi, Takuya Iida. Journal of Plastic, Reconstructive & Aesthetic Surgery 2017

Click to read the abstract

Multi-site lymphatic venous anastomosis using echography to detect suitable subcutaneous vein in severe lymphedema patients

Makoto Mihara, Hisako Hara, Yoshihisa Kawakami, Hang Peng Zhou, Shuichi Tange, Kazuki Kikuchi, Takuya Iida. Journal of Plastic, Reconstructive & Aesthetic Surgery 2017

Summary Background: The method of lymphatic venous anastomosis (LVA), including its indications or preoperative examinations, has not been established. The purpose of this study is to reveal the possible application of preoperative echography in surgical LVA outcome.

Methods: We performed a retrospective case-control study on patients with lower limb lymphedema who underwent LVA between August 15, 2013 and August 15, 2014. As a preoperative examination, we used venous echography to identify subcutaneous veins in the echo group, while we only used Accuvein visualizing system in the control group. The operation time, number of anastomoses, and limb circumference were compared between the two groups.

Results: Seventeen patients (34 limbs) were included in the echo group, and 21 patients (42 limbs) were included in the control group. The average follow-up period was 11.9 (6–16) and 12.4 (6–27) months, respectively. The average operation time in the echo group was 258.6min, and that in the control group was 216.5 min. The average number of anastomoses was 9.8 and 7.0 in the echo and control group, respectively. The average time per anastomosis was 27.4 and 32.6 min, respectively. The diameter of the vein had a tendency to be larger in the echo group than in the control group. In 5.8% of the echo group, we observed a circumference increase, compared with 23.8% in the control group.

Conclusions: Preoperative venous echography allowed surgeons to increase the number of anastomoses performed within the operating time, resulting in improvement of surgical outcomes.

Main findings

  • The vein/lymphatic vessel ratio was greater in the echo group than in the control group.
  • The mean limb circumference change was -2.7% (-14.5 to +10.6% ) in the echogroup,and-1.5% (-10.9 to+13.8%) in the control group (p = 0.31).
  • In the echo group, only 5.9% of patients showed postoperative exacerbation, compared with 23.8% in the control group.
  • In the control group, they used lymphoscintigraphy and ICG lymphography alone to identify superficial and deep lymphatic vessels and non-contact vein visualizing system (Accuvein) to determine subcutaneous veins suitable for the LVA procedure. Nonetheless, using these conventional methods only allowed us to identify superficial veins, which were difficult to apply to severe cases of lymphedema or patients with a thick layer of subcutaneous adipose tissue.
  • By introducing preoperative venous echography, they were able to identify suitable veins for anastomosis even in regions of thick adipose tissue. This resulted in the reduction of time required from making the skin incision to the end of anastomosis. Hence, surgeons were able to perform a greater number of anastomoses within the given time, leading to an improved surgical outcome.