Lymphovenous Coupler-Assisted Bypass for Immediate Lymphatic Reconstruction

Abstract

Background Breast cancer-related lymphedema is the most common cause of lymphedema in the United States and occurs in up to 50% of individuals receiving axillary lymph node dissection (ALND). Lymphovenous bypass (LVB) at the time of ALND may prevent lymphedema, but long-term results and anastomotic patency are unclear. This study evaluates the feasibility and outcomes of performing immediate lymphatic reconstruction via coupler-assisted bypass (CAB).

Methods This is a retrospective review of all patients undergoing prophylactic LVB following ALND at two tertiary care centers between 2018 and 2022. Patients were divided into cohorts based on whether they received the “standard” end-to-end (E-E) suturing or CAB technique. The primary outcome of interest was development of lymphedema. Quantitative and qualitative assessments for lymphedema were performed preoperatively and at 3, 6, 12, and 24 months postoperatively.

Results Overall, 63 LVBs were performed, of which 24 lymphatics underwent immediate reconstruction via “CAB” and 39 lymphatics via “standard” end-to-end suture. Patient characteristics, including body mass index, and treatment characteristics, including radiation therapy, did not significantly differ between groups. CAB was associated with a greater mean number of lymphatics bypassed per vein (standard 1.7 vs. CAB 2.6, p = 0.0001) and bypass to larger veins (standard 1.2 vs. CAB 2.2 mm, p < 0.0001). At a median follow-up of 14.7 months, 9.1% (1/11) of individuals receiving CAB developed lymphedema. These rates were similar to those seen following standard bypass at 4.8% (1/21), although within a significantly shorter follow-up duration (standard 7.8 vs. CAB 14.7 months, p = 0.0170).

Conclusion The CAB technique is a viable, effective technical alternative to the standard LVB technique. This comparative study of techniques in prophylactic LVB suggests that CABs maintain long-term patency, possibly due to the ease of anastomosing several lymphatics to single large caliber veins while reducing the technical demands of the procedure.

Keywords

breast - breast cancer-related lymphedema - prophylactic - anastomosis - outcomes

Publication History

Received: 27 January 2023

Accepted: 18 September 2023

Accepted Manuscript online:
26 September 2023

Article published online:
15 February 2024

• References

• 1 Greene AK. Epidemiology and morbidity of lymphedema. In: Greene AK, Slavin SA, Brorson H. eds. Lymphedema: Presentation, Diagnosis, and Treatment. Cham: Springer International Publishing; 2015: 33-44
• 2 Nguyen TT, Hoskin TL, Habermann EB, Cheville AL, Boughey JC. Breast cancer-related lymphedema risk is related to multidisciplinary treatment and not surgery alone: results from a large cohort study. Ann Surg Oncol 2017; 24 (10) 2972-2980
• 3 Li CY, Kataru RP, Mehrara BJ. Histopathologic features of lymphedema: a molecular review. Int J Mol Sci 2020; 21 (07) 2546
• 4 Schaverien MV, Coroneos CJ. Surgical treatment of lymphedema. Plast Reconstr Surg 2019; 144 (03) 738-758
• 5 Mehrara BJ, Coriddi M, Dayan J. et al 44 - Lymphedema: Anatomy, Pathophysiology, Evaluation, and Treatment. . In: Farhadieh RD, Bulstrode NW, Mehrara BJ. et al. (eds) Plastic Surgery - Principles and Practice. Elsevier; 2022: 666-683
• 6 Le NK, Weinstein B, Serraneau K, Tavares T, Laronga C, Panetta N. The learning curve: trends in the first 100 immediate lymphatic reconstructions performed at a single institution. Ann Plast Surg 2021; 86 (6S, Suppl 5): S495-S497
• 7 Johnson AR, Fleishman A, Granoff MD. et al. Evaluating the impact of immediate lymphatic reconstruction for the surgical prevention of lymphedema. Plast Reconstr Surg 2021; 147 (03) 373e-381e
• 8 Hill WKF, Deban M, Platt A, Rojas-Garcia P, Jost E, Temple-Oberle C. Immediate lymphatic reconstruction during axillary node dissection for breast cancer: a systematic review and meta-analysis. Plast Reconstr Surg Glob Open 2022; 10 (05) e4291
• 9 Coriddi M, Mehrara B, Skoracki R, Singhal D, Dayan JH. Immediate lymphatic reconstruction: technical points and literature review. Plast Reconstr Surg Glob Open 2021; 9 (02) e3431
• 10 Chiang SN, Skolnick GB, Westman AM, Sacks JM, Christensen JM. National outcomes of prophylactic lymphovenous bypass during axillary lymph node dissection. J Reconstr Microsurg 2022; 38 (08) 613-620
• 11 Boccardo F, Casabona F, De Cian F. et al. Lymphatic microsurgical preventing healing approach (LYMPHA) for primary surgical prevention of breast cancer-related lymphedema: over 4 years follow-up. Microsurgery 2014; 34 (06) 421-424
• 12 Lipman K, Luan A, Stone K, Wapnir I, Karin M, Nguyen D. Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for lymphedema prevention after axillary lymph node dissection-a single institution experience and feasibility of technique. J Clin Med 2021; 11 (01) 92
• 13 Boccardo F, Casabona F, De Cian F. et al. Lymphedema microsurgical preventive healing approach: a new technique for primary prevention of arm lymphedema after mastectomy. Ann Surg Oncol 2009; 16 (03) 703-708
• 14 Casabona F, Bogliolo S, Valenzano Menada M, Sala P, Villa G, Ferrero S. Feasibility of axillary reverse mapping during sentinel lymph node biopsy in breast cancer patients. Ann Surg Oncol 2009; 16 (09) 2459-2463
• 15 Agrawal J, Mehta S, Goel A, Pande PK, Kumar K. Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) for prevention of breast cancer-related lymphedema-a preliminary report. Indian J Surg Oncol 2018; 9 (03) 369-373
• 16 Schwarz GS, Grobmyer SR, Djohan RS. et al. Axillary reverse mapping and lymphaticovenous bypass: lymphedema prevention through enhanced lymphatic visualization and restoration of flow. J Surg Oncol 2019; 120 (02) 160-167
• 17 Feldman S, Bansil H, Ascherman J. et al. Single institution experience with Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for the primary prevention of lymphedema. Ann Surg Oncol 2015; 22 (10) 3296-3301
• 18 Hahamoff M, Gupta N, Munoz D. et al. A lymphedema surveillance program for breast cancer patients reveals the promise of surgical prevention. J Surg Res 2019; 244: 604-611
• 19 Johnson AR, Kimball S, Epstein S. et al. Lymphedema incidence after axillary lymph node dissection: quantifying the impact of radiation and the lymphatic microsurgical preventive healing approach. Ann Plast Surg 2019; 82 (4S, Suppl 3): S234-S241
• 20 Boccardo FM, Casabona F, Friedman D. et al. Surgical prevention of arm lymphedema after breast cancer treatment. Ann Surg Oncol 2011; 18 (09) 2500-2505
• 21 Boccardo F, Valenzano M, Costantini S. et al. LYMPHA technique to prevent secondary lower limb lymphedema. Ann Surg Oncol 2016; 23 (11) 3558-3563
• 22 Squitieri L, Rasmussen PW, Patel KM. An economic analysis of prophylactic lymphovenous anastomosis among breast cancer patients receiving mastectomy with axillary lymph node dissection. J Surg Oncol 2020; 121 (08) 1175-1178
• 23 Cakmakoglu C, Kwiecien GJ, Schwarz GS, Gastman B. Lymphaticovenous bypass for immediate lymphatic reconstruction in locoregional advanced melanoma patients. J Reconstr Microsurg 2020; 36 (04) 247-252
• 24 Levy AS, Murphy AI, Ishtihar S. et al. Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for the primary prevention of lymphedema: a 4-year follow-up matched cohort study. Plast Reconstr Surg 2023; 151 (02) 413-420
• 25 Sisk GC, Shuck JW, Lopez M, Chang EI. Lymphovenous anastomosis using the venous coupler. J Plast Reconstr Aesthet Surg 2020; 73 (05) 983-1007
• 26 Jabbour S, Chang EI. Recent advancements in supermicrosurgical treatment of lymphedema. Plastic and Aesthetic Research 2021; 8: 43
• 27 Sharma P, Sharma H, St Cyr M, Griffiths M. Never fear the venous-lymphatic coupler is here!. J Plast Reconstr Aesthet Surg 2015; 68 (02) 290-291
• 28 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40 (05) 373-383
• 29 Fu MR, Cleland CM, Guth AA. et al. L-dex ratio in detecting breast cancer-related lymphedema: reliability, sensitivity, and specificity. Lymphology 2013; 46 (02) 85-96
• 30 Che Bakri NA, Kwasnicki RM, Khan N. et al. Impact of axillary lymph node dissection and sentinel lymph node biopsy on upper limb morbidity in breast cancer patients: a systematic review and meta-analysis. Ann Surg 2023; 277 (04) 572-580
• 31 Helyer LK, Varnic M, Le LW, Leong W, McCready D. Obesity is a risk factor for developing postoperative lymphedema in breast cancer patients. Breast J 2010; 16 (01) 48-54
• 32 Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Arm edema in breast cancer patients. J Natl Cancer Inst 2001; 93 (02) 96-111
• 33 DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol 2013; 14 (06) 500-515
• 34 Aoishi Y, Oura S, Nishiguchi H. et al. Risk factors for breast cancer-related lymphedema: correlation with docetaxel administration. Breast Cancer 2020; 27 (05) 929-937
• 35 Levy AS, Murphy AI, Ishtihar S, Peysakhovich A, Taback B, Grant RT, Ascherman JA, Feldman S, Rohde CH. Lymphatic Microsurgical Preventive Healing Approach for the Primary Prevention of Lymphedema: A 4-Year Follow-Up. Plast Reconstr Surg 2023; Feb 1; 151 (02) 413-420
• 36 Ishiura R, Yamamoto T, Saito T, Mito D, Iida T. Comparison of lymphovenous shunt methods in a rat model: supermicrosurgical lymphaticovenular anastomosis versus microsurgical lymphaticovenous implantation. Plast Reconstr Surg 2017; 139 (06) 1407-1413
• 37 Onoda S, Satake T, Kinoshita M. Relationship between lymphaticovenular anastomosis outcomes and the number and types of anastomoses. J Surg Res 2022; 269: 103-109
• 38 Mulroney SE, Myers AK, Netter FH. Netter's Essential Physiology. Vol 2. Philadelphia, PA: Elsevier; 2016
• 39 Masoodi Z, Steinbacher J, Tinhofer IE. et al. “Double Barrel” lymphaticovenous anastomosis: a useful addition to a supermicrosurgeon's repertoire. Plast Reconstr Surg Glob Open 2022; 10 (04) e4267
• 40 Campisi CC, Ryan M, Boccardo F, Campisi C. A single-site technique of multiple lymphatic-venous anastomoses for the treatment of peripheral lymphedema: long-term clinical outcome. J Reconstr Microsurg 2016; 32 (01) 42-49
• 41 Chen WF, Yamamoto T, Fisher M, Liao J, Carr J. The “Octopus” lymphaticovenular anastomosis: evolving beyond the standard supermicrosurgical technique. J Reconstr Microsurg 2015; 31 (06) 450-457