Delayed Distally Based Prophylactic Lymphaticovenular Anastomosis: Improved Functionality, Feasibility, and Oncologic Safety?

With success in the surgical treatment of extremity lymphedema, reconstructive microsurgeons are now seeking means by which to prevent this pathology. Axillary-based, immediate lymphaticovenular anastomosis (AI-LVA) at the time of axillary lymph node dissection (ALND) represents such an attempt, and thus far, has shown promising results.[1] AI-LVA, however, has several theoretical concerns. From an oncologic standpoint, is it safe to drain afferent vessels associated with cancer-containing lymph nodes into systemic circulation[2]? From a physiologic standpoint, proximal lymph-vein pressure gradients with small lymph vessels and large veins can result in a nonfunctioning LVA. From a functionality standpoint, there is questionable long-term patency of AI-LVA secondary to the adverse effect of postoperative radiation.[3] Finally, from a feasibility standpoint, there is the difficulty in scheduling due to the preoperative uncertainty of whether an ALND will be necessary.

After having performed AI-LVA and plagued by the aforementioned problems, the senior author began offering prophylactic, delayed, distally based LVA (DD-LVA) in the elbow and upper arm. The procedure was offered 1 to 2 weeks following ALND. As only one or two incisions were necessary ([Fig. 1]), the procedures could be performed under local anesthesia with sedation. The techniques of lymph vessel mapping, incision placement, and anastomosis were identical to those for standard LVA as previously described[4] ([Fig. 2]). Briefly, lymph vessels were mapped using distal-to-proximal sequential injection technique. Veins adjacent to the mapped lymph vessels were then mapped with infrared vein finder. Incisions were planned at spots where lymph vessels and veins were in proximity. Since the anastomosis was performed distally with healthy lymph vessels, the surgical approach was easier and faster than therapeutic LVA. Furthermore, since the target vessels were superficial, as opposed to the deep axillary vessels, supermicrosurgical maneuvers were noticeably less demanding. Rigorous “washout” was consistently observed due to the intact contractile mechanism of the involved lymph vessels. The procedure typically lasted approximately an hour. At conclusion of the procedure, the treated limb was immediately compressed with short-stretch compression bandage, simulating 30 to 40 mm Hg compression pressure, and the patients were discharged to home with over-the-counter pain medication.

Fig. 1 Incision planning after lymph vessel mapping.

Fig. 2 “Octopus” anastomosis with patency demonstrated by transmission of indocyanine green dye from lymphatics into vein. Three lymph vessels shown connected to a vein in the right lower corner. The LVA resembled a “squid” in this case. LVA, lymphaticovenular anastomosis.

DD-LVA conceptually resolves all issues associated with AI-LVA. The lymph vessels recruited in DD-LVA are far from the site of ALND, thus, making the theoretical oncologic risk minimal. A desirable lymph-vein pressure gradient is more consistently achieved secondary to the improved lymph vessel-vein size match in the superficial subcutaneous layer in the distal limb. Creating the LVA outside of the future radiation site removes these delicate supermicrovascular connections from the field of harmful radiation. Lastly, by performing DD-LVA 1 to 2 weeks following ALND, there is no uncertainty in surgical scheduling, and block time is not wasted due to negative sentinel lymph node dissections. Other benefits include less general anesthesia as the DD-LVA is performed under local anesthesia and a less physiologically demanding surgery, as the breast reconstruction and DD-LVA are not performed on the same days.

The senior author has performed DD-LVA in patients undergoing both axillary and groin lymph node dissection to prevent upper/lower extremity lymphedema with highly favorable preliminary results. While longer follow-up is required to determine the efficacy of this approach as compared with traditional AI-LVA, due to the early success of this technique while addressing common concerns associated with AI-LVA, there was a nidus to publish this approach and encourage other surgeons to consider its adoption.

Publication History

Received: 05 June 2020

Accepted: 07 August 2020

Article published online:
21 September 2020

• References

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• 3 Roth NM, Sontag MR, Kiani MF. Early effects of ionizing radiation on the microvascular networks in normal tissue. Radiat Res 1999; 151 (03) 270-277
• 4 Chen WF. How to get started performing supermicrosurgical lymphaticovenular anastomosis to treat lymphedema. Ann Plast Surg 2018; 81 (6S): (Suppl. 01) S15-S20