Indocyanine Green Lymphographic Evidence of Surgical Efficacy Following Microsurgical and Supermicrosurgical Lymphedema Reconstructions

Abstract

Background Microsurgical vascularized lymph node transfer (VLNT) and supermicrosurgical lymphaticovenular anastomosis (LVA) are increasingly performed to treat lymphedema. The surgical outcome is commonly assessed by volume-based measurement (VBM), a method that is not consistently reliable. We describe indocyanine green (ICG) lymphography as an alternative postoperative tracking modality after lymphatic reconstruction with VLNT and LVA.

Methods VLNT and LVA were performed in patients with therapy-refractory lymphedema. Patients were evaluated qualitatively by clinical assessment, quantitatively with VBM, and lymphographically using ICG lymphography. The evaluation was performed preoperatively, and at 3, 6, and 12-month postoperatively.

Results Overall, 21 patients underwent lymphatic reconstruction with either VLNT or LVA. All reported prompt and durable relief of symptoms during the study period. All experienced disease regression based on the Campisi criteria. Out of the 21 patients, 20 (95%) demonstrated lymphographic down staging of disease severity. Out of the 21 patients, 3 (14%) developed a paradoxical increase in limb volume based on VBM despite clinical improvement.

Conclusions ICG lymphography correlated highly with patient self-assessment and clinical examination, and is an effective postoperative tracking modality after lymphatic reconstruction.

Keywords

supermicrosurgery - lymphaticovenular anastomosis - LVA - lymphedema surgery - lymph node transfer - indocyanine green lymphography - lymphedema measurement

Statement of Authorship

Each person listed as an author has participated in the study to a significant extent.

• References

• 1 Yamamoto T, Matsuda N, Doi K , et al. The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg 2011; 128 (4) 314e-321e
• 2 Masia J, Olivares L, Koshima I , et al. Barcelona consensus on supermicrosurgery. J Reconstr Microsurg 2014; 30 (1) 53-58
• 3 Lin C-H, Ali R, Chen S-C , et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg 2009; 123 (4) 1265-1275
• 4 Cheng M-H, Chen S-C, Henry SL, Tan B-K, Lin MC, Huang J-J. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg 2013; 131 (6) 1286-1298
• 5 Sapountzis S, Singhal D, Rashid A, Ciudad P, Meo D, Chen H-C. Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg 2014; 73 (4) 398-401
• 6 Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg 2013; 132 (5) 1305-1314
• 7 Yamamoto T, Narushima M, Yoshimatsu H , et al. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multisite lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg 2014; 72 (1) 67-70
• 8 Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000; 16 (6) 437-442
• 9 Campisi C, Boccardo F, Zilli A, Macciò A, Napoli F. Long-term results after lymphatic-venous anastomoses for the treatment of obstructive lymphedema. Microsurgery 2001; 21 (4) 135-139
• 10 Chang DW. Lymphaticovenular bypass for lymphedema management in breast cancer patients: a prospective study. Plast Reconstr Surg 2010; 126 (3) 752-758
• 11 Yamamoto T, Matsuda N, Todokoro T , et al. Lower extremity lymphedema index: a simple method for severity evaluation of lower extremity lymphedema. Ann Plast Surg 2011; 67 (6) 637-640
• 12 Yamamoto T, Yamamoto N, Hara H, Mihara M, Narushima M, Koshima I. Upper extremity lymphedema index: a simple method for severity evaluation of upper extremity lymphedema. Ann Plast Surg 2013; 70 (1) 47-49
• 13 Granzow JW, Soderberg JM, Kaji AH, Dauphine C. An effective system of surgical treatment of lymphedema. Ann Surg Oncol 2014; 21 (4) 1189-1194
• 14 Damstra RJ, Voesten HGJ, van Schelven WD, van der Lei B. Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema. A prospective study of 11 LVA procedures in 10 patients with breast cancer related lymphedema and a critical review of the literature. Breast Cancer Res Treat 2009; 113 (2) 199-206
• 15 Yamamoto T, Yamamoto N, Doi K , et al. Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns. Plast Reconstr Surg 2011; 128 (4) 941-947
• 16 Yamamoto T, Narushima M, Doi K , et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns. Plast Reconstr Surg 2011; 127 (5) 1979-1986
• 17 Yamamoto T, Narushima M, Yoshimatsu H , et al. Indocyanine green velocity: lymph transportation capacity deterioration with progression of lymphedema. Ann Plast Surg 2013; 71 (5) 591-594
• 18 Yamamoto T, Yoshimatsu H, Narushima M, Yamamoto N, Hayashi A, Koshima I. Indocyanine Green Lymphography Findings in Primary Leg Lymphedema. Eur J Vasc Endovasc Surg 2015; 49 (1) 95-102
• 19 Yamamoto T, Narushima M, Yoshimatsu H , et al. Dynamic Indocyanine Green (ICG) lymphography for breast cancer-related arm lymphedema. Ann Plast Surg 2014; 73 (6) 706-709
• 20 Yamamoto T, Yoshimatsu H, Narushima M , et al. Sequential anastomosis for lymphatic supermicrosurgery: multiple lymphaticovenular anastomoses on 1 venule. Ann Plast Surg 2014; 73 (1) 46-49
• 21 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 (6) 450-457
• 22 Brorson H, Höijer P. Standardised measurements used to order compression garments can be used to calculate arm volumes to evaluate lymphoedema treatment. J Plast Surg Hand Surg 2012; 46 (6) 410-415
• 23 Gharb BB, Rampazzo A, Spanio di Spilimbergo S, Xu E-S, Chung K-P, Chen H-C. Vascularized lymph node transfer based on the hilar perforators improves the outcome in upper limb lymphedema. Ann Plast Surg 2011; 67 (6) 589-593
• 24 Armer JM. The problem of post-breast cancer lymphedema: impact and measurement issues. Cancer Invest 2005; 23 (1) 76-83
• 25 Tierney S, Aslam M, Rennie K, Grace P. Infrared optoelectronic volumetry, the ideal way to measure limb volume. Eur J Vasc Endovasc Surg 1996; 12 (4) 412-417
• 26 Narushima M, Yamamoto T, Ogata F, Yoshimatsu H, Mihara M, Koshima I. Indocyanine Green Lymphography Findings in Limb Lymphedema. J Reconstr Microsurg 2016; 32 (1) 72-79
• 27 Patel KM, Lin C-Y, Cheng M-H. From theory to evidence: long-term evaluation of the mechanism of action and flap integration of distal vascularized lymph node transfers. J Reconstr Microsurg 2015; 31 (1) 26-30
• 28 Keeley V, Crooks S, Locke J, Veigas D. A quality of life measure for limb lymphoedema (LYMQOL). Journal of Lymphoedema. 2010; 5 (1) 26-37
• 29 Cemal Y, Jewell S, Albornoz CR, Pusic A, Mehrara BJ. Systematic review of quality of life and patient reported outcomes in patients with oncologic related lower extremity lymphedema. Lymphat Res Biol 2013; 11 (1) 14-19
• 30 Penha TR, Botter B, Heuts EM, Voogd AC, von Meyenfeldt MF, van der Hulst RR. Quality of Life in Patients with Breast Cancer-Related Lymphedema and Reconstructive Breast Surgery. J Reconstr Microsurg 2016; 32 (6) 484-490
• 31 Becker C, Vasile JV, Levine JL , et al. Microlymphatic surgery for the treatment of iatrogenic lymphedema. Clin Plast Surg 2012; 39 (4) 385-398