Ultrasound-guided lymphaticovenous anastomosis without indocyanine green lymphography mapping: A preliminary report

Although indocyanine green (ICG) lymphography is the standard preoperative examination for lymphaticovenous anastomosis (LVA), it cannot be performed in patients allergic to ICG. This report aimed to clarify the effects of LVA with lymphatic ultrasound and without ICG lymphography.

Lymphatic ultrasound was performed preoperatively on six limbs of four patients with lower limb lymphedema who were allergic to ICG to detect the lymphatic vessels. All patients were women and had secondary lymphedema after uterine cancer treatment, with a mean age of 57.0 years (range; 47-68 years). The severity of lymphedema was stage 2a in two limbs, stage 2b in three limbs, and stage 3 in one limb. During the preoperative lymphatic ultrasound, we searched for the dilated lymphatic vessels in the saphenous, lateral calf, and lateral thigh lymphosomes. The incision sites were determined based on the ultrasonographic findings, and LVA was performed under local anesthesia. The surgical results were evaluated based on the limb volume calculated from the circumferences.

Totally, 13 skin incisions were made, and the lymphatic vessels consistent with the ultrasonographic findings were found in all locations. The mean number of the lymphatic vessels anastomosed per limb was 2.2 (range; 1-4). The mean diameter of the lymphatic vessel was 0.69 mm (range; 0.3-1.0 mm). No complications were observed in the perioperative period. The mean follow-up period was 386.8 days. The mean preoperative and postoperative limb volumes were 5468 ml (range; 4552-6378 ml) and 5027.4 ml (range; 4353-5561 ml). Limb volume decreased in all six limbs.

The effectiveness of performing LVA by identifying the lymphatic vessels using lymphatic ultrasound was demonstrated. More medical institutions will be able to perform LVA in the future, even without ICG devices.