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Published on: May 15, 2020
Use of axillary vascular grafts in prophylactic lymphovenous bypass: technical challenges and lessons learned
Jorge Flores Garcia1, J Michael Smith2, Ramin Rajaii1
1Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States.
Background:
Breast cancer-related lymphedema (BCRL) is a common and debilitating complication of axillary lymph node dissection (ALND), affecting approximately 1 in 5 patients. While preventive lymphatic surgeries such as prophylactic lymphovenous bypass (pLVB) performed at the time of ALND have been shown to decrease the risk of developing BCRL, success is frequently limited by inadequate recipient veins within the axilla. In this study, we report our experience with utilizing axillary vascular grafts harvested from within the axillary dissection field to perform pLVB in vein-depleted axillae to prevent the development of BCRL in patients undergoing ALND.
Methods:
A retrospective review was performed of breast cancer patients undergoing ALND with planned pLVB at a single institution. Patients in whom axillary vascular grafts were used to enable lymphatic reconstruction were included. Demographic, oncologic, operative, and graft-specific variables were collected. Outcomes included successful lymphatic reconstruction and development of BCRL, assessed using a standardized institutional surveillance protocol incorporating circumferential measurements or perometry.
Results:
Thirty-two patients had a mean age of 52.3 years (SD, 12.9) and median BMI of 26.9 kg/m2 (IQR, 23.8-28.7), with median follow-up of 15 months (IQR, 11-31). Of the 121 transected lymphatic vessels, interposition grafts were required for 74.8% of reconstructions. A total of 35 grafts (74.3% venous, 25.7% arterial) with median length of 5 cm (IQR, 4-6) were performed with a median of 3 pLVBs (IQR, 2-5) performed per patient. BCRL developed in 6 patients (18.8%) with an average follow-up of 21.3 months (IQR, 11-31); those affected had a higher mean number of lymph nodes removed (22.3 vs. 15.4; P < .05), and as a result, more graft-based pLVBs (median 4.5 vs. 2; P < .05).
Conclusion:
Axillary-based vascular grafting is a versatile strategy that expands reconstructive capacity during pLVB without additional donor-site morbidity. This approach enables completion of lymphatic reconstruction in anatomically challenging, vein-depleted axillae and represents a practical adjunct for immediate lymphatic reconstruction in high-risk breast cancer patients.
