Targeted LVA guided by ultra-high frequency ultrasound and ICG lymphography: A pilot study

Breast cancer-related lymphedema (BCRL) is a chronic sequela that significantly impairs quality of life. Lymphovenous anastomosis (LVA) is a promising microsurgical treatment, but its success relies on accurate identification of functional lymphatic vessels and adjacent venules. While indocyanine green lymphography (ICG-L) provides functional lymphatic mapping, venous visualization is often limited. Ultra-high frequency ultrasound (UHFUS), offering high-resolution imaging, may complement ICG-L in preoperative planning. This feasibility study investigated the combined use of ICG-L and UHFUS for vessel identification prior to LVA.

Ten female patients with BCRL were included. Preoperative mapping combined ICG-L for lymphatics and UHFUS (45-70 MHz) for venules before LVA surgery. The primary outcome was agreement between preoperatively identified and intraoperatively confirmed lymphatic and venous vessels, as well as between planned and performed anastomoses. Secondary outcomes included changes in arm volume, quality of life, and L-Dex scores over 12 months.

Preoperative mapping identified a median of two lymphatic and two venous vessels per patient, leading to a median of two planned anastomoses. Intraoperative findings confirmed most vessels, with a median of two anastomoses performed per patient (p = 0.65). Arm volume did not decrease significantly over the 12 months. Quality-of-life and L-Dex scores showed a trend towards improvement.

Combining UHFUS with ICG-L for preoperative planning of LVA is feasible and enables accurate identification of suitable lymphatic and venous vessels. Although no significant reduction in arm volume was observed, improvements in quality of life and L-Dex scores suggest a possible clinical benefit.