The Intravascular Stenting Method for Treatment of Extremity Lymphedema with Multiconfiguration Lymphaticovenous Anastomoses

Abstract

In secondary extremity lymphedema, normal antegrade lymphatic flow is disrupted by the disease state. Attempts to capture aberrant retrograde lymphatic flow by means of microsurgical lymphaticovenous anastomoses have been hindered because of technical limitations. The authors applied the intravascular stenting method to the surgical correction of extremity lymphedema to generate multiconfiguration lymphaticovenous anastomoses capable of decompressing both proximal and distal lymphatic flow. Lymphatic channels were detected using indocyanine green injection and infrared scope imaging. Sites felt to be adequate for lymphaticovenous anastomosis were accessed through 2-cm skin incisions under local anesthesia. Using the intravascular stenting method, the authors performed a total of 39 lymphaticovenous anastomoses (15 flow-through, 11 end-to-end, eight end-to-side, two double end-to-end, two end-to-end/end-to-side, and one pi-type) on both the proximal and distal ends of lymphatic channels in 14 female patients with upper (n = 2) and lower (n = 12) extremity lymphedema. At an average follow-up of 8.9 months, average limb girth decreased 3.6 cm (range, 1.5 to 7 cm) or 11.3 percent (range, 4 to 33 percent). There was a greater reduction in cross-sectional area with increasing number of lymphaticovenous anastomoses per limb. The intravascular stenting method facilitated multiconfiguration lymphaticovenous anastomoses capable of decompressing both antegrade and retrograde lymphatic flow. This approach resulted in durable reduction of both upper and lower extremity lymphedema. As multiconfiguration lymphaticovenous anastomoses are now technically feasible, the influence of the number of lymphaticovenous anastomoses and the effectiveness of specific lymphaticovenous anastomosis configurations for the treatment of lymphedema deserves further study.