Multipoint injection indocyanine green lymphography can reduce lymphaticovenular anastomosis surgical time and improve the surgical results for lymphedema

Abstract

Aim: Lymphaticovenular anastomosis (LVA) is the mainstay of surgical treatment of lymphedema now. Indocyanine green (ICG) lymphography is a method for detecting lymphatic pathways and for the clinical evaluation of patients with extremity lymphedema. The essential point of LVA is to find more functional lymphatic vessels. Sometimes, in cases of lymphatic dysfunction, ICG injections into the distal extremities are insufficient. The purpose of this study was to elucidate the effect of multi-injection of ICG lymphography on LVA.

Methods: In this study, we injected ICG into the second web of the hands or the first web of the feet. In the multi-injection group, we injected additional ICG in other sites. We observed the presence or absence of a linear pattern at each injection site with a near-infrared camera. Then, we performed LVA and evaluated the circumference change and the operation time.

Results: In the multi-injection group, we injected ICG into the upper limb at an average of 2.2 sites (range: 1-3 sites) and the lower limb at an average of 3.2 sites (range: 1-5 sites). The circumference change of upper limbs in the control group was -3.95% ± 1.34% and in the multi-injection group was -6.96% ± 0.88% (P < 0.05). The change in circumference of lower limbs was -5.01% ± 2.2% in the multi-injection group and -2.33% ± 1.77% in the control group (P = 0.003). The mean surgical duration was significantly shortened in the multi-injection group (P < 0.05).

Conclusion: By injecting ICG into multiple sites of the affected limbs, we could detect more functional lymphatic vessels during LVA, which was helpful for achieving a successful surgical result.

Keywords

Lymphedema / indocyanine green / indocyanine green lymphography / multipoint injection / lymphaticovenular anastomosis

References

[1] Hara H.Multi-area lymphaticovenous anastomosis with multi-lymphosome injection in indocyanine green lymphography: a prospective study.Microsurgery2019;39:167-73

[2] Liu HL,Chung JHP.Indocyanine green lymphangiography-guided liposuction in breast cancer-related lymphedema treatment - patient selection and technique.Plast Aesthet Res2020;7:6

[3] Hara H.Multilymphosome injection indocyanine green lymphography can detect more lymphatic vessels than lymphoscintigraphy in lymphedematous limbs.J Plast Reconstr Aesthet Surg2020;73:1025-30

[4] Mihara M,Zhou HP,Kikuchi K.Lymphaticovenous anastomosis releases the lower extremity lymphedema-associated pain.Plast Reconstr Surg Glob Open2017;5:e1205 PMCID:PMC5293304

[5] Mihara M,Furniss D.Lymphaticovenular anastomosis to prevent cellulitis associated with lymphoedema.Br J Surg2014;101:1391-6

[6] Campisi CC,Boccardo F.A single-site technique of multiple lymphatic-venous anastomoses for the treatment of peripheral lymphedema: long-term clinical outcome.J Reconstr Microsurg2016;32:42-9

[7] Yamamoto T,Doi K.Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns.Plast Reconstr Surg2011;127:1979-86

[8] Hara H.Blocking of the lymphatic vessel in lymphedema.Eplasty2017;17:e11 PMCID:PMC5372755

[9] Mihara M,Shibasaki J.Indocyanine green lymphography and lymphaticovenous anastomosis for generalized lymphatic dysplasia with pleural effusion and ascites in neonates.Ann Vasc Surg2015;29:1111-22

[10] Guermazi A,Hennequin C.Lymphography: an old technique retains its usefulness.Radiographics2003;23:1541-58; discussion 1559

[11] Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2013 consensus document of the international society of lymphology.Lymphology2013;46:1-11

[12] Pan WR.Atlas of lymphatic anatomy in the head, neck, chest and limbs. Singapore: Springer; 2017.

[13] Narushima M,Ogata F,Mihara M.Indocyanine green lymphography findings in limb lymphedema.J Reconstr Microsurg2016;32:72-9

[14] Hara H.Lymphaticovenous anastomosis for advanced-stage lower limb lymphedema.Microsurgery2021;41:140-5

[15] Sty JR,Scanlon GT.Radionuclide “dermal backflow” in lymphatic obstruction.J Nucl Med1979;20:905-6

[16] Mihara M,Tange S.Multisite lymphaticovenular bypass using supermicrosurgery technique for lymphedema management in lower lymphedema cases.Plast Reconstr Surg2016;138:262-72