Changing the Paradigm: Lymphovenous Anastomosis in Advanced Stage Lower Extremity Lymphedema.

INTRODUCTION Traditionally, lymphovenous anastomosis (LVA) is not routinely performed in the patients with advanced stage lymphedema due to difficulty with identifying functioning lymphatics. This study presents the use of Duplex ultrasound and MR lymphangiogram to identify functional lymphatics and clinical outcome of LVA in advanced stage lower extremity lymphedema patients. MATERIALS AND METHODS This is a retrospective study of 42 patients (50 lower limbs) with advanced lymphedema (stage 2 or 3) which underwent functional LVAs. Functional lymphatic vessels were identified preoperatively using MR lymphangiogram and Duplex ultrasound. RESULTS An average of 4.64 LVAs were performed per one limb using the lymphatics located in the deep fat underneath the superficial fascia. The average diameter of lymphatic vessel was 0.61mm (range 0.35-1mm). The average limb volume was reduced 14.0% postoperatively, followed by 15.2% after 3 months, and 15.5% after 6 months and 1 year (p<0.001). For the patients with unilateral lymphedema, 32.4% had less than 10% volume excess compared to contralateral side postoperatively while 20.5% remained to have more than 20% volume excess. The incidence of cellulitis has decreased from 0.84/year to 0.07/year after surgery (p<0.001). CONCLUSION This study shows that functioning lymphatic vessels can be identified preoperatively using ultrasound and MR lymphangiogram and thus LVAs can effectively reduce the volume of the limb and improve subjective symptoms in patients with advanced staged lymphedema of the lower extremity.