Reverse Axillary Mapping and Lymphaticovenous Bypass for Lymphedema Prevention in Breast Cancer: Optimizing Lymphatic Visualization and Restoration of Flow

Lymphedema (LA) following breast cancer treatment is a critical and underappreciated problem with long-term health, functional, aesthetic and economic implications. Growing interest in LA prevention has motivated protective strategies. Our aim was to develop a novel intraoperative paradigm for breast cancer patients undergoing axillary lymphadenectomy(ALND) that protects against iatrogenic LA through enhanced lymphatic visualization during reverse axillary mapping (ARM), and refinement in microsurgical decision making during lymphaticovenous bypass (LVB). 

Methods

All patients with planned ARM+LVB from October 2016-February 2018 were reviewed.  Patient demographics and oncologic history were recorded.  Operative details were noted including post-ALND lymphatic anatomy, availability of recipient veins with competent valves and technical microanastomotic details.   Ability to achieve patency of lymphaticovenous bypass was documented by blue dye and ICG lymphangiography .

Results

Thirty patients underwent ARM+LVB.  26 underwent modified radical mastectomy, 4 underwent lumpectomy with ALND, 15 underwent implant-based breast reconstruction.   LVB operative time ranged from 40 – 150 min.  1-3 LVB were performed per patient.   Bypass completion occurred in 29/30 patients and patency with ICG lymphangiography and blue dye was confirmed in 27/29.    Two anastomoses were felt to be insufficient due to venous backflow into the lymphatic vessel.   When size match was equivalent, end to end anastomoses were performed.  If size mismatch between the chosen vein branch and lymphatic was present, or multiple cut lymphatics were in proximity and had sufficient mobility, an invagination technique was used to maximally restore anterograde lymphatic drainage (5/26).    Short term follow-up has revealed no instances of transient or progressive lymphedema.

Conclusion

We have developed an intraoperative paradigm that accounts for post-ALND lymphatic and venous anatomy.   By combining radioisotope free axillary reverse mapping under loupe magnification and lymphaticovenous bypass, we maximally preserve lymphatic continuity and reestablish physiologic upper extremity lymphatic drainage pathways.