The Dynamic-Lymphaticovenular Anastomosis Method for Breast Cancer Treatment-Related Lymphedema: Creation of Functional Lymphaticovenular Anastomoses with Use of Preoperative Dynamic Ultrasonography

Background: Lymphaticovenular anastomosis (LVA) is generally effective for breast cancer treatment-related upper extremity lymphedema (UEL).¹ Clinical improvement is, however, limited by the degree of sclerosis of the lymphatic vessels. Lymphatic vessels with degenerated smooth muscle are inadequate in propelling lymph into the anastomosed vein.^2-4 The author developed a reliable method, the dynamic-lymphaticovenular anastomosis (dynamic-LVA) method for detecting the incision points by preoperative dynamic ultrasonography to utilize even sclerotic lymphatic vessels, in which patient’s natural hand movements theoretically propel lymphatic fluid to the site of anastomosed vein.

Methods: Thirty patients with breast cancer treatment-related lymphedema treated by 3 incisions at the forearm for creating lymphaticovenular anastomoses were assessed ⁵: 15 in whom the dynamic-LVA method were used and 15 in whom the conventional method was used. Intraoperative status of lymphatic vessels and postoperative lymphedematous volume reduction were compared.

Results: Placement of incisions at a total of 90 forearm sites (3 per patient) yielded creation of 90 LVAs (32 in “linear ICG lymphography pattern incisions” and 58 in “stardust pattern incisions.” Sclerotic lymphatic vessels were encountered at greater frequency in "linear pattern incisions” in the dynamic-LVA group than in the conventional LVA group (7.1% vs. 38.9%, P = 0.030). Diameters of the lymphatic vessels did not differ significantly between the conventional LVA group and dynamic LVA group (0.43 ± 0.25 mm vs. 0.47 ± 0.14 mm, respectively; P = 0.332) or in the prevalence of dynamic flow of lymph to veins without venous reflux (64.4% vs. 73.3%, respectively; P = 0.362). Postoperative volume reduction was significantly greater in the dynamic-LVA group than in the conventional LVA group; the UEL index at 1 month was 8.12 ± 3.06 vs. 3.74 ± 5.82, respectively (P = 0.018) and at 6 months was 8.74 ± 3.58 vs. 2.62 ± 10.39, respectively (P = 0.046).

Conclusions: Dynamic-LVA is clinically beneficial because the imaging guides decisions over where the incisions should be placed so that a patient’s natural hand motions can be utilized to propel lymph into the anastomosis despite the presence of sclerotic lymphatic vessels. It is also beneficial because even early improvements are obtained.

 

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