SUMMARY
Immediate lymphatic reconstruction (ILR) is targeted at preventing breast cancer related lymphedema (BCRL) by anastomosing disrupted arm lymphatic channels to axillary vein tributaries. Inadequate vein length and venous back-bleeding are two technical reasons that lead to ILR procedures being aborted intraoperatively. Recently, our team began routinely harvesting a lower extremity vein graft (LEVG) for all ILR procedures to reduce our abort rate. We describe the surgical approach of an LEVG and evaluate the effects on aborted case rates and intraoperative time. A retrospective review of our institutional lymphatic database was conducted. Two hundred and forty-seven breast cancer patients were taken to the operating room for attempted ILR in the past 5 years. Prior to the use of an LEVG (n=205), our abort rate was 14%. Since routinely performing an LEVG with ILR (n=42), we have not aborted a single case. Despite an LEVG requiring one additional anastomosis to connect the vein graft to the native axillary vein tributary, this technique has not changed the intraoperative time for ILR procedures. In this technical contribution, we describe our early experience performing immediate lymphatic reconstruction utilizing a lower extremity vein graft. Implementation of this technique appears to have promising effects on aborted case rates without affecting intraoperative time, and greatly facilitates the lymphovenous anastomosis.
Keywords: lymphatic, reconstruction, lymphovenous bypass, LYMPHA
INTRODUCTION
Immediate lymphatic reconstruction (ILR) is a microsurgical technique to reduce the risk of breast cancer related lymphedema (BCRL) development after axillary lymph node dissection (ALND). Inadequate length of the axillary vein tributary as well as venous back bleeding are two technical challenges that can lead to ILR procedures being aborted at a rate of approximately 25%1,2. Unsuccessful ILR procedures leave patients with a greater risk of developing BCRL3. Yamamoto et al4 described their experience using a vein graft in lymphovenous anastomoses performed to treat lymphedema, however the use of vein grafts in preventative lymphovenous anastomoses has not yet been observed. Recently, our team began routinely harvesting a lower extremity vein graft (LEVG) for all ILR procedures. We describe the technical approach of an LEVG for ILR and evaluate the effects on aborted case rates and intraoperative time.
METHODS
Retrospective Review
A retrospective review of our lymphatic surgery database was conducted. We identified consecutive patients diagnosed with node-positive unilateral breast cancer who were taken to the operating room for attempted ILR immediately between September 2016 and November 2021. Demographics and intraoperative variables were analyzed descriptively.
Surgical Technique
After induction, a 5-cm target vein with a diameter of 1–2 mm was identified by ultrasound in the medial lower leg. Branching was identified to increase the likelihood of valve presence5. During the ALND, the graft was harvested by the reconstructive team. The vein was clipped distally and divided to test for valve competency. The proximal vein was then clipped and divided. The graft was flushed with heparinized saline and was wrapped in a moist gauze.
The native axillary vein tributary was preserved by the oncologic surgeon1,5. Following the ALND, the proximal LEVG was anastomosed end-to-end to the distal end of the axillary vein tributary, The orientation of the vein was maintained in order to appropriately position the valve for the prevention of venous backflow into the LEVG (Figure 1). The distal part of the LEVG was utilized for the lymphovenous bypass using the intussusception technique5. Anastomotic patency of the bypass was confirmed using fluorescein isothiocyanate. The incision was closed in a standard manner. Postoperatively, ILR patients were enrolled in our lymphedema surveillance protocol3.
Figure 1.
Illustration of ILR utilizing a lower extremity vein graft (LEVG). The axillary vein tributary is anastomosed to the vein graft using an anastomotic coupling device (Synovis MCA Inc., Birmingham, AL, USA). The orientation of the LEVG is maintained, with the proximal LEVG anastomosed to the distal axillary vein tributary. By doing so, the valve orientation is maintained.
RESULTS
Two hundred and forty-seven patients with nodal-positive unilateral breast cancer were taken to the OR for attempted ILR in the past 5 years. The average patient age was 54 years. 205 consecutive patients underwent ILR without an LEVG and 42 consecutive patients underwent ILR with an LEVG.
Prior to the use of an LEVG (n=205), our abort rate was 14%. Since routinely utilizing an LEVG with ILR (n=42), we have not aborted a single case (Figure 2). Prior to the use of an LEVG, the average intraoperative time for ILR was 81 minutes (range = 29 minutes to 4 hours and 23 minutes). Following the routine implementation of an LEVG with ILR, our average intraoperative time was 71 minutes (range = 37 minutes to 2 hours and 2 minutes). Anastomotic patency was confirmed in all patients by visualization of fluorescein in the vein. One patient developed a partial dehiscence of their graft donor site, requiring revision under local anesthesia.
Figure 2.
Institutional Immediate Lymphatic Reconstruction Aborted Case Rates Before and After Routine Implementation of Lower Extremity Vein Graft on January 1, 2021
DISCUSSION
In this technical overview, we introduce and describe the use of an LEVG for ILR. Since the routine implementation of an LEVG, no ILR procedures have been aborted. There are two reasons for this. First, the added length of the vein graft reduces the reliance on the oncologic surgeon to identify and preserve an adequate venous conduit. Second, the LEVG increases the likelihood of valve presence, thereby reducing the potential for venous back-bleeding by promoting unidirectional flow4,5.
As lymphatic care becomes centralized, we have begun to serve as a major regional center in lymphatic care, and many of our patients travel long distances for treatment. In doing so, patients make both emotional and financial investments in their care. Therefore, using an LEVG to reduce aborted ILR procedures is of significant benefit to patients. Additionally, the incidence of donor site complication was minimal.
Despite an LEVG requiring one additional anastomosis to connect the graft to the axillary vein tributary, ILR intraoperative time was not affected. The LEVG was harvested during the oncologic surgery, which maximized efficiency without changing workflow. The added length of the LEVG gave the reconstructive surgeon more flexibility in choosing the optimal lymphatic channel(s) to bypass while simultaneously reducing the technical demands of the bypass itself.
In this technical contribution, we describe our early experience performing ILR utilizing an LEVG. This is a relatively straight-forward technique and allows for reduction in aborted case rates without increasing intraoperative time, however, the clinical value and the impact of this technique on the development of BCRL has yet to be determined.
Supplementary Material
SUPPLEMENTARY VIDEO CONTENT 1 Surgical Technique of Immediate Lymphatic Reconstruction Utilizing a Lower Extremity Vein Graft (LEVG). The graft is first harvested from the medial lower leg. The axillary vein tributary is coupled to the LEVG and the divided lymphatic channels are then bypassed in standard fashion. Patient consent was obtained for the video recording.
Funding:
Rosie Friedman is supported by the JOBST Lymphatic Research Grant awarded by the Boston Lymphatic Symposium, Inc.
Footnotes
Presented as an e-poster presentation at the American Society for Reconstructive Microsurgery 2022 Annual Meeting (Carlsbad, California)
Conflicts of Interest: None to disclose
Statement of Ethical Approval: Formal and documented ethical approved was obtained by the Beth Israel Deaconess Medical Center Institutional Review Board under Protocol #2021P000540.
REFERENCES
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Associated Data
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Supplementary Materials
SUPPLEMENTARY VIDEO CONTENT 1 Surgical Technique of Immediate Lymphatic Reconstruction Utilizing a Lower Extremity Vein Graft (LEVG). The graft is first harvested from the medial lower leg. The axillary vein tributary is coupled to the LEVG and the divided lymphatic channels are then bypassed in standard fashion. Patient consent was obtained for the video recording.