Complete lymphatic restoration by simultaneous vascularized lymph node and lymphatic vessel transplantation

Treatment of breast cancer-related lymphedema includes complete decongestive therapy (CDT), lymphaticovenous anastomosis and vascularized lymph node transfer (VLNT). VLNT is hypothesised to function by lymphangiogenesis or lymphatic pump theory. This may however be impeded in advanced lymphedema by the presence of subcutaneous fibrosis leading to failure. We propose harvesting an afferent lymphatic vessel draining into the lymph nodes and supermicrosurgical anastomosis to a native limb lymphatic for direct restoration of lymphatic continuity and bypass any fibrotic tissues. We present 2 cases who underwent VLNT and lymphatic vessel transplantation. Patient 1 had recurrent cellulitis, whilst patient 2 had increasing limb volume despite compliance to CDT. VLNT were based on the superficial inferior epigastric artery and superficial circumflex iliac artery respectively. The afferent lymphatic vessel draining into the lymph nodes was identified using patent blue and indocyanine green (ICG). The native lymphatic vessel was identified on Magnetic Resonance Lymphangiogram or ICG pre-operatively and confirmed intra-operatively with ICG. Compression bandaging started post-operative day 4 and changed to customized garments at 2 weeks. Sequential circumference measurements of the arm were performed. Patient 1 showed maximal improvement in volume excess from 26.6 to 9.4% with complete resolution of cellulitis. Thirty-month postoperative lymphoscintigraphy showed prompt tracer flow through the transplanted afferent lymphatic vessel, reaching the lymph nodes within 15 min (similar rate as the unaffected limb). Patient 2 declined repeat lymphoscintigraphy due to cost, but showed maximal improvement in volume excess from 21.0 to 14.9% and was able to wean off pressure garments.

Level of evidence: Level V, therapeutic study