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Peripheral Venous Angle Plasty: A New Lymphovenous Anastomosis Technique for Lower Extremity Lymphedema

Yamaguchi, Kazuaki M.D.; Kimata, Yoshihiro M.D.; Yamada, Kiyoshi M.D.; Suami, Hiroo M.D., Ph.D.

Plastic & Reconstructive Surgery: July 2012 - Volume 130 - Issue 1 - p 233e–235e
doi: 10.1097/PRS.0b013e3182550274

Department of Plastic and Reconstructive Surgery, Okayama University, Okayama, Japan (Yamaguchi, Kimata, Yamada)

Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas (Suami)

Correspondence to Dr. Yamaguchi, Department of Plastic and Reconstructive Surgery, Okayama University, 2-5-1 Shikata, Okayama 700-8558, Japan

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Lymphovenous anastomosis is now commonly used to treat lymphedema; however, the procedure still does not always achieve optimal outcomes. The key to consistently achieving good outcomes with lymphovenous anastomosis may be to create a valve at the anastomosis that prevents venous reflux. We devised a new lymphovenous anastomosis technique, peripheral venous angle plasty, in which a functional semilunar valve is fashioned at the anastomosis.1

Patients who underwent peripheral venous angle plasty for secondary extremity lymphedema at Okayama University Hospital or Ako Central Hospital between August of 2010 and May of 2011 were included. Campisi criteria were used to classify patients' stages of lymphedema.1

Ultrasonography was used to identify superficial veins in the legs preoperatively. Fluorescence lymphography with indocyanine green performed with the Photodynamic Eye lymphography system (Hamamatsu Photonics K.K., Hamamatsu, Japan) was used to detect lymphatic vessels. A 27-gauge needle was used to inject 5 mg/ml indocyanine green into the dermis at each web space of digits around the ankle and knee. Lymphatic vessels were identified and their courses drawn on the skin.

Lymphatic vessels that were translucent (indicating a lack of fibrosis), had a patent lumen, and showed an efflux of lymph when severed were used for peripheral venous angle plasty. The drainage lymphatic vessel was cut obliquely and the stump was inserted proximally into the vein and sutured to the adventitia with 11-0 or 12-0 nylon sutures to create a valvular structure within the venous lumen (Fig. 1).

After surgery, reconstructive surgeons or lymphedema physiotherapists measured the circumferences of the patients' legs at five points from toe to thigh and the percent difference between preoperative and postoperative leg measurements was calculated using the following formula:

where Vpre is the preoperative value, Vpost is the postoperative value, 1 is the operative side, and 2 is the nonoperative side. Four women and one man who underwent peripheral venous angle plasty were included in the present study. The patients' mean age was 66 years (range, 55 to 73 years). Two patients had stage II lymphedema and three patients had stage III lymphedema based on Campisi criteria.

Intraoperative lymphography revealed that anterograde efflux from the lymphatic vessel was intermittently flushed out by venous flow (Fig. 2). (See Video, Supplemental Digital Content 1, which demonstrates lymph fluid containing indocyanine green intermittently ejected from the lymphatic vessel (arrows), Venous reflux was not detected.) Venous reflux into the lymphatic vessel after peripheral venous angle plasty was not detected in any of the patients. The mean decrease in lower leg circumference was 10.4 ± 4.9 percent.

Extrinsic and intrinsic pumps drive lymphatic drainage. The extrinsic lymphatic pump includes central venous pressure fluctuations, respiration, and skeletal muscle contraction,2 whereas the intrinsic pump is the spontaneous activity of the smooth muscle cells that regulates and coordinates peristaltic lymphangion action.3,4 In patients with obstructive lymphedema, endothelial cells and smooth muscle cells become fibrotic, often in a proximal-to-distal manner, because the high pressure of lymphostasis caused by the chronic backflow of lymph fluid into lymph capillaries in the dermis.3,5

Using lymphography with indocyanine green, we could easily identify functional lymphatic vessels, and in peripheral venous angle plasty the stump of the lymph vessel inserted into the drainage vein functions as a check valve and prevents reflux of blood into the lymph vessel.

Kazuaki Yamaguchi, M.D.

Yoshihiro Kimata, M.D.

Kiyoshi Yamada, M.D.

Department of Plastic and Reconstructive Surgery, Okayama University, Okayama, Japan

Hiroo Suami, M.D., Ph.D.

Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas

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The authors have no source of financial or other support or any financial or professional relationships that might pose a competing interest.

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1. El Zawahry MD, Sayed NM, El-Awady HM, Abdel-Latif A, El-Gindy M. A study of the gross, microscopic and functional anatomy of the thoracic duct and the lympho-venous junction. Int Surg. 1983;68:135–138.
2. Gashev AA. Physiologic aspects of lymphatic contractile function: Current perspectives. Ann N Y Acad Sci. 2002;979:178–187; discussion 188–196.
3. Suami H, Pan WR, Taylor GI. Changes in the lymph structure of the upper limb after axillary dissection: Radiographic and anatomical study in a human cadaver. Plast Reconstr Surg. 2007;120:982–991.
4. von der Weid PY, Crowe MJ, Van Helden DF. Endothelium-dependent modulation of pacemaking in lymphatic vessels of the guinea-pig mesentery. J Physiol. 1996;493:563–575.
5. Koshima I, Kawada S, Moriguchi T, Kajiwara Y. Ultrastructural observations of lymphatic vessels in lymphedema in human extremities. Plast Reconstr Surg. 1996;97:397–405; discussion 406–407.
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