Indocyanine green lymphography has been a highly useful modality in the clinical examination and surgical management of patients with lymphedema. No formal classification system of indocyanine green imaging findings according to the severity of lymphedema exists, however. The purpose of this study was to describe, analyze, and classify characteristic indocyanine green lymphography findings to uniformly guide surgical management of lymphedema using this modality. Forty-five patients (78 limbs) with lower extremity lymphedema underwent indocyanine green lymphography. All lymphography images were recorded in photographs and videos. Images were reviewed and analyzed to classify characteristic findings according to clinical severity as determined by Campisi clinical lymphedema staging. Lymphography findings were classifiable into two patterns. Mild cases of lymphedema were characterized by a linear lymphatic channel pattern (linear pattern). In more severe cases, lymphatic channels demonstrated retrograde lymphatic flow (dermal backflow pattern) and diminution or absence of linear channel patterning. Three dermal backflow patterns, splash, stardust, and diffuse, were identified and correlated with the progression of lymphedema severity. These findings supported the generation of a novel anatomical lymphedema severity staging system, the dermal backflow staging system. Indocyanine green lymphography is a safe, minimally invasive, and useful tool for the surgical evaluation of extremity lymphedema. Characteristic indocyanine green lymphography patterns are consistent and correlate with clinical severity. The dermal backflow staging system can facilitate patient stratification, discussion between referring parties, and surgical planning.

Management of arm lymphedema following breast cancer treatment is challenging, and emphasis should be put on early diagnosis and prevention of secondary lymphedema. Indocyanine green lymphography is becoming a method of choice for evaluation of lymphedema. Twenty patients with secondary arm lymphedema after breast cancer treatment underwent indocyanine green lymphography. Characteristic findings of indocyanine green lymphography were analyzed according to corresponding clinical stages and duration of edema. Based on changes in indocyanine green lymphography findings with progression of lymphedema, a new severity stage, arm dermal backflow stage, was developed and compared with clinical stages. The indocyanine green lymphographic findings were classified into two large groups: linear pattern and dermal backflow patterns. The dermal backflow pattern could be subdivided into splash, stardust, and diffuse patterns. The dermal backflow patterns were found more frequently than the linear pattern in the proximal upper extremity (p=0.001). The dermal backflow patterns also increased significantly in prevalence overall as the duration of lymphedema increased (p=0.032). The arm dermal backflow stage was linearly correlated with clinical stage as described by the line y=1.092x+0.083 (R=0.997; analysis of variance, p<0.001). Indocyanine green lymphography is a safe and convenient evaluation method for lymphedema that allows qualitative pathophysiologic assessment of lymphedema. The arm dermal backflow stage, based on indocyanine green lymphographic findings, is a simple severity staging system that demonstrates a significant correlation with clinical stage. Indocyanine green lymphography may come to play an important role in early diagnosis of secondary arm lymphedema. Diagnostic, V.

Early diagnosis and treatment are as important for management of secondary lymphedema following cancer treatment as in primary cancer treatment. Indocyanine green lymphography is the modality of choice for routine follow-up evaluation of patients at high risk of developing lymphedema after cancer therapy. Fifty-six limbs of 28 so-called unilateral secondary lower extremity lymphedema patients who underwent indocyanine green lymphography were compared with dermal backflow patterns of indocyanine green lymphography on 28 asymptomatic limbs and assessed using leg dermal backflow stage. Of 28 asymptomatic limbs of secondary lower extremity lymphedema patients, the dermal backflow patterns were detected in 19 limbs but were absent in nine limbs. Significant differences were seen between asymptomatic limbs with dermal backflow patterns (n=19) and limbs without them (n=9): age, 51.4±15.3 years versus 34.8±12.7 years (p=0.007); body weight, 75.1±7.9 kg versus 50.1±5.3 kg (p=0.012); body mass index, 23.1±4.2 versus 19.7±1.8 (p=0.005); leg dermal backflow stage of asymptomatic limb, 1.2±0.4 versus 0.0±0.0 (p<0.001); and leg dermal backflow stage of symptomatic limb, 3.5±0.6 versus 2.8±0.8 (p=0.033). The splash pattern is the earliest finding on indocyanine green lymphography of asymptomatic limbs of secondary lower extremity lymphedema patients. The leg dermal backflow stage allows early diagnosis of secondary lower extremity lymphedema even in a subclinical stage. The concept of subclinical lymphedema could play an important role in early diagnosis and prevention of lymphedema after cancer treatment. Diagnostic, V.

Lymphaticovenular anastomosis has become an increasingly common treatment for lymphedema. Supermicrosurgical techniques are essential for the successful performance of lymphaticovenular anastomosis. A positive correlation between the number of lymphaticovenular anastomoses performed and therapeutic efficacy has been reported, and in performing these anastomoses, the establishment of as many bypasses as possible is important. Forty limbs of 20 patients with lower extremity lymphedema who underwent lymphaticovenular anastomosis in our department were assessed. All cases were performed under local anesthesia using two to four surgical microscopes. A new method of anastomosis, lambda-shaped anastomosis assisted by intravascular stenting, was chosen in required cases. Lymphaticovenular anastomoses resulted in 186 anastomoses on 20 patients with lower extremity lymphedema; the average number of anastomoses per case was 9.3 (range, five to 18). The number of surgical microscopes used ranged from two to four (average, 3.3), and the duration of the operation ranged from 3 to 5 hours (average, 4.1). In the cases of lambda-shaped anastomosis (n = 11), the number of anastomoses was significantly greater than in the cases without lambda-shaped anastomosis (n = 9; 10.2 ± 2.3 versus 8.2 ± 1.4; p < 0.05). Lambda-shaped anastomosis assisted by intravascular stenting is a safe and relatively easy method that can be performed by surgeons with less than 1 year of experience in microsurgery. This in turn allows efficient lymphaticovenular anastomoses to be performed simultaneously by a team of surgeons, resulting in an increased number of bypasses.

Measurement of the circumference is the most commonly used method for evaluating extremity lymphedema. However, comparison between different patients is difficult with this measurement. To resolve this problem, we have formulated a new index, lower extremity lymphedema (LEL) index, which can be easily obtained from measurements of the body. We evaluated correlation between lower LEL index and clinical stage in patients with LEL. The LEL indices were significantly correlated with clinical stages and could be used as a severity scale. The LEL index makes objective assessment of the severity of lymphedema through a numerical rating, regardless of the body type. This numerical rating makes the index useful for evaluation of lymphedema severities between different cases.