Outcomes of lymphaticovenous side-to-end anastomosis in peripheral lymphedema Jiro Maegawa, MD, Yuichiro Yabuki, MD, Hiroto Tomoeda, MD, Misato Hosono,

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Outcomes of lymphaticovenous side-to-end anastomosis in peripheral lymphedema Jiro Maegawa, MD, Yuichiro Yabuki, MD, Hiroto Tomoeda, MD, Misato Hosono, MD, Kazunori Yasumura, MD Journal of Vascular Surgery Volume 55, Issue 3, Pages 753-760 (March 2012) DOI: 10.1016/j.jvs.2011.08.062 Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 1 Operative photographs (upper row) and illustrations (lower row) show the lymphaticovenous side-to-end anastomosis technique. A, The side wall of the lymphatic vessel (L) is incised with a microknife. V, Subcutaneous vein. B, A nylon suture-stent (*) is inserted into the lumen of the lymphatic vessel and a stitch is inserted at the edge. C, Another nylon suture-stent is inserted and stitches are inserted from edge-to-edge. D, After completion of the anastomosis, stents are removed through the anastomosis. Journal of Vascular Surgery 2012 55, 753-760DOI: (10.1016/j.jvs.2011.08.062) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 2 Patency of a lymphaticovenous anastomosis is confirmed through the surgical wound by indocyanine green fluorescence lymphography during surgery. The star and triangle indicate a cutaneous vein and a lymphatic vessel, respectively. Journal of Vascular Surgery 2012 55, 753-760DOI: (10.1016/j.jvs.2011.08.062) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 3 Kaplan-Meier survival curve is shown for patency of lymphaticovenous side-to-end anastomosis. The error bars show the standard error. Journal of Vascular Surgery 2012 55, 753-760DOI: (10.1016/j.jvs.2011.08.062) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 4 A, A 64-year-old patient with secondary lymphedema of the left lower extremity. The star indicates the site of a lymphaticovenous side-to-end anastomosis at the dorsum of the right foot. B, Indocyanine green fluorescence lymphographic images at the same site in the same patient (star, anastomosis site; triangles, lymphatic vessel; and arrows, subcutaneous vein). At this time, the image shows a straight pattern. C and D, When the vein is compressed, indocyanine green flows proximally through its branches, and the image shows a tree pattern. Journal of Vascular Surgery 2012 55, 753-760DOI: (10.1016/j.jvs.2011.08.062) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 5 A 64-year-old patient with secondary lymphedema of the left lower extremity. A, Five lymphaticovenous side-to-end anastomoses were performed from the foot to the thigh on the affected limb. B, Enlargement of the anastomosis at the ankle. C, A radial pattern is seen in the indocyanine green fluorescence lymphographic imaging. The star indicates the site of anastomosis at the ankle, and the triangles indicate the lymphatic vessels. B and C, The white arrows indicate subcutaneous veins that resemble a tree with several branches. Journal of Vascular Surgery 2012 55, 753-760DOI: (10.1016/j.jvs.2011.08.062) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 6 An L-pattern in a 32-year-old patient with primary lymphedema of the left lower extremity. The star, triangles, and arrows indicate the anastomosis site, lymphatic vessel, and subcutaneous vein, respectively, at the extensor side of the left lower leg. Journal of Vascular Surgery 2012 55, 753-760DOI: (10.1016/j.jvs.2011.08.062) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 7 A, A 72-year-old woman presented with lymphedema of the left lower extremity after an extended hysterectomy with regional lymph node dissection performed 15 years previously because of uterine cancer. Severe lymphedema was evident (volume, 5413 mL). B, Two lymphaticovenous side-to-end anastomoses (LVSEAs) were performed for the dorsum of the foot, three were performed for the leg, and one for the thigh. C, Postoperative indocyanine green fluorescence lymphography shows patency of the LVSEA at the medial side of the dorsum of the foot, where a tree pattern was observed, and nonpatency at the other LVSEA of the foot (star, anastomosis site; triangles, lymphatic vessel; arrow, subcutaneous vein). D, At 6 months after LVSEA, lymphedema of the left lower extremity has improved (volume, 4326 mL). Journal of Vascular Surgery 2012 55, 753-760DOI: (10.1016/j.jvs.2011.08.062) Copyright © 2012 Society for Vascular Surgery Terms and Conditions