Supermicrosurgical Lymphovenous Anastomosis for Early-Moderate Stage Lymphedema

Lymphaticovenular anastomosis (LVA) addresses pathophysiology of obstructive lymphedema. LVA is basically recommended for early-moderate stage lymphedema, as its efficacy decreases with progression of lymphedema due to lymphosclerosis. Appropriate preoperative evaluation and mapping are keys to maximize therapeutic efficacy of LVA for the treatment of lymphedema. Indocyanine green (ICG) lymphography stage is useful to predict efficacy and consider indication of LVA. Overlapping regions, where ICG lymphography shows linear pattern at an early transient phase and then stardust pattern at a late plateau phase, are the most suitable sites for LVA; lymph vessels can definitely be found and are slightly sclerotic with high lymph flows optimal for LVA. In subclinical and early-stage lower-extremity lymphedema following pelvic lymphadenectomy, efferent lymph vessel-to-venous anastomosis (ELVA) is applicable, in which the efferent lymph vessels of the inguinal lymph nodes are bypassed. ELVA allows preservation of the inguinal lymph nodes’ function by a single-site surgery and is useful for secondary prevention of lower-extremity lymphedema.