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Complications in Microsurgery/Vascularized Lymp Node Transfer
Sunday January 25, 2015
1:30pm-3:15pm Grand Ballroom EFG
Sami Khan, MD; Howard Levinson, MD; David Chang, MD; Joseph Dayan,
MD
1:30 PM - 1:34 PM Flap Salvage in the Thrombophilic Patient: Managing Expectations in the Setting of Vascular
Thrombosis
Georgetown University, Washington DC, CT, USA
Rex Hung, MD; Kevin D. Han, MD; Haley Bunting, MS; Michael V. Defazio, MD; Karen K.
Evans, MD; Georgetown University Hospital
INTRODUCTION
Refinements in microsurgical technique have improved free flap survival to nearly 90% in most
settings. Thrombosis remains the most frequent cause of reoperation, and salvage rates
following venous and arterial compromise fall to 71% and 40%, respectively. There is currently
no consensus in the literature regarding perioperative management and/or flap salvageability in
thrombophiliacs who undergo microsurgical reconstruction. We present our experience with free
tissue transfer (FTT) and flap salvage in this high-risk population.
METHODS
A retrospective review of all patients who underwent FTT by a single surgeon (K.K.E.),
following initiation of a thrombophilia screening protocol, from January 2012 through April
2014, was completed. The defects were largely non-traumatic lower extremity wounds requiring
free tissue transfer in high-risk patients. Patients with history of thromboembolic events in the
absence of a diagnosis of thrombophilia were excluded. Demographic data, diagnosed
thrombophilias, operative events, complications, and postoperative management were
documented for all cases. Outcomes for the thrombosis and non-thrombosis cohorts were
compared using unpaired t-tests.
RESULTS
A total of 43 free flaps were performed. Thrombophilic traits were identified in 26 patients
(60.5%), who received 26 flaps. Of these, 15 (57%) were male and 11 (43%) were
female. Mean age was 51 years and average BMI was 30 kg/m2. Smoking status was the only
statistically significant difference between thrombosis and non-thrombosis cohorts (p=0.04)
(Table 1). Of 49 identified thrombophilic traits, the most common were the plasminogen
activator inhibitor-1 4G variant (12), methylenetetrahydrofolate reductase A1298C (10), and
C677T variant (9) mutations (Table 2). The most common flap performed was from the
anterolateral thigh (12). Seven thromboembolic events (26.9%) were detected in 4 flaps,
eventually resulting in flap loss in all 4 cases after salvage attempts (Table 3). The hematology
service was consulted in all cases of suspected thrombophilias. Overall flap success rate was
84.6% and salvage rate following thrombosis was 0%.
CONCLUSION
We present one of the largest cohorts of FTT to the lower extremity in thrombophilic patients
reported to date. Despite a high overall success rate, thrombophilia significantly increased the
risk of flap failure in our study, with 100% flap loss in the setting of thrombosis. This
information should be used to help counsel patients regarding the risks and benefits of FTT, as
salvage rates following a thrombotic event approach 0% in the presence of thrombophilia.
1:34 PM - 1:38 PM Pharmacologic Inhibition of Phosphodiesterase 5 as a Strategy to Reduce Vascular Injury During
Microsurgery
NYU Medical Center, New York, NY, USA
Marc Soares, MD1; Mark McRae, MD
2; Yee Low, MD
3; Pierre Saadeh
2; Daniel Ceradini
4;
(1)New York University Medical Center, (2)New York University Langone Medical Center,
(3)NYU Medical Center, (4)New York University School of Medicine
Intro: Ischemic microvascular injury compromises the endothelial barrier that maintains tissue
homeostasis and initiates the inflammatory cascade. Following reperfusion, vascular injury is
exacerbated and poses a critical clinical challenge to microsurgery, particularly with regards to
vascularized composite allotransplantation. Phosphodiesterase 5 inhibitors (PDE5i), most
commonly represented by the FDA-approved drug sildenafil citrate (trade-name Viagra), can
potentiate vasodilation in ischemic vasculature and suppress inflammatory pathways. If
ischemic injury to the endothelium initiates a pathologic cascade leading to impaired
revascularization, persistent tissue hypoxia, and accelerated inflammation, then we hypothesize
that pharmacologic treatment microvascular flaps with sildenafil will improve tissue physiology
and survival in the context of prolonged ischemia.
Methods: Using in vitro and in vivo models of ischemia-reperfusion injury (IRI), we
characterized the effect of FDA-recommended doses of sildenafil (10nM and 100nM) on
vascular inflammatory markers. Functionally, an adhesion assay was performed to assess the
effect of PDE5i on the ability of the vascular endothelium to reduce allogenic lymphocyte
adherence. In vivo, using an established rat model of VCA, composite flaps were perfused with
sildenafil-containing perfusate and transplanted into allogenic rats. Laser doppler assess tissue
perfusion in the immediate post-operative period.
Results: PDE5-inhibition decreased endothelial expression of vascular inflammatory markers
ICAM-1 and MCP-1 following ischemia reperfusion injury (3.4-fold, and 8.1-fold reduction
from non-treated controls, respectively p<0.01), while increasing vasculoprotective expression of
VEGF and eNOS (2-fold & 4.5-fold respectively compared to non-treated controls
p<0.05). Functionally, PDE5i-treatment correlated with a 23% decrease in allogenic lymphocyte
adhesion compared to non-PDE5i controls (p =0.04). In the immediate post-operative period,
PDE5i-allografts demonstrated a 3-fold increased vascular perfusion compared to non-treated
allografts (310 FU v.s. 117 FU, p=0.01). Ongoing studies are evaluating the role of PDE5
inhibition on graft survival and rejection.
Conclusions: PDE5 inhibition using an FDA-approved compounds can attenuate vascular
inflammation associated with ischemia-reperfusion injury and may be a rapidly-translatable
therapy to improve outcomes in microvascular surgery and allotransplantation.
1:38 PM - 1:42 PM The Efficacy of Postoperative Antithrombotics in Free Flap Surgery: A Systematic Review and
Meta-Analysis
Samsung Medical Center, Seoul, , South Korea
Kyeong-Tae Lee; Goo-Hyun Mun, MD; Samsung Medical Center, Sungkyunkwan University
School of Medicine
Abstract
Purpose
Although the efficacy of postoperative antithrombotics in free flap survival is well demonstrated
through animal studies, debates still remain in the clinical literature. Many review papers have
considered this topic, but most have been descriptive in nature, offering few meta-analyses. This
review estimates the benefits and risks of each antithrombotic drug and evaluates whether
antithrombotics can produce better outcomes than non-antithrombotic treatment by meta-analytic
methodology.
Methods
A literature search was conducted through the Medline, Ovid, and Cochrane databases for papers
on the efficacy of postoperative antithrombotic agents in outcomes of free flap surgery. Because
outcomes of free flap surgery can vary widely according to microsurgeons and their surgical
skill, only papers comparing surgical outcomes between case and control groups were included
and analyzed in this meta-analysis. The outcome measure was total flap failure, pedicle
thrombosis, and hematoma formation.
Results
Twelve articles representing 4,984 cases were analyzed, including three assessing the efficacy of
heparin or low molecular weight heparin, four of dextran and two of aspirin. None of the
antithrombotics showed significant benefits for flap survival. Heparin reduced the risk of flap
loss by 35%, but it is not significant (relative risk (RR): 0.65; 95% confidence interval (CI): 0.25
– 1.69). Dextran and aspirin showed little protective effects on pedicle thrombosis and flap
failure. While all antithrombotics showed increased risks of hematoma, and aspirin raised the
risk of hematoma significantly (RR: 1.99; 95% CI: 1.06 – 3.75).
In an analysis using six articles comparing outcomes between antithrombotics group and non-
antithrombotic group, antithrombotics administration did not reduce the risk of total flap loss
(RR: 1.06; 95% CI: 0.78 – 1.44) and thrombosis (RR: 1.03: 95% CI: 0.76 – 1.39) but
significantly increased the risk of hematoma (RR: 1.73; 95% CI: 1.17 – 2.56).
Conclusions
There is little evidence suggesting that the use of antithrombotics reduces the risks of thrombosis
and total flap failure. Although the randomized controlled studies would be required, the risks of
routine administration of antithrombotics may outweigh the benefits.
Figure 1. Study attrition diagram
Figure 2. Forest plots evaluating the potential benefits and risks of heparin or low-molecular-
weight heparin administration.
Figure 3. Forest plots evaluating the potential benefits and risks of dextran administration.
Figure 4. Forest plots evaluating the potential benefits and risks of aspirin administration.
Figure 5. Forest plots comparing the incidence of flap failure, pedicle thrombosis and hematoma
between antithrombotics group and non-antithrombotics group.
Complications in Microsurgery/Vascularized Lymp Node Transfer, Sunday January 25, 2015,
1:30pm-3:15pm
1:42 PM - 1:48 PM
Discussion
1:48 PM - 1:52 PM Reconstructive Microsurgery in a Large Volume Institution from 1993 through 2012: A
Retrospective Identification of Independent Risk Factors for Flap Failure in 1,683 Free Flaps
Erasmus MC, University Medical Center Rotterdam, Rotterdam, , Netherlands
Marc A.M. Mureau, MD, PhD; David E. Las, MD; Tim de Jong, MD, PhD; Michiel Zuidam,
MD; Norbert M. Verweij, MD; Steven E.R. Hovius, MD, PhD; Erasmus MC Cancer Institute,
University Medical Center Rotterdam
Background: Microvascular free tissue transfer is a reliable method for reconstruction of
complex defects. Although in experienced hands high flap survival rates can be achieved, the
occurrence of (sub)total flap loss still remains a real possibility which should be prevented
whenever feasible. Risk of flap failure may vary between different indications. Therefore, we
retrospectively analyzed our results of a 20-year time period to identify risk factors for partial
and total flap failure after microvascular breast, head and neck and limb reconstruction.
Methods: Medical files from all consecutive patients treated with a free flap between January
1993 and December 2012 within a single center were retrospectively reviewed. Patient
characteristics, surgical data, postoperative complications and reoperations were scored and
variables associated with partial and total flap loss were identified per indication using univariate
analyses and multivariate regression analyses.
Results: A total of 1,683 free flaps were performed in 1,385 patients. Partial and total flap loss
occurred in 5.7% and 4.6% of all free flaps, respectively. Partial free flap loss was seen most
often after posttraumatic limb reconstruction (7.7%), followed by breast (5.1%) and head and
neck reconstruction (4.6%). Total free flap failure occurred in 1.7%, 6.0%, and 6.4% after breast,
limb, and head and neck reconstruction, respectively.
In breast reconstruction, previous radiotherapy and venous anastomosis revision were significant
predictors for partial flap loss, the use of a gluteal artery perforator flap and postoperative
bleeding were significant predictors for total flap loss, and a compromised flap circulation
postoperatively for both partial and total flap loss.
In head and neck reconstruction, pulmonary comorbidity and anastomosis to the lingual vein
were significant predictors for partial flap loss, while the use of a radial forearm flap was a
significant protector for partial flap loss. The use of the superficial temporal artery as a recipient
vessel and a compromised flap circulation postoperatively significantly predicted total flap loss.
After posttraumatic limb reconstruction postoperative wound infection and a compromised flap
circulation significantly predicted partial flap loss, while diabetes and total anesthesia time
exceeding 10 hours were predictors for total flap loss.
Conclusions: The incidence of free flap failure varies between different indications. Several risk
factor associated with free flap failure in three main indications for free flap reconstruction were
identified. These results may be used for counseling and to improve patient, flap, as well as
recipient vessel selection to reduce the chance of free flap failure.
1:52 PM - 1:56 PM The Fifteen-year Trend in Incidence of Post-Mastectomy Lymphedema in The United States
Duke University, Durham, NC, USA
Sneha Kulkarni, MD; Eugenia H. Cho; Kate Buretta; Rachel Anolik; Jared Blau; Suhail K.
Mithani; Scott T. Hollenbeck; Duke University
Purpose: Post-mastectomy lymphedema (PML) is a debilitating problem for many women in the
United States. There are a growing number of options for treating these patients including
physical therapy, lymphaticovenous anastomosis and lymph node transfer. With a number of
changes occurring in management of breast cancer patients it is unclear how the incidence of
PML has changed over the past fifteen years.
Methods: The Nationwide Inpatient Sample (NIS) was used to identify the population of
patients with the diagnosis of post-mastectomy lymphedema (ICD-9 diagnosis code 457.0)
between 1997 and 2011. This generated 56,583 hospital discharges for review. Additionally, the
incidence of breast cancer (ICD-9 diagnosis code 174.0-174.0) and mastectomy (ICD-9
procedure code 85.20-85.25) was also acquired from NIS for this same time period. Patient age,
third party payer, and regional variation were examined. Trends in the annual rates of breast
cancer diagnosis, mastectomy, and PML diagnosis were analyzed using Poisson regression
analysis in MATLAB (MathWorks, Natick, MA).
Results: During the fifteen-year study period, the incidence of breast cancer diagnosis rose by
0.4 percent per year from 191,492 cases in 1997 to 206,382 cases in 2011 (incidence rate ratio
[IRR], 1.004; p<0.01). The number of mastectomies declined by 65 percent over the study period
at an average decrease of 8 percent per year (IRR, 0.924; p<0.01). Diagnosis of post-mastectomy
lymphedema increased by 93 percent from 2742 cases in 1997 to 5284 cases in 2011 (Figure 1).
This trend was significant, at an average increase of 5 percent per year (IRR, 1.050; p<0.01). Of
the 56,583 cases examined, 50% of patients were 65-84 and 31.6% of patients were 45-64 and
4.5% were 18-44 years old. The two primary third party payers associated with this diagnosis
were Medicare 64.6% and private insurance 27%. The incidence of PML was highest in the
South (31.21%) and Midwest (30.61%) and lowest in the Northeast (20.08%) and West
(18.09%).
Conclusion: Data from the NIS show that the rate of PML diagnosis is increasing in the United
States. This is occurring despite the decrease in number of mastectomies performed during this
time. The majority of these patients are over 45 years old, covered by Medicare and live in the
South and Midwest. This data provides insight into the recognition of PML and may be used to
develop programs to help these patients.
1:56 PM - 2:00 PM Postoperative Antithrombotic Use in Free Flap Surgery: A Systematic Literature Review
McMaster University, Hamilton, ON, Canada
Yu Kit Li, MD1; Vinai Bhagirath, MD
1; A. Thoma, MD, MSc, FRCS(C)
2; (1)McMaster
University, (2)St. Joseph's Healthcare and McMaster University
Introduction:
Free flap surgery is a reliable and versatile method for reconstructing complex defects of various
etiologies. While free flap survival rates now generally approach 95%, flap loss remains a
complication associated with significant morbidity. Thromboses at the sites of vascular
anastomoses or distal flap circulation is one cause of flap loss. To minimize the risk of flap
failure, many microsurgeons therefore use antithrombotics as part of their postoperative
regimen. It is unclear, however, if these agents are of any benefit, or if there is superiority of one
agent, dose, or duration of administration over another. The purpose of this study was to
systematically review the literature and determine the effect of postoperative antithrombotics on
flap loss and other objective outcomes.
Methods:
A comprehensive literature search was conducted in multiple electronic databases: MEDLINE,
EMBASE, HealthSTAR, and Cochrane (up to February 2013). Studies were selected by two
independent assessors if the studies investigated the use of postoperative antithrombotics in free
flap surgery and were comparative by design. Outcomes of interest were rates of flap failure, re-
operation, arterial or venous thromboses, local or systemic complications, length of hospital stay,
and death.
Results:
Twelve studies were identified and included, eleven of which were retrospective cohort studies
(ASPS level III evidence). The use of postoperative antithrombotics in the setting of head and
neck free flap reconstruction was most commonly investigated (ten studies). There was
significant variation in the agents used (low molecular weight heparin, heparin, low molecular
weight dextran, aspirin, and ketorolac) as well as their dosing and duration of administration
among studies. Low molecular weight heparin and dextran-40 were the most commonly used
agents; both agents were used in six studies. Flap failure rates did not differ when agents were
compared with each other or with no antithrombotic use at all. Use of aspirin did not confer a
greater risk of bleeding. Use of dextran-40 conferred a greater risk of medical complications.
Conclusions:
Based on largely retrospective data, flap loss rates did not differ between, or seem to be affected
by, various postoperative antithrombotic agents. Prospective studies, however, remain
lacking. Use of dextran-40 is not advised given the increased risk of medical complications and
lack of superiority in flap survival rates. Future studies should measure bleeding based on
objective standardized criteria to facilitate meta-analyses.
Teaching Objectives:
Readers will review the highest quality evidence surrounding the use of postoperative
antithrombotics in free flap surgery.
2:00 PM - 2:06 PM
Discussion
2:06 PM - 2:10 PM Unplanned Reoperations Following Microvascular Free Tissue Transfer: An Analysis of 1745
Patients Using the American College of Surgeons National Surgical Quality Improvement
Program Database
University of Utah School of Medicine, Salt Lake City, UT, USA
Alvin Kwok, MD, MPH; Jayant Agarwal, MD; University of Utah School of Medicine
Background:
Microvascular free tissue transfers are at the top of the reconstructive ladder and often represent
a considerable cost both for the patient and for the healthcare system. Unplanned reoperations
(UR) following these procedures add to significant clinical and financial burden. The rate of UR
and associated risk factors are largely unknown. We sought to use a national multi-institutional
database to identify rates of UR and perioperative predictors of 30-day UR after microvascular
free tissue transfer.
Methods:
Microvascular free tissue transfer cases from January 2011 to December 2012 were identified
using the American College of Surgeons National Surgical Quality Improvement Program (ACS
NSQIP) database. UR within 30 days was the primary outcome. Univariate analysis was used to
determine the association between UR and operative and preoperative factors. Factors with a
significance of p<0.05 in the univariate analysis were included in a multivariate logistic
regression to determine independent risk factors.
Results:
The ACS NSQIP dataset was used to identify 1745 microvascular free tissue transfer
cases. There were 226 UR (12.95%). Free flaps involving reconstruction of the trunk had the
highest rate of UR (19.44%), followed by head and neck (15.43%), breast (11.69%) and
extremity flaps (6.32%) (8.71% flaps could not be classified). The majority of the UR were
vascular procedures (33.8%) and debridements (33.8%), followed by flap revisions (15.9%), and
wound closures (10.3%) (6.6% of the unplanned reoperations could not be classified). Half of
the UR occurred within 3 days of the primary procedure and 75% within 12 days. Patients who
underwent an UR had a higher rate of complications compared to those who did not require an
UR (62.39% vs. 23.11%, p-value <0.0001). Elevated creatinine > 1.5 mg/dL [OR 3.059, 95% CI
(1.307, 7.156), p=0.0056] and history of smoking [OR 1.533, 95% CI (1.029, 7.156), p=0.0345]
were independent risk factors associated with UR.
Conclusions:
There is a high rate of UR within 30-days following microvascular free tissue transfer. Elevated
creatinine and history of smoking were independent factors associated with increased risk for
UR. Further research should examine the how modification of these preoperative factors can
affect the rate of UR.
2:10 PM - 2:14 PM Free flap take-backs following microvascular thrombosis: Updated findings and review of
revised floor monitoring protocol
University of Pennsylvania, Philadelphia, PA, USA
Michael N. Mirzabeigi, MD; Stephen J. Kovach; Liza C. Wu; Joseph M. Serletti; Suhail
Kanchwala; University of Pennsylvania
Purpose
High rates of success in microsurgery have become the standard of care. The inevitability of
microvascular thromboses; however, and the resultant challenge of flap salvage remain a
certainty. Factors associated with unsuccessful salvage have been poorly understood, or at a
minimum, ineffectively mitigated. The purpose of this study is to further elucidate factors
associated with flap salvage and examine the efficacy of the updated flap monitoring protocol.
Methods
A retrospective chart review was performed on all free flaps performed from January 2005 – July
2014. All flaps were monitored by means of conventional clinical indicators and hand-held
Doppler ultrasonography. From 2005-2011, the institutional floor protocol was as follows: q1
hour flap checks on a dedicated plastic surgery floor for 48 hours, at which time patients were
transferred to a general surgical floor with q4 hour flaps checks until discharge. Following the
published review of the abovementioned flap monitoring protocol, patients now remain on a
dedicated plastic surgery floor with flap check intervals that do not exceed two hours during
hospitalization. The primary endpoint, successful salvage, was defined as any flap that did not
result in total loss. A value of p<0.05 was utilized to determine statistical significance.
Results
A total 3,660 flaps were examined and 75 take-backs for delayed microvascular compromise
were identified. Preoperative factors were examined amongst those flaps which were salvaged
versus those which failed. Following univariate analysis, the mean time until take-back
(p<0.001), presence of thrombophilia (p=0.001), chronic hypertension (p=0.05), and elevated
preoperative platelet counts (p=0.030) were significant factors predictive of unsuccessful
salvage. Intra-operative factors predictive of salvage were lower BMI (p=0.05), more
experienced attending surgeon (p=0.024), and complete mechanical thrombectomy (p=0.011). In
comparing arterial and venous take-backs, preoperative platelet counts (p=0.029) and lower
extremity reconstruction (p=0.038) were predictive of venous compromise. In comparing
monitoring protocol, the revised protocol has resulted in patients returning to the operating room
earlier in the postoperative period (Table 1).
Conclusion
There is evidence to suggest that there are perioperative factors which are predictive of
successful free flap salvage. The data herein emphasizes the need for complete mechanical
thrombectomy during a take-back. In comparison to breast or head/neck reconstruction, lower
extremity free flap reconstruction was associated with venous compromise. The modified floor
monitoring protocol resulted in earlier return to the operating room and minimized late return to
the operating room (greater than 120 hours) at which time salvage is generally futile.
2:14 PM - 2:18 PM Do Adjunctive Flap Monitoring Technologies Impact Clinical Decision Making? An Analysis of
Microsurgeon Preferences and Behavior by Body Region
Johns Hopkins Hospital, Baltimore, MD, USA
Gerhard S. Mundinger1; Justin L. Bellamy
1; Jose M. Flores
1; Eric Wimmers
1; Georgia C.
Yalanis1; Eduardo D. Rodriguez
2; Justin M. Sacks
1; (1)Johns Hopkins Hospital, (2)New York
University
Introduction: Multiple perfusion assessment technologies exist to identify compromised
microvascular free flaps. The effectiveness, operability, and cost of each technology vary. We
investigated surgeon preference and clinical behavior with several perfusion assessment
technologies in the post-operative period.
Methods: A questionnaire was sent to members of the American Society of Reconstructive
Microsurgeons concerning perceptions and frequency of use of several technologies in varied
clinical situations (Figure 1). Demographic information was also collected. Adjusted odds-ratios
were calculated using multinomial logistic regression after accounting for clustering of similar
practices within institutions/regions.
Results: The questionnaire was completed by 157/389 participants (40.4% response rate).
Handheld Doppler was the most commonly preferred free flap monitoring technology (91.7%),
followed by implantable Doppler (59.9%), and cutaneous tissue oximetry (33.1%) (Figure 2).
Surgeons were significantly more likely to opt for immediate take-back to the operating room
when presented with a concerning tissue oximetry readout compared to a concerning handheld
Doppler signal (OR 2.04, p<0.05), while they were less likely to change management for
concerning color duplex sonography images (OR 0.29, p<0.05). Clinical decision making did not
significantly differ by demographics, training, or practice setup. However those who performed
fewer free flaps annually were significantly more likely to opt for operative interventions to
determine the status of microvascular anastomosis. (P<0.01).
Conclusions: While most surgeons still prefer to use standard handheld Doppler for free flap
assessment, respondents were significantly more likely to opt for immediate take-back to the
operating room for a concerning tissue oximetry reading than an abnormal Doppler signal. This
implies that tissue oximetry may have the greatest impact on clinical decision making in the
post-operative period.
Figure 1. Use (A), preference (B), and clinical behavior (C) survey questionnaire for post-
operative flap perfusion monitoring technologies. Respondents were prompted to answer all
questions as they pertained to their self-identified primary body region of expertise.
Figure 2. Proportion of respondents who endorsed frequent (>50% of the cases) use for each
technology by body region.
2:18 PM - 2:24 PM
Discussion
2:24 PM - 2:28 PM A Cadaveric Assessment of the Supraclavicular and the Thoracdorsal-Based Axillary Flaps for
Vascularized Lymph Node Transfer
University of Pennsylvania, Philadelphia, PA, USA
Catherine Chang, MD1; Patrick A. Gerety, MD
1; Christopher J. Pannucci, MD
2; Amber R.
Wang, MD1; Suhail Kanchwala, MD
1; (1)University of Pennsylvania, (2)University of Utah
Background
Vascularized lymph node transfer has recently emerged as a treatment for lymphedema. Little
has been reported about the anatomy of the supraclavicular (SC) and thoracodorsal-based
axillary (TD) flaps. This study describes the anatomy of these flaps including pedicle
characteristics and lymphatic contents.
Methods
Five adult female fresh cadavers were used. Bilateral SC and TD flaps were dissected from each
cadaver. The pedicle characteristics and lymph nodes were quantified by the surgeon in each flap
and then verified by a pathologist grossly and microscopically. Statistical comparisons were
performed using student's t-test.
Results
10 SC flaps (Figure 1) and 10 TD flaps (Figure 2) were harvested and quantified. The SC flap
pedicle (transverse cervical) had an artery and vein caliber of 3.1mm and 2.8 mm with a pedicle
length of 3.3cm. The external jugular vein was included and was 7.9 mm in diameter. There were
no statistical differences between the right and left sides. The senior author found 2.5 lymph
nodes (range 0-5) while the pathologist found 2.6 grossly and 3.0 microscopically (range 1-8).
All SC flaps were found microscopically to have at least one lymph node. The left SC flap had
critical anatomic variability and the thoracic duct was not readily identifiable.
SC and TD flaps were not significantly different in vessel caliber or lymph node count. The TD
flap has significantly longer pedicle and higher weight. One TD flap was found to contain no
lymph nodes. See Table 1 for detailed comparison. There were no significant differences
between the number of nodes noted by the surgeon and the pathologists.
Conclusion
The SC flap harvested with a skin island has lower weight and similar number of nodes as the
TD flap giving it a higher nodal density. Both flaps have pedicles that readily allow
microvascular transfer. The SC flap has the additional advantage of avoiding iatrogenic limb
lymphedema. Importantly, a surgeon's assessment of the lymph nodes in a flap is concordant
with a pathologic examination.
Table 1. Supraclavicular (SC) vs Thoracodorsal (TD)
Flap Characteristics
Supraclavicular
Flap
Thoracodorsal
Flap p
Artery Diamter
(mm) 3.1 +/- 0.3 3.2 +/- 0.2 0.76
Vein Diameter
(mm) 2.8 +/- 0.8 3.5 +/- 1.1 0.24
Pedicle Length
(mm) 33 +/- 6.0 42 +/- 8.0 0.03
Surgeon LN
Count 2.5 +/- 1.7 1.8 +/- 1.2 0.33
Microscopic LN
Count 3.0 +/- 2.1 2.4 +/- 2.0 0.54
Flap weight (g) 12.9 +/- 3.3 17.0 +/- 4.8 0.04
Complications in
Microsurgery/Vascularized
Lymp Node Transfer,
Sunday January 25, 2015,
1:30pm-3:15pm
2:28 PM - 2:32 PM
Supermicrosurgical
Lymphaticovenular
Anastomosis for Treatment
of Lymphedema - the Iowa
Experience
University of Iowa, Carver
College of Medicine, Iowa
City, IA, USA
Wei F. Chen, MD; Justin J.
Guan, BS; John T.
Heineman, MD, MPH;
Jasmine Hernandez, BS;
Kubat Rahatbek, BS;
University of Iowa
Background: Lymphedema
is a chronic, progressive,
and often debilitating
condition that affects 3
million people in the US.
Conservative therapies for
lymphedema are not
consistently satisfactory. While lymphaticovenular anastomosis (LVA) using supermicrosurgical
techniques has become a promising new treatment option for both primary and secondary
lymphedema, indications for LVA remains controversial, and outcome data for LVA is limited.
The purpose of this study was to prospectively evaluate the outcomes of an initial series of 14
consecutive patients who were treated for primary and secondary lymphedema of both upper and
lower extremities at our institution.
Methods: Fourteen patients with upper and lower extremity lymphedema underwent
lymphaticovenular anastomosis. One patient had primary disease, while thirteen suffered from
secondary disease. There were nine with upper extremity lymphedema and five with lower
extremity lymphedema. The mean age of the patients was 53.2 yrs (range, 44 - 69), and the mean
duration of disease was 7.7 years (range, 0 – 34). Four patients had International Society of
Lymphology (ISL) stage III disease, two had stage II disease, and eight had stage I disease.
Evaluation included qualitative questionnaires, quantitative measurements, and ICG
lymphography performed before surgery as well as at 1, 3, and 6 months post-op.
Results: A total of 92 anastomoses were performed, with a mean of 6.6 LVAs performed per
limb. Lymphatics ranging in diameters 0.2 – 0.8 mm were anastomosed to venules ranging in
diameters 0.2 – 2.7 mm. The mean follow-up period was 11.6 months (range, 7.7 – 16.5). 100%
(14/14) of the patients reported symptomatic improvement following surgery. Quantitatively, 12
of 14 patients experienced improvement, defined as a reduction in the difference between
diseased and non-diseased extremity circumferences, with a mean improvement of 71.4%. Three
patients experienced downstaging, as demonstrated by their decreased lymphographic severity
stages. There were no postoperative complications, and no patients developed worsening of
lymphedema. All were highly satisfied with the surgical outcomes and would recommend the
surgery to others.
Conclusions: LVA is a promising procedure for the treatment of primary and secondary
lymphedema. It is safe, minimally invasive, and provides patients with noticeable qualitative and
quantitative improvements. Contrary to what was previously reported, its effectiveness does not
seem to be affected by the severity of lymphedema.
Complications in Microsurgery/Vascularized Lymp Node Transfer, Sunday January 25, 2015,
1:30pm-3:15pm
2:32 PM - 2:36 PM
Discussion
2:36 PM - 2:40 PM A Prospective Assessment of Anatomic Variability of the Submental Vascularized Lymph Node
Flap
Chang Gung Memorial Hospital, taoyuan, , Taiwan
Ming-Huei Cheng; Ketan M. Patel; Chang Gung Memorial Hospital, Chang Gung University
and Medical College
Introduction
The vascularized submental lymph node (VSLN) flap is an excellent option when deciding to
pursue surgical treatment of lymphedema. A detailed understanding of the anatomic variations
related to the VSLN flap will allow for a safe and predictable flap harvest.
Methods
Vascular anatomy was prospectively collected for a consecutive 42 VSLN flap transfers. A
classification system is described based on the frequency and occurrence of arterial and venous
variations. Arterial variation is described as related to the vessel coursing superior (A1), through
(A2), or inferior (A3) to the submandibular gland. Vein classification is based on a similar
relationship (V1-V3) with the addition of a dual venous system (V4).
Results
Two arterial (A1 & A2) variations existed, while 4 venous (V1-V4) variations existed in all
patients. Overall, the A1 arterial course (74%) was found in a greater frequency as compared to
the A2 course (26%). The most common arteriovenous (AV) configuration occurred in 31% of
patients (A1V1), followed by a divergent AV configuration (A1V3) in 21.4% of patients. Flap
harvest time was significantly longer when the A2 arterial course was found (p<0.01).
Conclusions
Consistent vascular variability exists as related to the submandibular gland. The most common
AV configuration is seen with the main vessels being present superior to the submandibular
gland just below the mandibular border. Overall, most AV configurations are found with
divergent vessels being present in relationship to the submandibular gland. In addition, the
presented classification system can aid in categorizing flap characteristics to standardize
outcome measure reporting.
Complications in Microsurgery/Vascularized Lymp Node Transfer, Sunday January 25, 2015,
1:30pm-3:15pm
2:40 PM - 2:44 PM
Effectiveness of Lymphatic Microsurgical Procedures in the Treatment of Primary Lymphedema
Chang Gung Memorial Hospital, Taoyuan, , Taiwan
Ming-Huei Cheng; Ketan M. Patel; Chang Gung Memorial Hospital, Chang Gung University
and Medical College
Introduction
Vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB) procedures
represent physiologic treatment options for symptomatic lymphedema. Secondary causes related
to oncologic surgery and/or radiation have been successfully treated using these surgical
procedures. Primary lymphedema represents a poorly understood lymphedematous condition
with equally poor understanding of the benefits of microsurgical intervention. The purpose of
this study was to review our experience with this patient population to better understand the
effectiveness of microsurgical procedures.
Methods
A retrospective review of a prospectively maintained database of patients who received
microsurgical treatment for primary lymphedema was reviewed. Both LVB and VLNT
procedures were used in this patient cohort. Outcomes related to demographics, circumference
differences, and symptoms, and quality of life (QoL) changes were evaluated. A validated
questionnaire, the LYMQOL, was used to assess QoL outcomes.
Results
Thirteen patients were identified and met inclusion criteria. All patients had primary lower
extremity lymphedema. Average age and symptom duration was 37.8 years and 162 months,
respectively. The average lymphedema stage was classified as Stage II in 66.7% of
patients. Average follow-up was 12.2 months. VLNT was used in most cases (69.2%) while
LVB was used in the remainder of patients. The average overall circumference reduction was
3.6 cm with more improvement seen in patients who received VLNT as compared to LVB
(4.2cm v. 1.9cm). Improvements in body weight and cellulitis occurrence was significantly
improved in the VLNT cohort (p<0.05). In addition, patient-reported QoL domains related to
function, appearance, symptoms, and mood were significantly improved following VLNT
(p<0.05 in all domains) as compared to LVB (p>0.05 in all domains).
Conclusion
Lymphatic microsurgical procedures are valuable treatment options for patients with primary
lymphedema. Vascularized lymph node transfer appears to result in improved overall outcomes
as compared to lymphovenous bypass procedures in this specific patient
population. Improvements in objective clinical measures (limb circumference, body weight, and
cellulitis occurrence) correlate well with improved patient-reported quality of life parameters.
Complications in Microsurgery/Vascularized Lymp Node Transfer, Sunday January 25, 2015,
1:30pm-3:15pm
2:44 PM - 2:48 PM
A Prospective Evaluation of Lymphedema-Specific Quality of Life Outcomes Following
Vascularized Lymph Node Transfer
Chang Gung Memorial Hospital, taoyuang, , Taiwan
Ketan M. Patel; Ming-Huei Cheng; Chang Gung Memorial Hospital, Chang Gung University
and Medical College
Introduction
Microsurgical techniques for the treatment of lymphedema have gained rapid
popularity. Although surgical success with vascularized lymph node (VLN) transfer has been
shown, limited studies have investigated the influence of microsurgical treatment on health
related quality of life (HRQoL) parameters. Therefore, the purpose of this study was to
prospectively evaluate the changes to HRQoL following VLN transfer for upper and lower
extremity lymphedema using a validated instrument.
Methods
An IRB-approved prospective study was performed of patients who underwent vascularized
lymph node transfer for symptomatic upper (ULL) or lower limb (LLL) lymphedema. A
validated lymphedema-specific questionnaire, LYMQOL, was utilized to assess specific quality
of life parameters at multiple time points in the 12-month perioperative period. For comparison
to HRQoL metrics, limb circumference measurements were used to calculate and assess
circumference differentiation.
Results
Twenty-five patients met study criteria. On limb circumference analysis, significant
improvements following VLN transfer were found early with continued improvement during the
study period (ULL: 24.4%, LLL: 35.2%). These improvements were mirrored by improvements
in all HRQoL domains and overall quality of life (p<0.01). Function, body appearance,
symptom, and mood domains were all significantly improved in the post-operative course, with
continued improvement throughout the study period (p<0.01 within each domain).
Conclusions
Microsurgical treatment of lymphedema with VLN transfer procedures is effective at decreasing
limb circumference. These improvements are mirrored by improvements in patient-reported
outcomes and quality of life measures. These changes can be seen as soon as one month post-
operatively and continued steady improvement can be expected.
2:48 PM - 2:54 PM
Discussion
2:54 PM - 2:58 PM Quantitative Assessment of Subjects Who Have Undergone LYMPHA to Prevent Breast Cancer-
Related Lymphedema
NewYork-Presbyterian/Columbia Medical Center, New York, NY, USA
Peter W. Henderson, MD, MBA; Sheldon M. Feldman, MD; Jeffrey A. Ascherman, MD, FACS;
Robert T. Grant, MD, FACS; Billie Borden, BA; Adewuni Ojo, MD; Bret Taback, MD;
Margaret Chen, MD; Preya Ananthakrishnan, MD; Amiya Vaz, BA; Christine H. Rohde, MD,
MPH, FACS; NewYork-Presbyterian/Columbia Medical Center
Introduction
Extremity lymphedema after axillary lymph node dissection (ALND) for breast cancer occurs in
up to 28% of patients. LYMPHA (Lymphatic Microsurgical Preventive Healing Approach) is a
newly developed modality with a number of theoretical advantages over other surgical
alternatives (e.g. ability to prevent lymphedema instead of just treat, lack of secondary lymphatic
donor sites, avoidance of complicated supermicrosurgery). A trial at our institution is underway
to evaluate the outcomes after LYMPHA procedures.
Methods
Females undergoing axillary lymph node dissection for breast cancer were eligible for immediate
LYMPHA. Intraoperatively, lymphatic channels are identified by antegrade dye injection into
the upper arm, and efferent veins by gross inspection. Lymphatic-venous anastomosis is
performed by “dunking” 1-3 lymphatic channels into an axillary vein branch distal to a
competent valve. Two interrupted nylon sutures (8-0, 9-0, or 10-0) approximate the lymphatic
and venous adventitae. Primary end points were clinical onset of lymphedema and arm volume
measurements (circumferential arm measurement and L-Dex bio-impedance spectroscopy at 0.5,
1, 3, 6, and 12 months). Secondary endpoints were complications (seroma, hematoma,
infection). Statistical significance was set at p<0.05.
Results
Twenty-four females with breast cancer who underwent ALND had LYMPHA attempted
concurrently (mean age: 55.5 ± 13.2 years, range: 27-74 years). Attempts at lymphatic-venous
anastomosis were successful in 20 (83.3%), and mean number of lymphatic-venous anastomoses
was 1.6 ± 0.7 (no suitable lymphatic channel was identified in 1 subject, and no suitable vein was
found in 3 subjects). Thirteen of the 20 subjects (65%) have received radiotherapy. The mean
follow-up was 4.0 ± 3.9 months (range: 0.5-12 months). Mean operating time for LYMPHA was
45 minutes, and there were no LYMPHA-related complications. Clinical lymphedema
developed in 3 subjects (15%), 2 of which resolved rapidly with physical therapy. There was no
statistically significant difference in quantitative lymphedema measurements in those subjects
who received radiation (15.4%) and those who did not (14.3%). Mean L-Dex change was +2.2 ±
8.1, and mean arm circumference change was -0.1% ± 1.5%.
Conclusion
These preliminary results demonstrate a lower incidence of lymphedema in the early post-
operative period than what is reported in the literature. Furthermore, there was only a modest
increase in L-Dex, and no increase in arm circumference. This ongoing study will strengthen as
the follow-up and sample size increase, but available results suggest that LYMPHA could be an
easily performed, safe, and efficacious surgical technique for prevention of lymphedema in
women undergoing ALND.
2:58 PM - 2:30 PM
Comprehensive Analysis of Recipient Site Vessels for Distal Vascularized Lymph Node
Transfers
Chang Gung Memorial Hospital, Taoyuan, , Taiwan
Ming-Huei Cheng; Chia-Yu Lin; Ketan M. Patel; Chang Gung Memorial Hospital, Chang Gung
University and Medical College
Introduction:
Distal vascularized lymph node (VLN) transfers are becoming recognized as a valuable surgical
option to treat extremity lymphedema. Native lymphedematous tissue may impact the quality,
location and reliability of recipient vessels in the distal upper and lower extremity. The purpose
of this study was to review the characteristics of recipient vessels in order to more accurately
predict peri-operative events.
Methods:
An IRB-approved review of a prospective database was performed for patients who underwent
distal VLN transfer for upper and lower extremity lymphedema. Pre-operative duplex
ultrasonography and intra-operative findings of the recipient sites for all distal VLN transfers
were evaluated. Findings related to artery, superficial and deep venous vessel diameter, vessel
choice, and vascular-related complications were reviewed.
Results:
Sixty cases of distal VLN transfer were evaluated; 55% lower extremity, 45% upper
extremity. In the lower extremity, a majority of transfers (94%) were placed around the ankle
region, while two patients received transfers to the proximal leg. Vascular systems used
included the posterior tibial (60.6%), the anterior tibial (33.3%), and the medial sural (6.1%)
arteries. Average artery diameters were similar around the ankle (3.0mm), and were 2mm for the
medial sural artery. The deep and superficial venous systems were used in equal portions, with a
smaller proportion using combined systems. Vascular complications occurred in 27.3% of cases,
but no site-specific differences were found. In the upper extremity, distal forearm/wrist received
a majority of transfers (89%), while three patients received transfers to the elbow
region. Recipient vessels included the radial artery-deep branch (59.3%), ulnar artery (29.6%),
and ulnar collateral artery (11.1%). Average artery (2.3mm) and vein diameter (2.5mm) were
similar in the upper extremity transfers. When specifically evaluating select recipient sites, the
volar wrist had a significantly smaller average vein diameter (2.0mm) as compared to other sites
(p=0.04) and less frequent use of the superficial venous system as outflow (p=0.02). Combined,
these resulted in a significantly greater occurrence of venous congestion (p=0.03).
Conclusions:
Recipient vessels for distal VLN transfers are reliably and predictably present. In the setting of a
lymphedematous extremity, deep venous systems appear to be relatively unaffected, with
medium caliber average vessel diameters. Regional differences appear to exist for the usability
and selection of recipient veins in various locations.
3:02 PM – 3:06 PM
Lymph Node Transplantation and Quantitative Clearance Lymphoscintigraphy
University of Florida, Gainesville, FL, USA
Walter Drane, MD1; Lisa Spiguel, MD
1; Christiana Shaw, MD
1; Stamatis Sapountzis, MD
2;
Bruce Mast, MD1; Hung-Chi Chen, MD
3; Dhruv Singhal, MD
1; (1)University of Florida,
(2)China Medical University, (3)E-Da Hospital
Background: Lymphedema remains a serious burden of disease with physical therapy the
primary readily available treatment option with limited success. Multiple surgical procedures
aimed at improving the lymphatic physiology of affected extremities are being performed at
many institutions worldwide. However, no ideal method of evaluating the severity and results of
these procedures has been agreed upon. We offer below the first report of quantitative clearance
lymphoscintigraphy in the pre- and post-operative evaluation of lymph node transplantation.
Methods: A 61 year old female with an 8 year history of left upper extremity lymphedema
following a left axillary dissection for breast cancer management presented to the University of
Florida. The patient's lymphedema was staged as a Campisi III/HCC IIIb. A lymph node
transplantation was performed based on the superficial circumflex iliac vessels in the right groin
and transferred to the left wrist. Pre- and post-operative quantitative clearance
lymphoscintigraphy was performed utilizing Tc-99m sulfur colloid (10% filtered, 1 micron; 90%
unfiltered) injected into the first web space. 5 minute and 24 hour clearance values were
obtained after each injection.
Results:Pre-operative quantitative lymphoscintigraphy demonstrated 18% removal of colloid
from the injection site at 24 hours with slow uptake at the supraclavicular nodes, no identifiable
axillary lymph nodes, severe dermal backflow, and no hepatic clearance. At 3 month follow-up,
repeat injection at the same site 24 hours later revealed visualization of the transplanted nodes,
40% removal of colloid from the injection site, persistent slow uptake at the supraclavicular
nodes, marked improvement in dermal backflow, and the presence of hepatic clearance.
Conclusion:In order to adequately compare procedures and results, surgeons undertaking
physiologic operations for lymphedema must develop standardized techniques to accurately
quantify levels of success or failure. Current methods of quantification such as circumferential
limb measurements and volumetry are user dependent thereby complicating our ability to
compare results between patients, surgeons and institutions. Although our experience is early,
quantitative clearance lymphoscintigraphy appears to be an ideal study that offers confirmation
of lymph node viability, qualitative information regarding lymphatic flow patterns, and objective
lymphatic clearance values.
Figure. Top 2 panels represent pre-operative lymphoscintigraphy demonstrating severe dermal
back flow, slow uptake within the supraclavicular nodes, and 18% clearance. Bottom 2 panels
represent 3 month post-operative lymphoscintigraphy. Visualization of the transplanted nodes,
minimal dermal backflow, hepatic uptake, and 40% clearance are shown.