Lymphaticovenular Anastomosis for Advanced-Stage Peripheral Lymphedema: Expanding Indication and Introducing the Hand–Foot Sign

Visconti, et al. J Plast Reconstr Aesthet Surg, 2022.

Key takeaways

• In 76 advanced-stage (ISL 2b or 3) limb lymphedema cases, lymphaticovenular anastomosis (LVA) yielded a positive 1-year composite outcome (a meaningful limb-size reduction and a lower compression class/less use) in 59.7%.

• A negative hand/foot sign (spared dorsal hand/foot edema) predicted functional lymphatics and better outcomes; a positive sign (edema of the dorsal hand/foot) predicted worse outcomes.

• Ultra–high-frequency ultrasound (UHFUS) mapped functional lymphatics when lymphoscintigraphy and ICG showed absent channels, enabling LVA in advanced disease.

• Upper- and lower-limb circumferences significantly decreased at 1 year.

Background

Advanced-stage lymphedema is often managed with vascularized lymph node transfer (VLNT) or debulking because contrast-based mapping can miss functional lymphatics. High- and ultra–high-frequency ultrasound can visualize channels despite dermal backflow, potentially expanding candidacy for LVA.

Objective

Evaluate LVA efficacy in advanced-stage secondary limb lymphedema and introduce a simple clinical predictor (“hand/foot sign”) to identify patients with salvageable functional lymphatics.

Methods

• Design/setting: Multicenter consecutive series (Rome, Italy; Kamogawa, Japan), Jan 2016–Jan 2019.

• Patients: 76 advanced-stage (ISL 2b/3) secondary upper-limb (ULL, n = 47) or lower-limb (LLL, n = 29) lymphedema; refractory to conservative therapy.

• Imaging/mapping: Lymphoscintigraphy and ICG lymphography (all with severe dermal backflow; few/any visible channels) plus UHFUS to localize lymphatics/venules.

• Intervention: LVA (mean 3 anastomoses UE; mean 4 LE).

• Hand/foot sign (index test):

  • Negative (spared): Stemmer sign present, no/minimal pitting on dorsum hand/foot.

  • Positive (not spared): Puffy dorsum with pitting or non-pitting edema.

• Outcomes (1 year): Quantitative—sum of circumferences (SC) change; Qualitative—compression garment class/use; Composite positive if both good–excellent.

Results

• Limb size reduction: ULL SC 143.8 → 133.3 cm; LLL SC 202.7 → 176.5 cm (both p = 0.0001).

• Composite success: 45/76 (59.7%) positive at 1 year.

• Predictive value of hand/foot sign:

  • Negative sign strongly associated with functional lymphatics and larger postoperative SC reductions.

  • Positive sign increased odds of poor–mediocre circumference outcome (OR ~5), need for higher compression (OR ~17), and adverse composite outcome (OR ~17).

  • Intraoperatively, a negative sign corresponded to large, functional s0/s1 lymphatics (>0.6 mm) with good–excellent SC reduction.

Conclusion

Even when dye-based imaging shows no channels, UHFUS can reveal functional lymphatics in advanced-stage lymphedema, enabling effective LVA for many patients; the bedside hand/foot sign helps triage candidates.

Strengths & limitations

• Usage of practical, reproducible clinical sign and modern ultrasound mapping to expand application of LVA in advanced stage patients

• Advanced, homogeneous severity (ISL 2b/3 with dermal backflow V) of patients

• Case-series design without controls; circumference (not volumetry) predominated; postoperative compression was not tightly documented.

Clinical relevance

Do not exclude advanced-stage patients from LVA solely on “negative” dye studies. Use the hand/foot sign at bedside to flag likely functional channels and apply UHFUS-guided mapping to plan LVAs. Expect meaningful limb-size reduction in appropriately selected cases.