Patient and Disease Factors Linked to Intraoperative Findings in Lymphaticovenous Anastomosis Surgery for Lymphedema: An International Multicenter Study

Abstract

Background

Lymphaticovenous anastomosis (LVA) is an established microsurgical treatment for lymphedema, but predictors of intraoperative vessel characteristics and immediate anastomosis patency remain unclear. This study investigated associations between preoperative patient and disease factors and intraoperative findings during LVA surgery.

Methods

In this prospective international multicenter study, 183 patients undergoing 426 LVAs were included. Preoperative patient and disease characteristics were recorded. Surgeons documented intraoperative findings using a standardized semiquantitative grading form, assessing lymphatic vessel function and fibrosis, and venous backflow and patency of the immediate anastomosis using intraoperative indocyanine green lymphography (ICG-L). Accuracy of preoperative ICG-L markings was also assessed. Associations between preoperative variables and intraoperative findings were analyzed using cumulative link mixed models and negative binomial regression.

Results

The upper extremity had markedly less lymphatic vessel fibrosis (OR: 10.23, 95% CI: 2.27–45.99, p = 0.002) and greater venous backflow (OR: 0.46 for reduced backflow, 95% CI: 0.22–0.97, p = 0.041). Increased age correlated with more accurate ICG-L markings (OR: 1.04 per year, 95% CI: 1.00–1.08, p = 0.048) and greater surgeon confidence in immediate LVA patency (OR: 1.02 per year, 95% CI: 1.00–1.05, p = 0.028). Prior radical lymph node dissection reduced surgeon confidence in LVA patency (OR: 0.40, 95% CI: 0.16–0.97, p = 0.042). Body mass index (BMI) > 30 showed a trend toward more venous backflow. Increased patient age (IRR: 1.03 per year, 95% CI: 1.00–1.07, p = 0.026) and lower extremity location (upper- vs. lower-extremity IRR: 0.33, 95% CI: 0.11–0.87, p = 0.020) were associated with more preoperative erysipelas infections. Lymphedema stage (0–2b), etiology and duration, gender, and adjuvant therapy had no significant association with intraoperative findings.

Conclusion

This multicenter study identified patient age and lymphedema location as factors associated with intraoperative findings in LVA surgery, including infection frequency, lymphatic vessel fibrosis, venous backflow, and surgeon-reported patency. Lymphedema stage (0–2b), etiology, and duration showed no significant associations.

Trial Registration

ISRCTN registry number: 72662721