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.