Functional Flow-through Vascularized Lymph Node Flap with Two End-to-Side Arterial Anastomoses: A Technical Report

Vascularized lymph node transfer (VLNT) is a reliable treatment for patients with chronic lymphedema. Capillary networks in VLNT are less robust than those in traditional free tissue transfers, possibly contributing to venous congestion when a single arterial and venous anastomosis is performed. This technical report describes a novel operative technique and associated advantages to a functional flow-through VLNT with two end-to-side arterial anastomoses. Six consecutive patients with upper or lower extremity lymphedema received buried supraclavicular or submental VLNT with two end-to-side arterial anastomoses and at least one venous anastomosis. Recipient arteries in the anastomoses were the brachial artery for patients with upper extremity lymphedema (n = 4), and the posterior tibial vasculature in patients with lower extremity lymphedema (n = 2). Five patients simultaneously underwent lymphovenous bypass. Mean patient follow-up was 14 months. Average preoperative Lymphedema Life Impact Score and L-DEX (bioimpedance spectroscopy measurement) were 25 points and 31.4 units, with a mean greatest decrease of 20 points and 9.4 units postoperatively (n = 5). The loop configuration created by flow-through VLNT with two end-to-side arterial anastomoses may reduce pressure gradients within the flap by limiting arterial inflow and thus, mitigate the risk of venous hypertension. Additional benefits of this approach include elimination of mismatch caliber discrepancies often appreciated in end-to-end arterial anastomosis between the lymph node flap and the recipient artery, and preservation of the recipient artery anatomy.