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Vascularized Lymph Node Transfer for Lymphedema: Anatomic Comparison of the Supraclavicular and Thoracodorsal Lymph Node Flaps
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS January 2015
124 Abstracts
Table. Brand comparison of compression pressures, gradients, and prices
Brand A B C D E F
Ankle pressure, mm Hg 23.22 23.86 23.30 25.72 27.74 26.85
6 6 6 6 6 6
0.34 0.29 0.27 0.21 0.32 0.44
Calf pressure, mm Hg 21.21 15.82 13.98 16.38 16.29 16.15
6 6 6 6 6 6
Pressure gradient
0.26 2.01 6 0.22 8.04 6 0.16 9.31 6 0.35 9.34 6 0.22 11.45 6 0.16 10.70 6
0.50a 0.39 0.26 0.40 0.40 0.49
Pressure gradient Price reduction per pair 8%b 34% 40% 36% 41% 40%
$61.80 $63.96 $62.38 $26.04c $62.39 $19.95c
P < .0001 compared with pressure gradient among all brands. P < .001 compared with the pressure gradient reduction among all brands. c P < .001 compared with the price per pair of stockings among all brands. a
b
brands. These results suggest the need for such data to be made available to clinicians so that they may properly advise patients when prescribing this therapy.
Fig 2. Thoracodorsal-based axillary flap (TD) incision design (left) and after flap harvest (right) with pedicle demonstrated (thoracodorsal artery and vein).
Author Disclosures: H. Ma: Nothing to disclose; J. Blebea: Nothing to disclose. Vascularized Lymph Node Transfer for Lymphedema: Anatomic Comparison of the Supraclavicular and Thoracodorsal Lymph Node Flaps C. Pannucci,1 P. A. Gerety,2 M. N. Basta,2 A. R. Wang,2 C. Mies,2 P. Zhang,2 S. K. Kanchwala2. 1University of Utah, Salt Lake City, Utah; 2 University of Pennsylvania, Philadelphia, Pa Objectives: Microvascular transfer of lymph nodes has recently reemerged as a treatment option 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, lymphatic contents, and harvest technique. 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 with Student t-test. Results: Ten SC flaps (Fig 1) and 10 TD flaps (Fig 2) were harvested and quantified. The SC flap pedicle (transverse cervical) had an artery and vein caliber of 3.1 mm and 2.8 mm, with a pedicle length of 3.3 cm. 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); 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. There were no significant differences between the number of nodes noted by the surgeon and the pathologists. Gross and microscopic images (Fig 3) show lymph nodes in the supraclavicular specimen (left) and thoracodorsal specimen (right). Conclusions: The SC flap harvested with a skin island has lower weight than the TD flap and similar number of nodes, 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.
Fig 1. Supraclavicular (SC) flap design (left) and after harvest (right) with pedicle demonstrated (transverse cervical artery and vein).
Fig 3. Gross-micro photos of lymph node specimens. Author Disclosures: C. Pannucci: Nothing to disclose; P. A. Gerety: Nothing to disclose; M. N. Basta: Nothing to disclose; A. R. Wang: Nothing to disclose; C. Mies: Nothing to disclose; P. Zhang: Nothing to disclose; S. K. Kanchwala: Nothing to disclose. The Effect of Obesity on Long-Term Outcomes After UltrasoundGuided Foam Sclerotherapy K. Darvall, H. Davies, G. Bate, A. Bradbury. Birmingham University Department of Vascular Surgery, Solihull, United Kingdom Objectives: The objective of this study was to examine whether body mass index (BMI) affects long-term outcomes, both physician and patient reported (PROMs), after ultrasound-guided foam sclerotherapy (UGFS). Methods: BMI was calculated in 116 consecutive patients undergoing UGFS between April 2005 and September 2006. Patients were reviewed after 5 years and underwent clinical examination and duplex ultrasound and completed quality of life questionnaires. Results: Ninety-five patients (135 legs) attended follow-up (82%). Twenty-nine patients (41 legs) were normal weight (BMI <25); 48 patients (69 legs) were overweight (BMI 25-29.9); 18 patients (25 legs) were obese (BMI >30). More obese patients than normal-weight patients had visible varicose veins at 5 years (56% vs 15%; P < .0005; c2 trend). CEAP C and Venous Clinical Severity Score were worse in overweight and obese patients than in normal-weight patients before treatment (both P < .0005; Jonckheere-Terpstra test) and at 5 years (P ¼ .004 and P ¼ .002, respectively). Mean CEAP C improvement was unaffected by BMI; however, Venous Clinical Severity Score improvement was better in overweight and obese patients (P ¼ .027). Aberdeen Varicose Vein Symptom Severity and 12-Item Short Form Health Survey physical component summary scores were worse in overweight and obese patients before treatment (P ¼ .003 and P ¼ .010, respectively; Jonckheere-Terpstra test); but by 5 years, there were no significant differences across the groups. Mean Aberdeen Varicose Vein Symptom
124 Abstracts
Table. Brand comparison of compression pressures, gradients, and prices
Brand A B C D E F
Ankle pressure, mm Hg 23.22 23.86 23.30 25.72 27.74 26.85
6 6 6 6 6 6
0.34 0.29 0.27 0.21 0.32 0.44
Calf pressure, mm Hg 21.21 15.82 13.98 16.38 16.29 16.15
6 6 6 6 6 6
Pressure gradient
0.26 2.01 6 0.22 8.04 6 0.16 9.31 6 0.35 9.34 6 0.22 11.45 6 0.16 10.70 6
0.50a 0.39 0.26 0.40 0.40 0.49
Pressure gradient Price reduction per pair 8%b 34% 40% 36% 41% 40%
$61.80 $63.96 $62.38 $26.04c $62.39 $19.95c
P < .0001 compared with pressure gradient among all brands. P < .001 compared with the pressure gradient reduction among all brands. c P < .001 compared with the price per pair of stockings among all brands. a
b
brands. These results suggest the need for such data to be made available to clinicians so that they may properly advise patients when prescribing this therapy.
Fig 2. Thoracodorsal-based axillary flap (TD) incision design (left) and after flap harvest (right) with pedicle demonstrated (thoracodorsal artery and vein).
Author Disclosures: H. Ma: Nothing to disclose; J. Blebea: Nothing to disclose. Vascularized Lymph Node Transfer for Lymphedema: Anatomic Comparison of the Supraclavicular and Thoracodorsal Lymph Node Flaps C. Pannucci,1 P. A. Gerety,2 M. N. Basta,2 A. R. Wang,2 C. Mies,2 P. Zhang,2 S. K. Kanchwala2. 1University of Utah, Salt Lake City, Utah; 2 University of Pennsylvania, Philadelphia, Pa Objectives: Microvascular transfer of lymph nodes has recently reemerged as a treatment option 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, lymphatic contents, and harvest technique. 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 with Student t-test. Results: Ten SC flaps (Fig 1) and 10 TD flaps (Fig 2) were harvested and quantified. The SC flap pedicle (transverse cervical) had an artery and vein caliber of 3.1 mm and 2.8 mm, with a pedicle length of 3.3 cm. 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); 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. There were no significant differences between the number of nodes noted by the surgeon and the pathologists. Gross and microscopic images (Fig 3) show lymph nodes in the supraclavicular specimen (left) and thoracodorsal specimen (right). Conclusions: The SC flap harvested with a skin island has lower weight than the TD flap and similar number of nodes, 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.
Fig 1. Supraclavicular (SC) flap design (left) and after harvest (right) with pedicle demonstrated (transverse cervical artery and vein).
Fig 3. Gross-micro photos of lymph node specimens. Author Disclosures: C. Pannucci: Nothing to disclose; P. A. Gerety: Nothing to disclose; M. N. Basta: Nothing to disclose; A. R. Wang: Nothing to disclose; C. Mies: Nothing to disclose; P. Zhang: Nothing to disclose; S. K. Kanchwala: Nothing to disclose. The Effect of Obesity on Long-Term Outcomes After UltrasoundGuided Foam Sclerotherapy K. Darvall, H. Davies, G. Bate, A. Bradbury. Birmingham University Department of Vascular Surgery, Solihull, United Kingdom Objectives: The objective of this study was to examine whether body mass index (BMI) affects long-term outcomes, both physician and patient reported (PROMs), after ultrasound-guided foam sclerotherapy (UGFS). Methods: BMI was calculated in 116 consecutive patients undergoing UGFS between April 2005 and September 2006. Patients were reviewed after 5 years and underwent clinical examination and duplex ultrasound and completed quality of life questionnaires. Results: Ninety-five patients (135 legs) attended follow-up (82%). Twenty-nine patients (41 legs) were normal weight (BMI <25); 48 patients (69 legs) were overweight (BMI 25-29.9); 18 patients (25 legs) were obese (BMI >30). More obese patients than normal-weight patients had visible varicose veins at 5 years (56% vs 15%; P < .0005; c2 trend). CEAP C and Venous Clinical Severity Score were worse in overweight and obese patients than in normal-weight patients before treatment (both P < .0005; Jonckheere-Terpstra test) and at 5 years (P ¼ .004 and P ¼ .002, respectively). Mean CEAP C improvement was unaffected by BMI; however, Venous Clinical Severity Score improvement was better in overweight and obese patients (P ¼ .027). Aberdeen Varicose Vein Symptom Severity and 12-Item Short Form Health Survey physical component summary scores were worse in overweight and obese patients before treatment (P ¼ .003 and P ¼ .010, respectively; Jonckheere-Terpstra test); but by 5 years, there were no significant differences across the groups. Mean Aberdeen Varicose Vein Symptom