Side-to-End Lymphaticovenular Anastomosis through Temporary Lymphatic Expansion

Objective: The number of bypasses is the most important factor in lymphaticovenular anastomosis (LVA) for lymphedema treatment. Side-to-end (S-E) LVA, which can bypass bidirectional lymph flows via one anastomosis, is considered to be the most efficient bypass, but creation of lateral window to a small lymphatic vessel is technically demanding. To overcome the difficulty, we introduced S-E anastomosis through temporary lymphatic expansion (SEATTLE) procedure in S-E LVA. Methods: This was a retrospective observational study set in a teaching hospital. Forty eight lower extremity lymphedema (LEL) patients underwent LVA. S-E LVAs were performed with (SEATTLE group) or without (non-SEATTLE group) temporary lymphatic expansion. S-E LVAs were evaluated to compare anastomosis result in SEATTLE and non-SEATTLE groups. Results: S-E LVAs resulted in 44 anastomoses in SEATTLE group (n = 25) and 37 anastomoses in non-SEATTLE group (n = 23). LEL index reduction in SEATTLE group was significantly greater than that in non-SEATTLE group (16.5±14.5 vs. 10.9±11.8, P = 0.041). Success rate of S-E LVA in SEATTLE group was significantly higher than that in non-SEATTLE group (95.5% vs 81.1%, P = 0.040). Thirty seven of 44 (84.1%) lymph vessels in SEATTLE group were successfully dilated by temporary lymphatic expansion maneuver. All of 9 failed S-E LVAs used a lymphatic vessel with diameter of 0.35 mm or smaller. Conclusions: The SEATTLE procedure facilitates S-E LVA by a simple and easy maneuver. When the diameter of the lymphatic vessel is 0.35 mm or smaller even after the temporary lymphatic expansion maneuver, S-E LVA is not recommended due to relatively high failure rate.