Algorithmic approach to the lymphatic leak after vascular reconstruction: a systematic review

LVAs in a Pedicled SIEA Flap for the Treatment of Recurrent Lymphocele of the Groin Using Superficial Veins of the Flap for Lymphovenous Anastomosis: A Case Report and Literature Review

Persistent lymphocele of the groin is a complication of groin surgery that can severely impact the quality of life. The restoration of the interrupted lymphatic pathway is considered by many authors the ideal treatment to prevent a recurrence. However, multiple aspiration procedures and surgical revisions can compromise the availability of local veins needed for a lymphovenular bypass surgery. In addition, surgical debridement of a long-standing lymphocele can generate extensive dead space and contour deformity. A flap delivering additional venules for trans-flap lymphovenular anastomoses (LVAs) can overcome both problems by providing soft tissue and competent veins harvested outside the zone of injury. A successful case of severe groin lymphocele treated with trans-flap LVAs from an abdominal-based flap is presented. The patient was referred to us for a recurrent lymphocele developed in the right groin after lipoma excision that persisted despite multiple surgical attempts. After the identification of patent and draining inguinal lymphatic vessels, a pinch test was used to design a mini-abdominoplasty superficial inferior epigastric artery flap. The superficial veins of the cranial incision were identified and anastomosed to the lymphatic vessels after the pedicled flap harvested and insetted in the groin. The early restoration of lymphatic drainage and the optimal aesthetic outcome supports the combined approach offered by trans-flap LVAs as a valuable therapeutic option for severe and persistent lymphocele.

The Role of the Omniflow II Biosynthetic Graft in Postoperative Wound Problems After Lower Limb Revascularization: A Single Center Prospective Registry

OBJECTIVE

To investigate the role of the Omniflow II prosthesis in the prevention of vascular graft infection (VGI) in patients with peripheral arterial disease and to report on short-and mid-term graft-related morbidity.

MATERIAL AND METHODS

Patients were included in prospective registry between October 2019 and March 2023. The primary endpoint was to report infection-related problems, operation-related wound problems, and short- and mid-term graft-related morbidity. Secondary endpoint was to report the bypass patency rates and limb salvage rates.

RESULTS

A total of 146 Omniflow II grafts were implanted in 125 patients. Sixty-seven patients (45.9%) received a femoral interposition graft, and 77 patients (52.7%) underwent ipsilateral bypass surgery (femoropopliteal or femorocrural). Forty-one patients (28.1%) underwent crural bypass surgery. Seventy-six patients (52.1%) had previous vascular operation in the groin. The mean follow-up time was 352 days (range 0-1108 days). 3.4% of the patients suffered a wound infection limited to the dermis, and in 8.2%, the subcutaneous tissue was involved. Five early VGI (3.4%) and one late VGI (0.7%) occurred. One year primary patency rate of above-the-knee bypass was significantly better compared to the bypass below the knee (74.5% ± 0.131 versus 54% ± 0.126 (P = 0.049)). This difference was not significantly different when below-the-knee bypass surgery was compared with crural bypass surgery (54% ± 0.126 versus 23.8% ± 0.080 (P = 0.098)).

CONCLUSIONS

The performance of the Omniflow II prosthesis in the preventive setting is highly influenced by the anatomic location of the distal anastomosis. No influence on the incidence of postoperative wound problems could be observed. The rate of Omniflow II VGI in a high-risk population is similar to reported outcomes in other prosthetic grafts.

Bilateral rectus femoris myocutaneous flaps to salvage exposed axillo-bifemoral graft of bilateral groins

Exposed prosthetic grafts are a challenge to vascular specialists. Groin dissections in vascular surgery can lead to local tissue breakdown, especially in patients who have multiple comorbidities and poor nutritional status. In this report, we describe a patient with exposed prosthetic bypass conduits in the groin region which was successfully covered with bilateral myocutaneous flaps. A 75-year-old Sri Lankan male with diabetes, hypertension and Parkinson's disease presented with bilateral non-healing wound and rest pain for 3 months. Since his premorbid status precluded the aortic cross-clamping and aorto-bifemoral graft, a decision was made to perform a right axillo-bifemoral bypass using a prosthetic graft. Re-operation was required for graft thrombectomy on the same day of surgery. His post-operative period was complicated with lymph leak and surgical site infection of bilateral groin wounds which ultimately led to exposed prosthetic graft which was fortunately patent. After optimizing his nutritional status and comorbidities, he underwent bilateral rectus femoris myocutaneous flaps to cover the soft-tissue defect over the exposed prosthetic grafts. His initial post-operative period was unremarkable except for a small area of skin breakdown. Myocutaneous flaps are preferred as they are more resilient to breakdown compared to facio-cutaneous flaps, especially in a patient with compromised blood supply. The type of loco-regional flap should be carefully selected in an individualized manner depending on the regional vascularity. The rectus femoris flap is a suitable option in terms of ease of surgical technique and durability. Comorbidities and local factors should be optimized prior to definitive reconstruction to maximize the chances for optimal wound healing.

Intranodal Glue Embolization for Postoperative Lymphatic Leaks in the Groin and Pelvis: Comparison with Sclerotherapy

PURPOSE

To compare the effectiveness of and adverse events related to intranodal glue embolization (IGE) with those of intracavitary sclerotherapy for the treatment of postoperative groin and pelvic lymphatic leaks.

MATERIALS AND METHODS

From November 2015 to July 2021, IGE for postoperative pelvic or groin lymphocele or lymphorrhea was performed in 33 patients. From January 2010 to July 2021, 28 patients with postoperative pelvic or groin lymphocele were treated with sclerosis alone. Clinical success was defined as resolution of drainage within 3 weeks of the last intervention performed without recurrence. Patients presenting >1 year after surgery or with <30 days of follow-up were excluded. Patients with lymphorrhea treated with IGE were not statistically compared with those in the sclerosis group because they were not eligible for sclerosis.

RESULTS

Clinical success was similar between the groups (lymphocele IGE, 15/18, 83.3%, vs sclerosis, 15/23, 65.2% [P = .29]; lymphorrhea IGE, 8/9, 88.9%). The mean number of interventions performed to successfully treat a lymphocele was significantly higher in the sclerosis group (2.5 for sclerosis vs 1.3 for IGE; P = .003; lymphorrhea IGE, 1.0). The mean time to resolution was significantly longer for sclerosis than for IGE (27 vs 7 days; P = .002; 4 days for lymphorrhea IGE). There were no sclerosis-related adverse events and 2 IGE-related adverse events: (a) 1 case of mild lymphedema and (b) 1 case of nontarget embolization resulting in deep vein thrombosis.

CONCLUSIONS

For treatment of postoperative pelvic and groin lymphoceles, IGE results in faster resolution with fewer interventions compared with sclerosis. IGE is also an effective treatment for postoperative groin lymphorrhea.