• Shuhei Yoshida, Isao Koshima, Hirofumi Imai, Toshio Uchiki, Ayano Sasaki, Yumio Fujioka, Shogo Nagamatsu, Kazunori Yokota, Mitsunobu Harima, Shuji Yamashita, and Kensuke Tashiro.
• International Center for Lymphedema, Hiroshima University, Hiroshima, Japan. Electronic address: syuheiyoshida44@gmail.com.
• J Vasc Surg Venous Lymphat Disord. 2020 Jul 1; 8 (4): 646-657.

ObjectiveWe have previously reported that patients with idiopathic primary lymphedema of adult onset can be classified into an older group with bilateral involvement and a younger group with unilateral involvement and that there are significant differences in the characteristics of these groups. The aims of this study were to investigate the features of these two groups further by evaluating the lymphatics while performing lymphaticovenular anastomosis (LVA) and to compare the effectiveness of LVA between the two groups.MethodsThis study enrolled 74 patients (136 edematous legs) in whom indocyanine green (ICG) lymphography and LVA were performed. The rate of detection and the diameter of the lymphatic vessels were recorded. The lower extremity lymphedema index (the total sum of the squares of the circumference for five areas in each leg divided by the body mass index) was obtained before and 6 months after LVA. The rate of improvement in the affected lower limbs after LVA was also calculated.ResultsThe clinical lymphedema pattern was determined to be bilateral in 62 patients and unilateral in 12. Patients with bilateral lymphedema were significantly older than those with unilateral lymphedema (77.1 ± 7.8 years vs 55.5 ± 12.77 years; P < .01). A linear pattern was seen in 23 patients (46 legs), a low enhancement (LE) pattern in 12 patients (24 legs), a distal dermal backflow (dDB) pattern in 20 patients (40 legs), and an extended dermal backflow (eDB) pattern in 7 patients (14 legs). The lymphedema was unilateral in 12 patients (12 legs). There were significant between-group differences in lymphatic diameter in relation to lower leg area: linear (0.9 ± 0.1 mm) vs dDB (0.7 ± 0.2 mm), linear vs eDB (0.7 ± 0.2 mm), linear vs unilateral (0.5 ± 0.1 mm), LE (0.9 ± 0.2 mm) vs dDB, LE vs eDB, LE vs unilateral, and dDB vs unilateral, P < .01; and eDB vs unilateral, P < .05. There were also significant between-group differences in the rate of improvement in the lower extremity lymphedema index according to the ICG lymphography pattern and laterality: linear (10.5% ± 2.4%) vs unilateral (6.7% ± 0.6%), LE (10.4% ± 1.5%) vs unilateral, dDB (11.0% ± 1.3%) vs eDB (8.9% ± 1.5%), and dDB vs unilateral, P < .01; linear vs eDB, P < .05; and eDB vs unilateral, P < .05.ConclusionsThe lymphatic vessel diameter tended to be greater in older patients with bilateral lymphedema than in younger patients with unilateral lymphedema. The rate of detection and improvement tended to decrease with worsening of the ICG lymphography pattern. LVA is thought to be more effective in older patients with early-stage bilateral lower leg lymphedema than in their younger counterparts with late-stage unilateral lymphedema.Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

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