A new severity classification of lower limb secondary lymphedema based on lymphatic pathway defects in an indocyanine green fluorescent lymphography study

Abstract

Most protocols for lymphatic imaging of the lower limb conventionally inject tracer materials only into the interdigital space; however, recent studies indicate that there are four independent lymphatic vessel groups (anteromedial, anterolateral, posteromedial, and posterolateral) in the lower limb. Thus, three additional injection sites are needed for lymphatic imaging of the entire lower limb. We aimed to validate a multiple injection designed protocol and demonstrate its clinical benefits. Overall, 206 lower limbs undergoing indocyanine green fluorescent lymphography with the new injection protocol were registered retrospectively. To assess the influence of predictor variables on the degree of severity, multivariable logistic regression models were used with individual known risk factors. Using a generalized linear model, the area under the curve (AUC) of the conventional clinical model, comprising known severity risk factors, was compared with that of the modified model that included defects in the posterolateral and posteromedial groups. Multivariable logistic regression models showed a significant difference for the posteromedial and posterolateral groups. The AUC of the modified model was significantly improved compared to that of the conventional clinical model. Finding defects in the posteromedial and posterolateral groups is a significant criterion for judging lymphedema severity and introducing a new lymphedema severity classification.

Imaging of the Lymphatic Vessels for Surgical Planning: A Systematic Review

“…Generally, ICG was injected in the interdigital spaces (electronic supplementary Table 5); however, some studies investigated the advantages of multi-lymphosome injections. 72 , 79 , 80 , 96 , 97 Multiple ICG injections are possible due to the low risk, limited toxicity, and absence of radiation exposure concerns. 54 The added value of multi-lymphosome injection lies within the preoperative selection for LVB sites, yielding significantly better postoperative results because more functional lymphatic vessels were detected.…”

“… 72 Additionally, a multi-lymphosome-based severity classification system was proposed but one injection is sufficient for DBF evaluation. 80 , 96 , 97 …”

“…72 Additionally, a multi-lymphosome-based severity classification system was proposed but one injection is sufficient for DBF evaluation. 80,96,97 Magnetic Resonance Lymphography (MRL) MRL provides high-resolution imaging of large body surface areas. It facilitates in choosing the appropriate surgical or conservative treatment used for therapeutic outcome evaluation.…”

Indocyanine Green Lymphography in Conservative Lymphedema Therapy: A Scoping Review

“…Multiple articles used ICG lymphography to observe change in lymphatic drainage to diagnose lymphedema (n = 13) 1,2,38,42,55,64,66,75,76,81,84,85,89. Others identified and described altered lymphatic drainage patterns in limb (n = 13)16,35,39–41,56,61,65,67,68,70,72,83 and breast lymphedema (n = 1)51 for lymphedema diagnosis. One retrospective cohort study described use of ICG lymphography to identify lymphedema of unknown origin and proposed links to age-related change 89.…”

“…Intermittent pneumatic compression (n = 5) was examined in limb and head and neck lymphedema, assessing vessel response and change in flow under device application. 90,91,94,95,103 The effects of manual lymphatic drainage on lymphatic flow, lymphatic uptake, and lymphatic pathways were explored in 6 studies 16,67,68,93,98,100 and 1 large multisite randomized controlled trial 92 with 194 participants, which compared the addition of ICGguided manual lymphatic drainage versus traditional manual lymphatic drainage versus placebo massage to complex decongestive therapy. This study found no additional benefit to limb volume reduction from the addition of any manual lymphatic drainage (ICG-guided or otherwise).…”