The Use of Magnetic Resonance Angiography in Vascularized Groin Lymph Node Transfer: An Anatomic Study

Abstract

Vascularized groin lymph node transfer (VGLNT) has been successfully used to treat lymphedema. However, lack of familiarity with the inguinal node anatomy and concerns regarding donor site morbidity have limited its widespread use. The purpose of this study was to use magnetic resonance angiography (MRA) to clarify the inguinal anatomy and provide a reliable method for identifying the location of the superficial transverse inguinal lymph nodes. In this study MRA was used to evaluate the superficial inguinal lymph nodes in 117 patients. Coordinates of lymph nodes were plotted relative to an axis from the anterior superior iliac spine (ASIS) to the pubic tubercle (PT). The nodes were also plotted relative to the superficial circumflex iliac vein (SCIV) and superficial inferior epigastric vein (SIEV). A total of 1,938 lymph nodes were identified. These lymph nodes were concentrated on one-third the distance from the PT toward the ASIS and 3 cm perpendicularly below this line. About 67% of the superficial inguinal nodes were located within the bifurcation of the SIEV and SCIV. The results from this study provide useful guidelines for locating lymph nodes targeted for VGLNT.

Vascularized Lymph Node Transfer

“…Caplan studied the lymphatic drainage of the great toe in 50 human fetuses and found drainage to these nodes in nine cases. 60 In another study in patents with malignant melanoma of the lower limb, the sentinel node was located in the superolateral zone in 5 percent of the cases. 58 Direct injection studies in adult human cadavers by the current authors revealed that the superolateral nodes were the primary nodes draining the local collectors of the thigh; the latter originate from the watershed area of the posterior thigh.…”

Vascularized Lymph Node Transfer for Treatment of Lymphedema

“…19 Recently, magnetic resonance angiogram imaging has been used to evaluate the location of the transverse superficial inguinal lymph nodes. 22 All nodes were located deep to Scarpa's fascia and the mean distance of the nodes from the anterior superior iliac spine (ASIS) toward the pubic tubercle (PT) was 9.1 cm, and 3.1 cm in a perpendicular axis below that line. About 68% of the superficial inguinal nodes were located within a 3-cm radius of that epicenter, with clustering at the junction of the superficial inferior epigastric and superior circumflex iliac veins (67% within the venous bifurcation).…”

“…This technique, combined with further Doppler confirmation of superficial circumflex vessels and reverse lymphatic mapping using Technetium and indocyanine green, has allowed for 35 successful lymph node transfers without donor site lymphedema. 22 Vessel anastomosis differs in terms of flap choice. In cases where VLNT alone is performed, the superficial circumflex iliac vessels are anastomosed to recipient vessels.…”

Modern Perforator Flap Imaging with High-Resolution Blood Pool MR Angiography

“…Because these procedures are routinely performed on young, often female patients with an increased body mass index, the avoidance of unnecessary radiation exposure is of high importance, especially in those who already have been diagnosed with cancer. Second, high-resolution MR imaging (with similar spatial resolution to that of CT) can be achieved by using contrast agents with longer intravascular retention times, such as gadofosveset trisodium (Ablavar; Lantheus Medical Imaging, North Billerica, Mass) (15). Third, dynamic vascular information can be obtained, if needed, by using time-resolved angiography or other techniques for the assessment of inflow and outflow patterns.…”