134. Overcoming The “No Linear, No LVA” Paradigm: Feasibility of Lymphaticovenular Anastomosis Without Indocyanine Green Linear Patterns

PURPOSE: The presence of “linear” indocyanine green lymphography (ICGL) pattern is widely accepted as a prerequisite to successful lymphaticovenular anastomosis (LVA), with its absence considered a contraindication. However, studies have demonstrated that absence of lymphographic patterns does not equate to true anatomic absence of lymph vessels. Given the anatomic parallel between the superficial lymphatic and venous systems, we tested a “follow-the-vein” (FV) approach in performing LVA and evaluated its effectiveness in comparison to the conventional “follow-the-linear” (FL) approach. METHODS: All patients who underwent LVA from January 2020 to December 2023 at Cleveland Clinic were included in the study, with the control group being those who demonstrated “linear” pattern on ICGL and the study group being those who demonstrated its absence. The surgical feasibility and outcomes were evaluated and compared with patient reported outcomes (PRO), surgical times and ICGL. RESULTS: In our study, 98 patients underwent LVA, with 70 treated using the FL approach and 28 using the FV approach. Demographics were comparable. In the FL group, each surgery involved 4.56 incisions and 7.2 anastomoses. The success rate for locating lymphatic channels was 96.2%. The FV group had 5.1 incisions and 8.7 anastomoses per procedure. The success rate for identifying lymphatic channels was 93%. The FV group had significantly more incisions and anastomoses. Surgical times showed no statistical difference between groups. Both groups reported high satisfaction and significant improvements in edema, limb function, pain, and exercise tolerance. PRO improvements were seen in 97.1% of FL and 89.3% of FV cases, with ICGL improvements in 94.3% and 96.4%, respectively. CONCLUSIONS: The absence of a linear pattern in ICGL is not a contraindication for LVA. The “follow-the-vein” method provides a reliable alternative for patients without clear ICGL guidance.