Lymphovenous Anastomosis Using Pedicled Deep Inferior Epigastric Perforator Flap Vein for Ulcer With Lymphorrhea: A Case Report

Lymphovenous anastomosis (LVA) is an effective surgical treatment for inguinal lymphorrhea, a complication that can occur after surgery involving vessels. LVA, however, requires a suitable vein for anastomosis near the leaking lymphatic vessel, which is sometimes difficult to secure. Here we report the successful treatment of a refractory ulcer with lymphorrhea by anastomosis of a flap vein to the lymphatic vessel concerned, along with flap closure. The patient was a 26-year-old male who developed a lymphatic leak in the right inguinal region following cannula removal after mechanical circulatory support for fulminant cardiomyopathy. He received conservative therapy but developed an infected femoral artery aneurysm, leading to replacement with the femoral vein. However, because of the persistent, intractable ulcer with exposed graft vessels and continued lymphatic leakage, pedicled flap reconstruction and LVA were planned. A 14 × 6.5 cm spindle-shaped pedicled deep inferior epigastric perforator flap was elevated from the right lower abdomen with branches reserved for use in LVA, rotated 180° through the subcutaneous tunnel, and migrated to the ulcer site. The source of lymphorrhea in the ulcer was identified by indocyanine green (ICG) lymphangiography, and the lymphatic vessels were anastomosed to a branch of the flap pedicle vein. ICG lymphangiography confirmed unimpeded venous flow without the stagnation of lymphatic fluid. At 6 months postoperatively, there was no evidence of ulceration or recurrence of lymphorrhea or lymphedema. In cases of lymphorrhea with refractory ulceration, there often are no suitable veins for LVA in the wound area due to scarring or adhesions. The present case demonstrates the use of a flap pedicle vein to solve this problem, potentially offering a new treatment option for lymphorrhea with extensive ulceration.