Association between Residential Distance from Home to Hospital and Amputation of a Lower Extremity among Peripheral Artery Disease Patients in Japan.

Lack of access to care can lead to poor outcomes for patients with peripheral artery disease (PAD). We investigated the association between residential distance from home to hospital and amputation of the lower extremity among PAD patients in the Chiba peninsula, Japan. A retrospective cohort study with an average follow-up period of 2.96 years was conducted using data from 630 PAD patients who visited two hospitals in the Chiba peninsula, Japan, between 1 April 2010 to 31 March 2020. Information on disease status, residential address, and covariates was obtained from medical records. The association between amputation of a lower extremity, including toe amputation, and residential distance was evaluated by Cox proportional hazards model. Age, gender, Fontaine class, endovascular treatment, dialysis, diabetes mellitus, hypertension, dyslipidemia, current or past smoking, and aspirin use were adjusted. The median residential distance was 18.9 km (interquartile range, IQR: 22.1). Ninety-two patients (14.6%) underwent amputation of the lower extremity during the follow-up period. The longer residential distance was significantly associated with a higher risk of lower extremity amputation (hazard ratio per IQR = 1.35, 95% confidence interval, 1.01-1.82) after adjusting for covariates. Poorer access to a hospital, assessed as a longer residential distance from home to a hospital, was associated with amputation of the lower extremity among PAD patients.

Additional Lymphaticovenular Anastomosis on the Posterior Side for Treatment of Primary Lower Extremity Lymphedema.

The efficacy of lymphaticovenular anastomosis (LVA) for the treatment of primary lymphedema has been reported. Previous research suggested the efficacy of LVA on the anterior side of the lower limb, but no research has yet underlined the effectiveness of LVA on the posterior side. In the present study, we aimed to investigate the efficacy of LVA on the posterior side of the lower leg for treatment of primary lymphedema, i.e., whether further improvement of primary lower extremity lymphedema could be expected by performing LVA on the posterior side of the lower limb in addition to the LVA on the anterior side, which is usually performed. Forty-five patients with primary lower extremity lymphedema who underwent LVA twice between March 2018 and September 2020 were retrospectively investigated. Patients were classified into two groups: those who underwent LVA on the posterior side in the second operation (PoLVA group) and those who underwent LVA on the medial and anterior sides again in the second operation (MeLVA group). All patients underwent LVA on the medial and anterior sides in the first operation, but no sufficient improvement was observed. The following factors in the second operation were compared between the two groups: skin incision length, the number of anastomoses, the diameters of the lymphatic vessels, the time required for the dissection of the lymphatic vessels and veins and the reduction in volume. LVA resulted in 227 anastomoses (106 anastomoses in the PoLVA group and 121 anastomoses in the MeLVA group) in 26 patients with primary lymphedema of the lower extremities in two surgeries. The reduction in lower extremity lymphedema index was significantly greater in the PoLVA group than that in the MeLVA group (10.5 ± 4.5 vs. 5.5 ± 3.6; p = 0.008), and the number of anastomoses in the PoLVA group was significantly lower than that in the MeLVA group (3.5 ± 0.6 vs. 4.6 ± 1.0; p = 0.038). LVA on the posterior side subsequent to LVA on the medial and anterior sides resulted in the further improvement of primary lower extremity lymphedema with fewer numbers of anastomoses.

Recent Advances in Ultrasound Technology: Ultra-High Frequency Ultrasound for Reconstructive Supermicrosurgery.

BACKGROUND: Currently, microsurgeons are in the era of supermicrosurgery and perforator flap reconstruction. As these reconstructions frequently utilize vessels that are smaller than a single millimeter, understanding of location of lymphatic vessels and perforator anatomy preoperatively is essential. To change with the times, the role of ultrasound has changed from just an adjunct to primary imaging of the choice in reconstructive supermicrosurgery. Recently, a novel ultrasonographic technique involving the use of ultra-high frequency ultrasound (UHFUS) frequencies has entered the scene, and appears a promising tool in surgical planning. METHODS: The literatures on the applications of UHFUS in reconstructive supermicrosurgery were retrieved and reviewed from more than 60 literatures have been published on the surgical applications of UHFUS. RESULTS: Nine studies were retrieved from the literature on the applications of UHFUS in reconstructive supermicrosurgery. The articles report both application for lymphatic surgery and perforator flaps. CONCLUSION: UHFUS application involves an increasing number of reconstructive supermicrosurgery field. UHFUS is a valuable and powerful tool for any reconstructive surgeons who are interested in performing supermicrosurgery.

Intraoperative Real-Time Visualization of the Lymphatic Vessels Using Microscope-Integrated Laser Tomography.

BACKGROUND: Detection and selection of the lymphatic vessels are important for maximizing therapeutic efficacy of lymphaticovenular anastomosis (LVA). Some imaging modalities have been reported to be useful for intraoperative identification of the lymphatic vessels, but they have limitations. In this article, we present new capabilities of intraoperative laser tomography, which was used to evaluate the lumen of the lymphatic vessel and to validate the patency of anastomosis. METHODS: Fifty-two patients with upper extremity lymphedema secondary to breast cancer treatment underwent indocyanine green (ICG) lymphography and real-time laser tomography imaging of ICG-enhanced lymphatic vessels intraoperatively before transecting the vessels during LVA. The imaging findings of the lymphatic vessels in laser tomography were investigated. Time required for scanning of the lymphatic vessels was compared between laser tomography and ultrasonography. The correlation between the thickness of the lymphatic vessel wall measured with laser tomographic imaging and the histologically measured thickness of the lymphatic vessel wall was examined. The patency of anastomosis sites was determined based on the image using laser tomography immediately after establishment of LVA. RESULTS: A total of 132 ICG-enhanced lymphatic vessels were scanned with laser tomography showing clear lumen with surrounding vessel wall. The required time for lymphatic vessel scanning was significantly shorter with laser tomography than with ultrasonography (1.6 ± 0.3 vs. 4.8 ± 1.2 minutes; p = 0.016). Strong correlation was seen between the thickness of the lymphatic vessels wall measured using laser tomography and the histologically measured thickness of the lymphatic vessel wall (r = 0.977, 95% confidence interval: 0.897-0.992, p < 0.001). The quality of patency was evaluated immediately after anastomosis, which assisted in deciding whether reanastomosis was needed. CONCLUSION: Microscope-integrated laser tomography provides real-time images of the lymphatic vessels in extremely high resolution and enables evaluation of lymphatic lumen condition and objective post-LVA anastomosis status.

Replantation and simultaneous free-flap reconstruction of severely traumatic forefoot amputation: a case report.

We report a successful replantation of a severely damaged and partially amputated foot covered by a simultaneous free flap. Arterial thrombosis occurred at the flap anastomosis, causing partial flap loss, which were resolved through re-anastomosis and skin-grafting. The patient resumed full, unassisted ambulation 10 months after replantation.

Ultra High-frequency Ultrasonographic Imaging with 70 MHz Scanner for Visualization of the Lymphatic Vessels.

BACKGROUND: Identification and localization of functional lymphatic vessels are important for lymphaticovenular anastomosis. Conventional high-frequency ultrasound (CHFUS) has been reported to be useful for them, but it has some disadvantages. In this article, we present new capabilities of ultra high-frequency ultrasound (UHFUS) for imaging of the lymphatic vessels, which may overcome the weakness of CHFUS. METHODS: Thirty unaffected extremities in 30 unilateral secondary lymphedema patients (13 upper limbs and 17 lower limbs) were examined. Identification of the lymphatic vessels using UHFUS and CHFUS were performed at 3 sites in each unaffected extremity. Number and diameter of the detected lymphatic vessels were compared between UHFUS and CHFUS groups. At the same time, new characteristics of the lymphatic vessels seen with UHFUS were investigated. RESULTS: One hundred sixty-nine lymphatic vessels were detected with UHFUS, and 118 lymphatic vessels with CHFUS. The number of lymphatic vessels found in upper and lower extremities was significantly larger with UHFUS than with CHFUS. The diameter of lymphatic vessels found in upper and lower extremities was significantly smaller with UHFUS than with CHFUS. All lymphatic vessels that were detected in UFHUS were less likely to collapse when the transducer was against the skin of the examined sites. CONCLUSIONS: Detection rate of the lymphatic vessels in nonlymphedematous extremities with UHFUS was higher than that with CHFUS. UHFUS provides images with extremely high resolution, demonstrating new characteristics of the lymphatic vessels.

Lymphatic supermicrosurgery for the treatment of recurrent lymphocele and severe lymphorrhea.

BACKGROUND: Lymphocele and lymphorrhea are frequent complications after lymph node excision. Recurrent lymphoceles and intractable lymphorrhea are particularly difficult to treat conservatively. We describe the outcomes of four patients with recurrent lymphocele and nine patients with persistent lymphorrhea that were treated by supermicrosurgery. METHODS: Four patients with recurrent lymphoceles with a size between 7 and 21 cm and located in the groin (n = 1) or upper leg (n = 3), were referred for surgical treatment between 2013 and 2017 after unsuccessful conservative therapy. Nine patients with lymphorrhea from the groin (n = 7), scrotum (n = 1), or axilla (n = 1) after lymph node or lipoma excision were referred for surgical treatment. Of these, five patients presented with a drainage system and two had a lymphocutaneous fistula. Indocyanine green (ICG) lymphography was used to visualize the lymphatic flow toward the lymphocele, to detect ruptured lymph vessels causing lymphorrhea and for preoperative lymphatic mapping. RESULTS: All 13 patients were successfully treated by one or more (mean: 3, range 1-4) lymphaticovenous anastomoses without perioperative complications. The lymphoceles resolved in all four patients, and no recurrence was recorded during follow-up. The lymphorrhea was cured in all patients by means of lymphaticovenous anastomosis performed distal to the site of leakage. No recurrence was observed during follow-up. The patency of the lymphaticovenous anastomosis was confirmed intraoperatively by means of ICG lymphography in all cases. CONCLUSION: Lymphaticovenous anastomosis is a minimally invasive and effective procedure for the treatment of recurrent lymphocele and persistent lymphorrhea.

Effective and efficient lymphaticovenular anastomosis using preoperative ultrasound detection technique of lymphatic vessels in lower extremity lymphedema.

BACKGROUND: Identification of functional lymphatic vessels and localization of lymphatic vessels are important for lymphaticovenular anastomosis (LVA). Indocyanine green (ICG) lymphography is useful for localization of superficial lymphatic vessels where dermal backflow is not observed, but not for lymphatic vessels in deep layer or where dermal backflow is observed. Ultrasound has been applied in LVA and is considered useful for localization of lymphatic vessels with ICG lymphography cannot be visualized. METHODS: Fifty-five secondary lower extremity lymphedema (LEL) patients who underwent LVA were classified into two groups, ultrasound-detection-of-lymphatic group (US group, n = 29) and non-ultrasound-detection-of-lymphatic group (non-US group, n = 26), and assessed. Sensitivity and specificity to detect lymphatic vessel were evaluated in US group. Intraoperative findings, required time for dissecting lymphatic vessels and veins, length of skin incision, and postoperative lymphedematous volume reduction were compared between the groups. RESULTS: Lymphatic vessels were detected in all incisions in both groups. LVA resulted in 232 anastomoses in US group and 210 anastomoses in non-US group. Sensitivity and specificity of ultrasound for detection of lymphatic vessels were 88.2% and 92.7%, respectively. Diameter of lymphatic vessels found in US group was significantly larger than that in non-US group (0.66 ± 0.18 vs 0.45 ± 0.20 mm; P = 0.042). Time required for dissecting lymphatic vessels and veins in US group was shorter than that in non-US group (9.2 ± 1.7 vs 14.7 ± 2.4 min; P = 0.026). LEL index reduction was significantly greater in US group than that in non-US group (26.7 ± 13.6 vs 7.8 ± 11.3; P = 0.031). CONCLUSIONS: Ultrasound-guided detection of lymphatic vessels for lymphedema was performed with high precision, and allows easier and more effective LVA surgery.

Reconstruction of the ankle complex wound with a fabricated superficial circumflex iliac artery chimeric flap including the sartorius muscle: A case report.

Free flap reconstruction of the foot and ankle can be challenging in that it must fulfill functional and esthetic demands. Injury of this region is often associated with fractures, and muscle flaps are sometimes preferred. Here we present a case of the use of superficial circumflex iliac artery (SCIA) chimeric flap for reconstruction of ankle complex wound. A 78-year-old lady sustained open fractures of the left distal tibia, fibula, and talus, with a 10 × 6 cm2 soft-tissue defect over the lateral aspect of her left ankle due to an automobile accident. A 7 × 3 cm2 sartorius muscle component was inset to cover the exposed left ankle joint capsule, and a 5 × 10 cm2 SCIP skin paddle was used for coverage of the defect. The postoperative course was uneventful, and the sartorius muscle component and the SCIP skin paddle survived completely. Six months after the reconstruction, the flap and the donor site showed pleasing cosmesis, and the patient could ambulate with a supple ankle without crutches. The sartorius muscle component was elevated based on the deep branch of the SCIA, and was chimerically combined with a SCIP skin paddle for reconstruction of a complex ankle injury. © 2015 Wiley Periodicals, Inc. Microsurgery 37:421-425, 2017.

Practicality of the Lower Extremity Lymphedema Index: Lymphedema Index Versus Volumetry-Based Evaluations for Body-Type-Corrected Lower Extremity Volume Evaluation.

BACKGROUND: Volume measurement is one of the most commonly used methods for lower extremity lymphedema (LEL) evaluation because of its objectivity. However, volume comparison between different patients with different body types may be inappropriate because body-type difference seems to significantly affect leg volume (LV). METHODS: Twenty-seven nonedematous legs of 27 unilateral LEL patients were evaluated. The LEL index was calculated using circumferences and body mass index (BMI), and LV was calculated using a summed truncated cone model. The BMI of the examinees was classified into 3 groups: low BMI (BMI < 20), middle BMI (BMI, 20-25), and high BMI (BMI > 25). The LEL index, LV, LV divided by body surface area (LV/BSA), and LV divided by BMI (LV/BMI) were compared with the corresponding BMI groups. RESULTS: The mean (SD) LEL index was 218.6 (12.9), and the mean (SD) LV was 4081.3 (835.6) mL. Between the low-, middle-, and high-BMI groups, there were no significant differences in the LEL index [223.2 (11.4), 217.8 (13.3), and 214.6 (14.2), P > 0.5] or in LV/BMI [185.5 (9.2), 179.3 (11.3), and 175.7 (15.8) mL per kg/m, P > 0.3], whereas significant differences were seen in LV [3484.9 (366.0), 3924.4 (342.5), and 5387.7 (1038.4) mL, P < 0.001) and in LV/BSA [2404.3 (236.6), 2539.2 (141.4), and 3106.0 (460.8) mL/m, P < 0.001]. CONCLUSIONS: The LEL index and LV/BMI stayed constant regardless of BMI, whereas LV and LV/BSA significantly increased with increase in BMI. With simplicity of calculation, the LEL index would allow more practical body-type-corrected LV evaluation compared with volumetry-based evaluations.

Arm Volumetry Versus Upper Extremity Lymphedema Index: Validity of Upper Extremity Lymphedema Index for Body-Type Corrected Arm Volume Evaluation.

BACKGROUND: Volumetry, measurement of extremity volume, is a commonly used method for upper extremity lymphedema (UEL) evaluation. However, comparison between different patients with different physiques is difficult with volumetry, because body-type difference greatly affects arm volume. METHODS: Seventy arms of 35 participants who had no history of arm edema or breast cancer were evaluated. Arm volume was calculated using a summed truncated cone model, and UEL index was calculated using circumferences and body mass index (BMI). Examinees' BMI was classified into 3 groups, namely, low BMI (BMI, <20 kg/m), middle BMI (BMI, 20-25 kg/m), and high BMI (BMI, >25 kg/m). Arm volume and UEL index were compared with corresponding BMI groups. RESULTS: Mean (SD) arm volume was 1090.9 (205.5) mL, and UEL index 96.9 (5.6). There were significant differences in arm volume between BMI groups [low BMI vs middle BMI vs high BMI, 945.2 (107.4) vs 1045.2 (87.5) vs 1443.1 (244.4) mL, P < 0.001]. There was no significant difference in UEL index between BMI groups [low BMI vs middle BMI vs high BMI, 97.2 (4.2) vs 96.6 (4.6) vs 96.7 (9.9), P > 0.5]. CONCLUSIONS: Arm volume significantly increased with increase of BMI, whereas UEL index stayed constant regardless of BMI. Upper extremity lymphedema index would allow better body-type corrected arm volume evaluation compared with arm volumetry.

Ultrasound visualization of the lymphatic vessels in the lower leg.

BACKGROUND: Identification of lymphatic vessels for lymphaticovenular anastomosis (LVA), which is an effective surgical treatment for obstructive lymphedema, is important. Indocyanine green (ICG) lymphography is useful for that purpose, but is not common in many institutions. Although ultrasound is a very common modality, no research has yet underlined the feasibility of the device to detect the lymphatic vessels. METHODS: First, identification of lymphatic vessels in the lower legs using ultrasound was performed in non-edematous limbs with linear-pattern on ICG lymphography (n = 12). The imaging findings and characteristic of the lymphatic vessels in ultrasonography were investigated on transverse scans. Second, to assess the ultrasound detection technique, ICG was injected to healthy volunteers after identification and marking of the lymphatic vessels using ultrasound (n = 14). Sensitivity and specificity of the examination were calculated. RESULTS: In the first part, the lymphatic vessels were detected by ultrasound in all cases. Characteristic ultrasonography findings of lymphatic vessels included homogeneous, hypoechoic and spicular misshapen images in all cases. In the second part, the overall sensitivity and specificity were 95.5 and 92.9%, respectively. CONCLUSIONS: Ultrasonography can identify lymphatic vessels of the lower leg with precision and may aid lymphatic microsurgery for lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:397-401, 2016.

Correlation between indocyanine green (ICG) patterns and real-time elastography images in lower extremity lymphedema patients.

BACKGROUND/AIM: Indocyanine green (ICG) lymphography is becoming a popular modality, but unfortunately it is not available in all institutions. Elastography is a relatively new ultrasonographic technique to evaluate tissue elasticity, which visualizes fluid retention as a red region in lymphedema patients. The aim of this study was to evaluate the correlation between elastography and ICG lymphology. METHODS: Thirty-six legs in 18 patients with secondary lower extremity lymphedema (LEL) and 20 legs in 10 healthy volunteers were examined using elastography. Thirty-six legs in 18 secondary LEL patients were examined using ICG lymphography. Elastography was performed on both legs at the following three sites: medial thigh (MT), medial leg (ML), and anterior ankle (AA). The area of the red region in the subcutaneous tissue demonstrated by elastography was calculated using Image software. ICG lymphography findings were classified into the following four patterns: linear (ICG1), splash (ICG2), stardust (ICG3), and diffuse (ICG4) patterns. RESULTS: As ICG pattern progressed, the red region area was likely to increase. There was a correlation between ICG patterns and red region area according to the severity at bilateral MT (rs = 0.665), ML (rs = 0.623), and AA (rs = 0.668). Significant difference was demonstrated among group means of the red region area by analysis of variance (healthy vs. ICG1 vs. ICG2 vs. ICG3 vs. ICG 4: 14.4 ± 5.7 vs. 15.1 ± 10.3 vs. 25.2 ± 6.2 vs. 30.8 ± 9.4 vs. 35.0 ± 2.8; P < 0.001). CONCLUSIONS: The area of the red region in the subcutaneous tissue shown using elastography, which represents fluid, increases with the aggravation of lymphedema demonstrated by ICG patterns. As elastography is performed by ultrasonography, which is available in most institutions, elastography could be a useful alternative evaluation for lymphedema severity when ICG lymphography is not available.