External valvuloplasty for subcutaneous small veins to prevent venous reflux in lymphaticovenular anastomosis for lower extremity lymphedema.

Background: Subcutaneous ecchymosis caused by venous reflux is a preventable complication following lymphaticovenular anastomosis. The authors developed a series of operative procedures to prevent venous reflux. This is probably the first report on valvuloplasty for small subcutaneous veins (diameter, <1 mm).

Methods: A total of 165 anastomoses in 39 limbs were operated on using this novel procedure (study group). Extended vein dissection was performed to ensure inclusion of some venous valves. Venous regurgitation was assessed using a retrograde milking test. When regurgitation was observed at all peripheral branches, external valvuloplasty was performed at the small subcutaneous vein to prevent backflow. The rate of venous reflux was compared with 151 anastomoses in 34 limbs operated on using conventional procedures (control group). Moreover, the amount of volume reduction was compared between the patients with and without venous reflux.

Results: In the study group, the rate of regurgitation was reduced (3.0 percent) by extended vein dissection compared with that in the control group (9.9 percent), whereas the regurgitation ceased completely following external valvuloplasty (0 percent). In addition, postoperative ecchymosis was prevented completely in the study group (8.8 percent in the control group). Perioperative improvement in the lower extremity lymphedema index was significantly different between the patients with and without venous reflux (with venous reflux, 0.0706 ± 0.0742; without venous reflux, 0.0904 ± 0.0614).

Conclusions: The authors' results suggest that these operative procedures could be highly effective in preventing venous reflux. Moreover, venous reflux, if not corrected, leads to worsening of the results. Excellent results were consistently achieved by preventing venous reflux.

Clinical Question/level Of Evidence: Therapeutic, III.