Supermicrosurgical deep lymphatic vessel-to-venous anastomosis for a breast cancer-related arm lymphedema with severe sclerosis of superficial lymphatic vessels.

Lymphatic supermicrosurgery or supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming popular for the treatment of compression-refractory upper extremity lymphedema (UEL) with its effectiveness and minimally invasiveness. In conventional LVA, superficial lymphatic vessels are used for anastomosis, but its treatment efficacy would be minimum when superficial lymphatic vessels are severely sclerotic. Theoretically, deep lymphatic vessels can be used for LVA, but no clinical case has been reported regarding deep lymphatic vessel-to-venous anastomosis (D-LVA). We report a breast cancer-related UEL case treated with D-LVA, in which a less-sclerotic deep lymphatic vessel was useful for anastomosis but superficial lymphatic vessels were not due to severe sclerosis. A 62-year-old female suffered from an 18-year history of compression-refractory right UEL after right breast cancer treatments, and underwent LVA under local infiltration anesthesia. Because superficial lymphatic vessels found in surgical fields were all severely sclerotic, a deep lymphatic vessel was dissected at the cubital fossa. A 0.50-mm deep lymphatic vessel running along the brachial artery was supermicrosurgically anastomosed to a nearby 0.40-mm vein. At postoperative 12 months, her right UEL index decreased from 134 to 118, and she could reduce compression frequency from every day to 1-2 days per week to maintain the reduced lymphedematous volume. D-LVA may be a useful option for the treatment of compression-refractory UEL, when superficial lymphatic vessels are severely sclerotic.