Lymphovenous Coupler-Assisted Bypass (CAB) for Immediate Lymphatic Reconstruction
Two figures illustrating the preoperative imaging and intraoperative technique for lymphovenous coupler-assisted bypass (CAB). Created for Dr. Laura Tom, Department of Plastic and Reconstructive Surgery, MedStar Washington Hospital Center. In-press in Journal of Reconstructive Microsurgery for publication in September 2023.
Identification and Dissection of Lymphatic and Venous Targets Visual depiction of isolation of lymphatics and venous recipients. (A) Lymphatic visualized with ICG (white star) under near-infrared fluorescent imaging indicates continuity and drainage from the distal hand. (B) This intraoperative view demonstrates a lymphatic that is methylene blue positive and neighboring an appropriate venous recipient. Neighboring veins near branch points offer low-flow conduits for bypass and are the ideal recipient for lymphatic drainage. The serratus branch is an optimal target for lymphovenous bypass as it is often near the transected lymphatics and does not preclude later autologous breast reconstruction. (C) Image of neighboring vein and blue lymphatic in preparation for bypass (D) An anatomic illustration of the veins and lymphatics involved in prophylactic lymphovenous bypass. Named vessels include the following: axillary vein (ax); medial pectoral vein (not pictured) runs on the undersurface of the pectoralis major muscle; lateral thoracic vein (lt) runs of the lateral chest wall; thoracodorsal (td) vein, this vein is found deeper in the axilla generally posterior to the thoracoepigastric vein and anterior to the intercostal brachial nerve, proximally it will branch into the circumflex scapular vein and distally branches into the serratus branch; thoracoepigastric vein (te) sometimes referred to as the accessory vein, runs in a superficial plane that is deep to the clavipectoral fascia.9 (E) Demonstration of functional lymphatic via leakage of blue fluid following transection of lymphatic.
Lymphoveonus Coupler Assisted Bypass (CAB) Technique, Key Steps Critical steps for lymphovenous coupler assisted bypass (CAB) technique. The procedure is presented in Video S1. (A) superimposed cartoon of the lasso stitch, which grasps the adventitia of the target lymphatic and gently pulls the lymphatic into the venous lumen. This is assisted by the coupler device, allowing for precision in implantation. (B) superimposed cartoon of an example final product following CAB. The resulting LVB will involve 2-3 implanted lymphatics into a single vein. Depending on the the equipment used and the surgeon's preference, the coupler can remain or be removed. A fat/soft tissue bolster can be placed to prevent theoretical damage from the coupler spikes and secure the LVB.