Abstract:

Objective: To investigate the differential efficacy of super-microsurgical lymphaticovenular anastomosis (LVA) for limb lymphedema stratified by International Society of Lymphology (ISL) stage and indocyanine green (ICG) lymphographic Yamamoto pattern, and to provide evidence-based guidance for patient selection. Methods: A retrospective analysis was performed on 32 patients with unilateral limb lymphedema admitted between December 2023 and April 2025. Preoperatively, the patients were classified into ISL stage Ⅰ-Ⅱ (30 cases) and stage Ⅲ (2 cases), and into ICG patterns of splash (6 cases), stardust (14 cases), and diffuse (12 cases). The primary endpoint was percentage reduction of limb volume (%REV) and limb circumferential reduction at 6 months postoperatively; secondary endpoints included anastomotic patency rate, cellulitis recurrence rate, compression garment downgrade rate, and patient satisfaction. One-way ANOVA with Bonferroni correction was used to compare %REV between ISL stages Ⅰ-Ⅱ and different ICG patterns; effect size was calculated with Cohen's d; multi-variate linear regression identified independent predictors of %REV; descriptive analysis was only performed for stage Ⅲ patients. All statistical tests were two-tailed. Results: (1) ISL stratification: the overall %REV of the patients with stages Ⅰ-Ⅱ was 53%±9%, including 63%±8% for stage Ⅰ and 50%±7% for stage Ⅱ; the %REV of the patients with stage Ⅲ was 36%±5% (descriptive result). (2) ICG stratification: %REV was 63%±6% for splash, 56%±7% for stardust, and 36%±4% for diffuse patterns (P < 0.001, d=3.5). (3) A clinically observed trend of efficacy attenuation was found between diffuse pattern and stage Ⅲ (not included in the statistical model under two-tailed test). Anastomotic patency at the end of 1 year was 92.2 %. Cellulitis recurrence decreased from 28.1 % to 0.0 % (P=0.01). Compression garment was downgraded in 26 patients (81.3%), and overall satisfaction reached 96.9%. Conclusion: LVA efficacy was significantly associated with both ISL stage and ICG pattern. The patients with splash pattern or at stage Ⅱ and below could achieve > 55% volume reduction and should be considered the primary indications for LVA. The patients with diffuse pattern or at stage Ⅲ disease might require adjunctive liposuction or vascularized lymph node transfer to improve outcomes. Preoperative evaluation combining ISL staging and ICG lymphography can provide a reliable basis for the selection of LVA surgical indications and the formulation of treatment plans.

Key words: Lymphedema, Super-microsurgery, Lymphaticovenular anastomosis, Indocyanine green pattern, International Society of Lymphology stage