Vein Graft-Assisted LVA for Challenging Lymphedema Patient: A Case Report.

Lymphovenous anastomosis (LVA) is a cornerstone of physiologic lymphedema surgery. Its success, however, depends on the presence of a functional lymphatic vessel and a suitable reflux-free recipient vein in close proximity. In some cases, anatomical limitations make direct LVA impossible. In these situations, interposition of a vein graft may bridge the anatomical gap and allow completion of a functional bypass. In this case report, we present a case of a 58-year-old woman with secondary left upper-limb lymphedema following mastectomy, axillary lymphadenectomy, and autologous breast reconstruction. Preoperative indocyanine green (ICG) lymphography showed functional lymphatic channels, and LVA was planned. After an initial unsuccessful attempt on the dorsal wrist, a second incision on the volar forearm revealed a suitable lymphatic vessel and superficial vein, allowing an end-to-end anastomosis. Persistent retrograde lymphatic flow led to the creation of a second bypass using a short autologous vein graft, with an end-to-end anastomosis to the lymphatic vessel and an end-to-side anastomosis to the recipient vein. Intraoperative ICG confirmed that both LVAs were patent. The postoperative course was uneventful. At 1-year follow-up, the patient showed a clear reduction in limb swelling, subjective improvement, and less need for compression garments. This case report adds insight demonstrating that an interposition vein graft can enable successful LVA in anatomically challenging situations where a direct lymphaticovenous connection is not feasible. Vein graft-assisted LVA may expand the applicability of supermicrosurgery for lymphedema, though long-term data and larger series are needed to validate its durability and clinical efficacy.