# Lymphedema Surgical Treatment Using BioBridgeTM: A Preliminary Experience
## 2 Materials and Methods  
This was a retrospective institutional-review-board-approved study, performed following the Helsinki Declaration and its later amendments. We assessed the one-year outcome of three consecutive patients affected by primary LE (Table 1), who have been previously treated conservatively, with a suboptimal response, and without the desired additional improvement in their quality of life. All patients were clinically evaluated before the intervention and at one-year follow-up by clinicians experienced in LE management. Non-contrast MR lymphography was carried out according to our standard protocol using 1.5 Tesla equipment (Magnetom Avantofit, Siemens Medical Systems, Erlangen, Germany) with a lower-limb angiographic coil and an eight-channel phased-array body coil on the lower abdomen, with patients positioned supine feet-first [20] to confirm the diagnosis and assess the LE extent, map the identifiable lymph nodes, and characterize the lymphatic system according to a previously proposed classification [21; 22]. MR acquisition protocol consisted of T2-weighted high-spatial-resolution turbo spin echo with repetition time (TR) 2870 ms, echo time (TE) 797 ms, field of view (FOV) 380 mm \(\times\) 380 mm, matrix 358 \(\times\) 384, slice thickness 1 mm, and a T2-weighted 3D turbo spin echo short tau inversion recovery (STIR) with TR 3000 ms, TE 254 ms, inversion time (TI) 160 m, FOV 460 \(\times\) 504 mm, matrix 315 \(\times\) 384, and slice thickness 1 mm [23]. Indocyanine green fluorescence imaging was used for a pre- and postoperative lymphatic mapping. Patient 1 showed a complex malformation of the central lymphatics in the abdomen at preoperative non-contrast MR lymphography. He was treated with bilateral inguinal venolymphatic anastomosis with concomitant implantation of BioBridgeTM scaffolds. Five BioBridgeTM tracks were created by tunneling the collagen fibers subcutaneously from the site of intact lymphatic collectors (Figure 3), to proximal toward the nearest lymph-node basin, using an ENDO CLOSE Trocar Site Closure Device (Covidien). ENDO CLOSE troxers were used to create subcutaneous tunnels, where the BioBridgeTM scaffolds were pulled. Intra-operative indocyanine green fluorescence lymphography enabled the identification of functioning lymphatic vessels to create anastomoses. Patient 2 underwent a right inguinal vascularized lymph-node transfer, with the harvesting of autologous lymph nodes from the lateral thoracic site, and the creation of 5 tracks of BioBridgeTM by tunneling the scaffolds subcutaneously in the groin, next to the visualized stenotic lymphatic vessels in the ipsilateral groin. Indocyanine green allowed the identification of functioning lymphatics and BioBridgeTM scaffolds were placed to connect them. \begin{table}
\begin{tabular}{c c c c c c c} \hline \hline
**Patient** & **Sex** & **Age** & \begin{tabular}{c} **Lymphedema** \\ **Location** \\ \end{tabular} & \begin{tabular}{c} **Lymphedema** \\ **Duration** \\ \end{tabular} & \
\begin{tabular}{c} **Clinical ISL** \\ **Stage** \\ \end{tabular} &
\begin{tabular}{c} **Surgical Procedure** \\ \end{tabular} \\ \hline
1 & M & 32 & \
\begin{tabular}{c} Lower abdomen, groin, \\ scrotum, and penis \\ \end{tabular} & 8 years & 2 &
\begin{tabular}{c} Bilateral inguinal \\ venolymphatic anastomosis \\ \end{tabular} \\ \hline
\begin{tabular}{c} Left \\ lymph-node transfer, with the \\ harvesting of autologous lymph \\ nodes from the lateral thoracic site \\ \end{tabular} \\ \hline \hline \end{tabular}
\end{table} 
Table 1: Patients included in our study. M = male; F = female; ISL = International Society of Lymphology. The harvesting flap included lymph nodes clustered in the lateral chest wall, to avoid damaging the lymphatic pathway in the axilla, which is responsible for arm drainage, with flap harvest creation from the soft tissue near the lateral thoracic artery and thoracodorsal arteries [24].