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Objectives <p>Lymphatic-venous anastomosis (LVA) is an effective surgical treatment for lymphedema, which requires accurate identification of lymphatic vessels. Indocyanine Green (ICG) lymphography, the most common method for lymphatic mapping, cannot always successfully identify lymphatic vessels. We aimed to explore high-frequency ultrasound (HFUS) and contrast-enhanced ultrasound (CEUS) as a reliable alternative for lymphatic mapping when ICG lymphography is not feasible.</p> Materials and methods <p>We performed combined HFUS and CEUS for lymphatic mapping on the patients who exhibited no obvious linear pattern on ICG lymphography. The inner and outer diameters and depths of the lymphatic vessels were measured. We subsequently evaluated the accuracy of US lymphatic mapping by comparing it with the operative results. And the postoperative volume and circumference of the affected limbs were compared with the preoperative measurements.</p> Results <p>We recruited 111 patients with lymphedema, including 96 limbs and 24 perineal areas affected. Three hundred forty-five lymphatics in the limbs and 52 in the perineum underwent anastomosis and were analyzed. Comparable lymphatic vessel diameter (inner: 0.5–0.9 mm; outer: 0.8–0.9 mm) and depth (9-10 mm) measurements across HFUS, CEUS, and combined HFUS + CEUS. However, HFUS + CEUS significantly improved detection sensitivity, identifying 313 vessels (91.1% accuracy) vs 114 (88.6%) for HFUS and 22 (90.9%) for CEUS. Significant postoperative reductions in limb circumference (39.3 ± 7.4 cm to 37.8 ± 7.1 cm) and volume (8.23 ± 3.63 L to 7.52 ± 3.39 L, <i>p</i> &lt; 0.001). All ultrasound methods consistently showed volume reduction (HFUS: 9.37 ± 2.93 L to 8.46 ± 2.01 L; CEUS: 9.46 ± 2.57 L to 9.09 ± 2.45 L; HFUS + CEUS: 9.30 ± 3.21 L to 8.07 ± 3.12 L, <i>p</i> &lt; 0.001–0.002).</p> Conclusions <p>High-frequency US combined with CEUS serves as a reliable pre-op lymphatic mapping alternative when ICG lymphography fails.</p> Key Points <p><Emphasis Type="BoldItalic">Question</Emphasis><i> In over 40% of lymphedema patients, preoperative ICG lymphangiography fails to show a linear pattern; can HFUS and CEUS provide complementary information?</i></p> <p><Emphasis Type="BoldItalic">Findings</Emphasis><i> ICG failed to visualize in 42.53% of patients; HFUS and CEUS identified lymphatics in all and achieved 94.5% accuracy</i>.</p> <p><Emphasis Type="BoldItalic">Clinical relevance</Emphasis><i> This study confirmed that HFUS combined with CEUS improves the detection of lymphatic vessels and the success of LVA in ICG-negative cases</i>.</p> Graphical Abstract <p></p>

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High-frequency ultrasound combined with microbubbles for preoperative lymphatic mapping for lymphedema with a non-linear pattern in indocyanine green lymphography

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年1月24日

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  • ShuFang Yuan,
  • LiPing Chen,
  • LanJing Wu,
  • ChenYang Zhao,
  • JingJing WEN,
  • Long Biao YU,
  • ZheGang Zhou,
  • DeSheng Sun,
  • ZhengMing Hu

摘要

Objectives

Lymphatic-venous anastomosis (LVA) is an effective surgical treatment for lymphedema, which requires accurate identification of lymphatic vessels. Indocyanine Green (ICG) lymphography, the most common method for lymphatic mapping, cannot always successfully identify lymphatic vessels. We aimed to explore high-frequency ultrasound (HFUS) and contrast-enhanced ultrasound (CEUS) as a reliable alternative for lymphatic mapping when ICG lymphography is not feasible.

Materials and methods

We performed combined HFUS and CEUS for lymphatic mapping on the patients who exhibited no obvious linear pattern on ICG lymphography. The inner and outer diameters and depths of the lymphatic vessels were measured. We subsequently evaluated the accuracy of US lymphatic mapping by comparing it with the operative results. And the postoperative volume and circumference of the affected limbs were compared with the preoperative measurements.

Results

We recruited 111 patients with lymphedema, including 96 limbs and 24 perineal areas affected. Three hundred forty-five lymphatics in the limbs and 52 in the perineum underwent anastomosis and were analyzed. Comparable lymphatic vessel diameter (inner: 0.5–0.9 mm; outer: 0.8–0.9 mm) and depth (9-10 mm) measurements across HFUS, CEUS, and combined HFUS + CEUS. However, HFUS + CEUS significantly improved detection sensitivity, identifying 313 vessels (91.1% accuracy) vs 114 (88.6%) for HFUS and 22 (90.9%) for CEUS. Significant postoperative reductions in limb circumference (39.3 ± 7.4 cm to 37.8 ± 7.1 cm) and volume (8.23 ± 3.63 L to 7.52 ± 3.39 L, p < 0.001). All ultrasound methods consistently showed volume reduction (HFUS: 9.37 ± 2.93 L to 8.46 ± 2.01 L; CEUS: 9.46 ± 2.57 L to 9.09 ± 2.45 L; HFUS + CEUS: 9.30 ± 3.21 L to 8.07 ± 3.12 L, p < 0.001–0.002).

Conclusions

High-frequency US combined with CEUS serves as a reliable pre-op lymphatic mapping alternative when ICG lymphography fails.

Key Points

Question In over 40% of lymphedema patients, preoperative ICG lymphangiography fails to show a linear pattern; can HFUS and CEUS provide complementary information?

Findings ICG failed to visualize in 42.53% of patients; HFUS and CEUS identified lymphatics in all and achieved 94.5% accuracy.

Clinical relevance This study confirmed that HFUS combined with CEUS improves the detection of lymphatic vessels and the success of LVA in ICG-negative cases.

Graphical Abstract