Dear editor,
Breast cancer-related lymphedema occurs in 9 to 41% of patients, undergoing breast
cancer treatment.[1] Lymphedema significantly impacts an individual's appearance, capacity to perform
activities of daily living, and quality of life. First reported in 1977, lymphaticovenous
anastomosis (LVA) is a minimally invasive surgical treatment for lymphedema.[2]
Lymphatic vessels are identified by injecting indocyanine green through the dorsum
of the hand with the aid of a Photo Dynamic Eye (Hamamatsu Photonics, Japan). The
accurate evaluation of lymph vessels results in a successful surgery without complications.
Venous evaluation is equally important. Small veins are appreciable on ultrasound,
but evaluating the blood vessels is time consuming. Therefore, this study investigated
the utility of VueTek's Veinsite, a non-contact vein visualization system, in mapping
the small veins of upper extremity with lymphedema at a faster rate compared with
ultrasound ([Fig. 1]).
Fig. 1 Veinsite is a high performing, non-contact, vein viewer. Adjust it with the upper
and posterior notches until the appropriate position is met. When you wear the device
on your head, you will be able to see the screen inside the main unit. The screen
shows a visualized image of blood vessels.
The non-contact vein visualization system was developed primarily to facilitate blood
collection in infants. However, veins measuring less than 0.5 mm were difficult to
identify.[3] Veinsite is a high-performance, non-contact, and non-invasive vein visualization
device that uses near-infrared light. It is a portable device, that is worn on the
head, allowing the surgeon to use both hands. This allows for the real-time marking
of identified vessels.
There have only been two case reports on the application of Veinsite in LVA. Both
cases involved lower extremity lymphedema.[4]
[5] In the present study, LVA was performed using Veinsite on seven patients with upper
extremity lymphedema. A total of 15 anastomoses were performed on the forearm, while
seven were performed on the upper arm. All patients developed lymphedema secondary
to breast cancer surgery. The number of small veins identified using Veinsite in a
3 × 3-cm2 area centered at the orthogonal point of the incision line, and the linear patterns
were examined. Veins visible to the naked eye were excluded.
In upper extremity lymphedema, Veinsite easily identified small veins throughout the
forearm and upper arm, with an average of 2.42 veins in the forearm and 2.50 veins
in a 3 × 3-cm2 area of the upper arm ([Fig. 2]). The concordance rate was 100%.
Fig. 2 Lymphaticovenous anastomosis using Veinsite for right upper extremity lymphedema
with breast cancer of the refractory to compression therapy after total mastectomy
and axially dissection. Preoperatively, there was marked edema at the elbow, which
improved postoperatively. (A) Several small veins not visible to the naked eye identified using Veinsite on the
upper arm. (B) Lymphatic vessels identified using indocyanine green fluorescent contrast marked
in purple, and veins identified using Veinsite marked in red. (C) After skin incision, two small veins of 0.3 mm were identified just below the dermis.
Both of them exactly matched the markings using Veinsite. (D) Lymphatic venous anastomosis is performed using the identified veins.
The conventional ultrasonography-guided marking takes approximately 30 minutes. Meanwhile,
Veinsite is easy to use, and it marks a large area within approximately 5 minutes.
This significantly reduces the burden for patients who need to undergo other preoperative
tests, such as the indocyanine green function tests.
However, this study has some limitations. The detectable vein thickness was not determined.
Veins as small as 0.3 mm were identified in the area proximal to the dermis. However,
veins of the same thickness were not appreciated in deeper areas. The detection rate
varied with the depth of the vessels.
Veinsite is an accurate and simple tool for small vein identification. In upper extremity
LVA, it was also useful in determining the incision site and significantly reducing
the time spent on vein identification. Further improvements on this device will improve
the field of supermicrosurgery.
