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ASRM #1 Correlation between Indocyanine Green (ICG) Patterns and Real-time Elastography Images in Lower Extremity Lymphedema Patients
Nobuko Hayashi, MD; Takumi Yamamoto, MD; Akitatsu Hayashi, MD; Hidehiko Yoshimatu, MD
Plastic and Reconstructive Surgery, University of Tokyo Hospital, Tokyo, Japan

Background: ICG lymphography is becoming a popular modality with clear visualization of superficial lymph flows, but unfortunately not available in all institutions. Elastography is a relatively new ultrasonographic technique to evaluate tissue elasticity, which visualize fluid retention as a red region in lymphedema patients. The aim of this study was to evaluate the correlation between elastography and ICG lymphology.

Methods: The study was a retrospective observational study. Thirty-six legs in 18 patients with secondary lower extremities lymphedema (LEL) and 20 legs in 10 healthy volunteers were examined with elastography. Thirty-six legs in 18 secondary LEL patients were examined with ICG lymphography. Elastography was performed on both legs at the following 3 sites: medial thigh (MT), medial leg (ML), and anterior ankle (AA). The area of red region in the subcutaneous tissue demonstrated byelastography was calculated with Image J software (National Institute of Health, Bethesda, MD).ICG lymphography findings were classified into the following 4 patterns: linear (ICG1), splash (ICG2), stardust (ICG3), and diffuse (ICG4) patterns.

Results: As ICG pattern progressed, red region area was likely to increase. There was correlation between ICG patterns and red region area according to the severity at bilateral MT (rs = 0.665), ML (rs = 0.623), AA (rs = 0.668). Significant difference was demonstrated among group means of red region area by analysis of variance (healthy vs. ICG1 vs. ICG2 vs. ICG3 vs. ICG 4: 14.4 5.7 vs. 15.1 10.3 vs. 25.2 6.2 vs. 30.8 9.4 vs. 35.0 2.8; P < 0.001).

Conclusions: The area of red region in the subcutaneous tissue shown with elastography, which represents fluid, increases with aggravation of lymphedema demonstrated by ICG patterns. Since elastography is performed by ultrasonography which is available in most institutions, elastography could be a useful alternative evaluation for lymphedema severity when ICG lymphography is not available.

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