title: Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns.
abstract: BACKGROUND
  Indocyanine green lymphography has been a highly useful modality in the clinical examination and surgical management of patients with lymphedema. No formal classification system of indocyanine green imaging findings according to the severity of lymphedema exists, however. The purpose of this study was to describe, analyze, and classify characteristic indocyanine green lymphography findings to uniformly guide surgical management of lymphedema using this modality.
  
  
  METHODS
  Forty-five patients (78 limbs) with lower extremity lymphedema underwent indocyanine green lymphography. All lymphography images were recorded in photographs and videos. Images were reviewed and analyzed to classify characteristic findings according to clinical severity as determined by Campisi clinical lymphedema staging.
  
  
  RESULTS
  Lymphography findings were classifiable into two patterns. Mild cases of lymphedema were characterized by a linear lymphatic channel pattern (linear pattern). In more severe cases, lymphatic channels demonstrated retrograde lymphatic flow (dermal backflow pattern) and diminution or absence of linear channel patterning. Three dermal backflow patterns, splash, stardust, and diffuse, were identified and correlated with the progression of lymphedema severity. These findings supported the generation of a novel anatomical lymphedema severity staging system, the dermal backflow staging system.
  
  
  CONCLUSIONS
  Indocyanine green lymphography is a safe, minimally invasive, and useful tool for the surgical evaluation of extremity lymphedema. Characteristic indocyanine green lymphography patterns are consistent and correlate with clinical severity. The dermal backflow staging system can facilitate patient stratification, discussion between referring parties, and surgical planning.
authors.affiliation: Tokyo, Japan; and Baltimore, Md. From the Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, and Division of Plastic, Reconstructive, and Maxillofacial Surgery, The Johns Hopkins Hospital.
authors.forename: Takumi
authors.initials: T
authors.lastname: Yamamoto
authors.forename: Mitsunaga
authors.initials: M
authors.lastname: Narushima
authors.forename: Kentaro
authors.initials: K
authors.lastname: Doi
authors.forename: Azusa
authors.initials: A
authors.lastname: Oshima
authors.forename: Fusa
authors.initials: F
authors.lastname: Ogata
authors.forename: Makoto
authors.initials: M
authors.lastname: Mihara
authors.forename: Isao
authors.initials: I
authors.lastname: Koshima
authors.forename: Gerhard S
authors.initials: GS
authors.lastname: Mundinger
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D004396:Coloring Agents; D020405:Dermis; D005260:Female; D006801:Humans; D007208:Indocyanine Green; D035002:Lower Extremity; D042601:Lymphatic Vessels / Q000000981:diagnostic imaging*; D008209:Lymphedema / Q000175:diagnosis*; D008220:Lymphography / Q000379:methods*; D008875:Middle Aged; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012720:Severity of Illness Index; D055815:Young Adult
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green