From Failure to Flow: Indocyanine Green Improves Preoperative Mapping for Lymphaticovenular Anastomosis After Negative Contrast-enhanced Ultrasonography

Summary: Accurate identification of functional lymphatic vessels is essential for lymphaticovenular anastomosis (LVA) but it remains challenging. Contrast-enhanced ultrasound (CEUS) is increasingly used for preoperative mapping; however, failure to detect vessels of adequate caliber often leads to deferral of LVA. We report a case where CEUS indicated no suitable lymphatic vessels intraoperatively, yet a high-quality LVA was successfully performed using preoperative indocyanine green (ICG) lymphography–guided exploration. Preoperative ICG mapping revealed limited linear channels and dermal backflow, guiding targeted incisions. Intraoperatively, functional lymphatic vessels and suitable venules (0.3–0.4 mm) were identified despite failed CEUS-guided localization, and end-to-end anastomosis was completed. Postoperatively, maximal interlimb circumference difference decreased from 2.5 to 1.7 cm, with symptomatic relief. This is the first case demonstrating that when CEUS-guided intraoperative localization fails, individualized ICG findings can guide empirical incisions to identify better lymphatic vessels for LVA. A multimodal approach may improve patient outcomes.