Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part II. Classification and Treatment of the Lymphatic Disorders

Lymphatic Embolization for Primary Genital Lymphorrhea and Chylous Reflux-Related Lower Limb Lymphedema

PURPOSE

To evaluate the safety and effectiveness of lymphatic embolization for primary genital lymphorrhea.

MATERIALS AND METHODS

A retrospective analysis was conducted on patients who underwent lymphatic embolization for primary genital lymphorrhea and/or lower limb lymphedema between May 2016 and January 2022 at 3 specialized lymphatic centers. Following radiological evaluation of genital lymphorrhea, affected lymphatic vessels were selectively embolized to occlude abnormal lymphatic flow using a mixture of n-butyl cyanoacrylate glue and ethiodized oil. Clinical success was defined as the cessation of genital lymphorrhea or improvement of lymphedema at 1-month follow-up visit.

RESULTS

Among 11 patients (median age, 27 years; age range, 14-60 years; 10 men) included in this study, 5 had genital lymphorrhea, 1 had lower limb lymphedema, and the other 5 had both. A total of 15 embolization procedures were performed, with a technical success rate of 100%. Clinical success was achieved in 90% of genital lymphorrhea (9/10) and 50% of leg lymphedema (3/6). Three patients underwent additional embolization for recurrent genital lymphorrhea at 9 months after the embolization (n = 1) and for further improvement of leg lymphedema per patients' request (n = 2). A procedure-related adverse event with aggravation of pre-existing condition was reported in 1 patient.

CONCLUSIONS

Lymphatic embolization was effective in the management of primary genital lymphorrhea and associated primary lymphedema in lower limbs.

Interventional Radiology in Management of Postoperative Chylous Ascites

Postoperative chylous ascites is a rare condition that can be caused by abdominal and pelvic surgery. The mortality rate associated with untreated postoperative lymphorrhea is as high as 50%. Conservative management is the primary treatment, and most patients improve. However, some patients continue to exhibit high-volume chylous ascites and need invasive intervention. Many surgical series have shown that the outcomes of patients with chylous ascites were unfavorable. Therefore, the need for minimally invasive interventional radiology procedures, such as intranodal lymphangiography, thoracic duct, lymphatic pseudoaneurysm, lymph node, hepatic lymphatic embolization, and peritoneovenous shunting, is increasing. This review describes the anatomy, physics, and diagnosis related to interventional radiology for postoperative chylous ascites as well as interventional radiology treatment options and strategies for this condition referring to recent literature.

Postoperative lymphatic leakage following laparoscopic totally extraperitoneal inguinal hernia repair: the first case report and review of the literature

PURPOSE

Postoperative lymphatic leakage (PLL) is a rare and poorly understood complication following laparoscopic inguinal hernia repair (LIHR). While seroma is a well-documented postoperative finding, the potential for lymphatic leakage and subsequent lymphatic fistula is frequently overlooked and often misclassified. This report presents a unique case of postoperative lymphocele following Totally Extraperitoneal (TEP) inguinal hernia repair and discusses diagnostic considerations, management strategies, and implications for surgical practice.

METHODS

We report the case of a 56-year-old male who developed a large, symptomatic inguinal lymphocele after undergoing TEP LIHR. Diagnosis was confirmed via magnetic resonance imaging (MRI) and analysis of the drained fluid. Management involved surgical drainage followed by low-dose radiotherapy. A narrative literature review was also performed to identify existing evidence on PLL following LIHR.

RESULTS

The patient developed a significant septated fluid collection (115 × 60 × 50 mm) compressing the bladder, consistent with a lymphocele. Drain output peaked at 350 mL/day. Fractionated low-dose radiotherapy (0.5 Gy × 10 sessions) led to a marked reduction in lymphatic output to <10 mL/day, permitting safe drain removal. At two-month follow-up, the patient remained asymptomatic. A narrative literature search revealed no previously reported cases of PLL following LIHR.

CONCLUSION

To our knowledge, this is the first reported case of lymphocele and lymphatic fistula formation following TEP LIHR. This case highlights the need to recognize lymphatic leakage as a distinct complication. Low-dose radiotherapy appears to be an effective, minimally invasive treatment. Standardized terminology and further research are essential to improve diagnosis and management.

Overcoming therapeutic challenges in a case of refractory chylothorax following blunt abdominal trauma through the utility of cone-beam computed tomography lymphangiography

Chylothorax development following blunt abdominal trauma is a rare event. While low volume chylothoraxes usually improve with conservative treatment, invasive interventions are required in high-volume chylothoraxes with daily drainage exceeding 1000 ml. We report a case of a 14-year-old boy who developed high-volume (>3 L/d) chylothorax on the left side following blunt abdominal trauma. The patient did not respond to conservative treatments. He underwent thoracic duct ligation three times, with percutaneous lymphatic interventions, and percutaneous Lipiodol-glue mixture injections under computed tomography (CT) guidance, but all treatments were unsuccessful. We describe the four-month multidisciplinary challenge in this case that was ultimately successfully treated by surgical ligation of aberrant and/or collateral lymphatics draining from the left abdomen to the left pleural cavity, with the help of the novel cone-beam computed tomography (CBCT) lymphangiography (LAG) technique.

MR Lymphangiography: Congenital Lymphatic Flow Disorders

ABSTRACT

Congenital lymphatic flow disorders collectively refer to a heterogeneous group of diseases that manifest as chylothorax, chylous ascites, intestinal lymphangiectasia, protein-losing enteropathy, and peripheral extremity or genital lymphedema, all in the absence of identifiable injury to the lymphatic system. We have only recently begun to understand congenital lymphatic flow disorders through the ability to image lymph flow dynamically. Intranodal dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) is a crucial technique for imaging lymphatic flow in pediatric patients with congenital lymphatic flow disorders. However, as lymphatic imaging is still a nascent discipline with many uncertainties regarding optimal imaging and treatment, effective patient management requires a comprehensive understanding of imaging techniques, disease pathophysiology, and multidisciplinary treatment approaches. Above all, a fundamental understanding of the physiological lymphatic flow of the central conducting lymphatics is essential for the correct interpretation of DCMRL images. This knowledge helps to avoid unnecessary examinations, erroneous diagnoses, and potentially harmful treatment approaches. This review provides an overview of the methods, advantages, and precautions for interpreting the DCMRL examination, a state-of-the-art lymphatic system imaging technique, and shares various case studies.

Single-Center Experience With Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography for Diagnosing Lymphatic Disorders and Guiding Percutaneous Embolization

BACKGROUND

The pragmatic role of dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) needs to be evaluated and compared across distinct lymphatic disorders. We aimed to evaluate the performance of DCMRL for identifying the underlying causes of lymphatic disorders and to define the potential benefit of DCMRL for planning lymphatic interventions.

METHODS

Patients who underwent DCMRL between August 2017 and July 2022 were included in this retrospective analysis. DCMRL was performed with intranodal injection of a gadolinium-based contrast medium through inguinal lymph nodes under local anesthesia. Technical success of DCMRL and feasibility of percutaneous embolization were assessed based on the lymphatic anatomy visualized by DCMRL. Based on the underlying causes, clinical outcomes were evaluated and compared.

RESULTS

Seventy consecutive patients were included. The indications were traumatic chylothorax (n = 42), traumatic chylous ascites (n = 11), and nontraumatic lymphatic leak (n = 17). The technical success rate of DCMRL was the highest in association with nontraumatic lymphatic disorders (94.1% [16/17]), followed by traumatic chylothorax (92.9% [39/42]) and traumatic chylous ascites (81.8% [9/11]). Thirty-one (47.7%) patients among 65 patients who underwent technically successful DCMRL had feasible anatomy for intervention. Clinical success was achieved in 90.3% (28/31) of patients with feasible anatomy for radiologic intervention, while 62.5% (10/16) of patients with anatomical challenges showed improvement. Most patients with traumatic chylothorax showed improvement (92.9% [39/42]), whereas only 23.5% (4/17) of patients with nontraumatic lymphatic disorders showed clinical improvement.

CONCLUSION

DCMRL can help identify the underlying causes of lymphatic disorders. The performance of DCMRL and clinical outcomes vary based on the underlying cause. The feasibility of lymphatic intervention can be determined using DCMRL, which can help in predicting clinical outcomes.

Appropriate Use Criteria Committees: The professional society role in the development and implementation of Appropriate Use Criteria

Vascular surgeons have the ability to manage and intervene on numerous vascular diseases of both the arterial and venous systems. With the growing number of interventions available as endovascular technology evolves, it is important to determine when a procedure is safely indicated for a vascular surgery patient. Appropriate Use Criteria (AUC) offer synthesized clinical information and practice standards that can aid clinicians in making these management decisions. Professional societies, such as the Society for Vascular Surgery, bring experts in the field together to collaborate and create AUC for various vascular diseases and interventions. It is essential to publish these criteria in peer-reviewed journals, as well as make them available on public websites so the information is available to vascular surgeons and interventionalists from other specialties who also treat patients with vascular disease. Cardiology, interventional radiology, and interventional nephrology are some other specialties that perform procedures for vascular disease, and vascular interventions by nonsurgeon specialists continue to increase. The Society for Vascular Surgery has published AUC on intermittent claudication, carotid disease, and abdominal aneurysm management. These are intended to guide practice, but also have highlighted areas for improvement that would allow for more universal implementation of AUC in vascular patient care across medical specialties. Increased intersocietal participation and perhaps inclusion of government and other payer participation will allow professional society-sponsored AUC to evolve, resulting in coordinated, appropriate care for vascular surgery patients.

MR Lymphangiography in Lymphatic Disorders: Clinical Applications, Institutional Experience, and Practice Development

Lymphatic flow and anatomy can be challenging to study, owing to variable lymphatic anatomy in patients with diverse primary or secondary lymphatic pathologic conditions and the fact that lymphatic imaging is rarely performed in healthy individuals. The primary components of the lymphatic system outside the head and neck are the peripheral, retroperitoneal, mesenteric, hepatic, and pulmonary lymphatic systems and the thoracic duct. Multiple techniques have been developed for imaging components of the lymphatic system over the past century, with trade-offs in spatial, temporal, and contrast resolution; invasiveness; exposure to ionizing radiation; and the ability to obtain information on dynamic lymphatic flow. More recently, dynamic contrast-enhanced (DCE) MR lymphangiography (MRL) has emerged as a valuable tool for imaging both lymphatic flow and anatomy in a variety of congenital and acquired primary or secondary lymphatic disorders. The authors provide a brief overview of lymphatic physiology, anatomy, and imaging techniques. Next, an overview of DCE MRL and the development of an MRL practice and workflow in a hybrid interventional MRI suite incorporating cart-based in-room US is provided, with an emphasis on multidisciplinary collaboration. The spectrum of congenital and acquired lymphatic disorders encountered early in an MRL practice is provided, with emphasis on the diversity of imaging findings and how DCE MRL can aid in diagnosis and treatment of these patients. Methods such as DCE MRL for assessing the hepatic and mesenteric lymphatic systems and emerging technologies that may further expand DCE MRL use such as three-dimensional printing are introduced. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Thoracic Duct Embolization for Treatment of Chyle Leakage After Thyroidectomy and Neck Dissection

OBJECTIVE

This study aimed to evaluate the safety and efficacy of intranodal lymphangiography and thoracic duct embolization (TDE) for chyle leakage (CL) after thyroid surgery.

MATERIALS AND METHODS

Fourteen patients who underwent intranodal lymphangiography and TDE for CL after thyroid surgery were included in this retrospective study. Among the 14 patients, 13 underwent bilateral total thyroidectomy with neck dissection (central compartment neck dissection [CCND], n = 13; left modified radical neck dissection (MRND), n = 11; bilateral MRND, n = 2), and one patient underwent left hemithyroidectomy with CCND. Ten patients (76.9%) had high-output CL (> 500 mL/d). Before the procedure, surgical intervention was attempted in three patients (thoracic duct ligation, n = 1; lymphatic leakage site ligation, n = 2). Lymphangiographic findings, technical and clinical successes, and complications were analyzed. Technical success was defined as the successful embolization of the thoracic duct after access to the lymphatic duct via the transabdominal route. Clinical success was defined as the resolution of CL or surgical drain removal.

RESULTS

On lymphangiography, ethiodized oil leakage near the surgical bed was identified in 12 of 14 patients (85.7%). The technical success rate of TDE was 78.6% (11/14). Transabdominal antegrade access was not feasible due to the inability to visualize the identifiable cisterna chyli or a prominent lumbar lymphatic duct. Among patients who underwent a technically successful TDE, the clinical success rate was 90.1% (10/11). The median time from the procedure to drain removal was 3 days (with a range of 1-13 days) for the 13 patients who underwent surgical drainage. No CL recurrence was observed during the follow-up period (ranging from 2-44 months; median, 8 months). There were no complications, except for one case of chylothorax that developed after TDE.

CONCLUSION

TDE appears to be a safe and effective minimally invasive treatment option for CL after thyroid surgery, with acceptable technical and clinical success rates.

Lymphatic Leakage in Pediatric Heart Transplantation: Early Recognition and Timely Management with Interventional Radiologic and Endoscopic Therapy

Protein-losing enteropathy (PLE) is a severe complication of the Fontan procedure that leads to systemic complications owing to enteric protein loss. Hepatoduodenal lymphatic leakage resulting from increased lymphatic pressure is one such complication. We present the case of a pediatric heart transplant patient who experienced refractory PLE symptoms requiring serial albumin infusions and exhibited lymphatic leakage into the duodenum. Using diagnostic lymphangiography and endoscopy, we identified the affected area and treated it successfully with endoscopic sclerotherapy using ethanolamine injection. This treatment allowed for the cessation of lymphatic fluid and may serve as a potential intervention for PLE-associated hepatoduodenal lymphatic leakage. The present case highlights the importance of early recognition and timely intervention with radiology and endoscopic therapy to manage PLE and its associated complications.