Extremities, Lymph nodes, Interventional vascular, Conventional radiography, Fluoroscopy, CT, Embolisation, Ablation procedures, Technical aspects, Fistula, Outcomes, Trauma
C. M. Sommer1, F. Offensperger1, A. Hatopp1, C. Goerig1, J. Hornung1, T. Hupp1, J. Köninger1, H. U. Kauczor2, G. M. Richter1; 1Stuttgart/DE, 2Heidelberg/DE
Findings and procedure details
Transpedal lymphangiography applying iodized oil as contrast and occlusion material and radiography and CT as imaging modalities is the first-line approach to visualize type (e.g.
lymphopseudoaneurysm or lymphocele),
unifocal or multifocal) and exact location (e.g.
efferent to lymph nodes) of post-operative therapy-refractory lymphatic fistula in the groin region.
The major steps of transpedal lymphangiography - including preparation,
cut-down and iodized oil application - is presented in Figures 2 and 3.
In a considerable number of patients,
transpedal lymphangiography alone is a curative treatment due to blockage of afferent lymph ducts and sterile inflammation processes with subsequent scarring in the location of the pathological iodized oil extravasation (Figures 4-7). According to our clinical experience with more than 500 transpedal lymphangiographies during the last 25 years, cure of lymphatic fistula located at or below the level of the inguinal ligament can be expected after single or repetitive transpedal lymphangiography in approximately 50% of patients within some days or few weeks.
technical success and procedure-related complication rates are approximatelly 90% and <0.5%,
After transpedal lymphangiography,
patent blue at the injection site undergoes resorption within different intervals (Figure 8).
Percutaneous lymphatic second-line interventions:
In case of clinical failure after transpedal lymphangiography,
which should be confirmed not earlier than 2 weeks after transpedal lymphangiography,
percutaneous lymphatic second-line interventions are indicated.
Depending on type,
degree and exact location of the lymphatic fistula,
ultrasound- and/or CT- or cone-beam CT-guided sclerotherapy or embolization of afferent lymph ducts,
pathologic iodized oil extravasation,
and/or the lymphopseudoaneurysm (e.g.
applying ethanol 95% and/or histoacryl/iodized oil mixtures in different ratios) can be performed safely and effectively.
In a substantial number of patients,
these different percutaneous lymphatic second-line interventions can be performed without repeated transpedal lymphangiography (Figures 9 and 10).
different percutaneous lymphatic second-line interventions can be combined with transpedal lymphangiography in a one-stage procedure with the intention to accelerate cure of the lymphatic fistula (Figure 11-13).
According to our current clinical experience,
percutaneous lymphatic second-line interventions increase the clinical success rate of transpedal lymphangiography alone by >25%.
the cure of lymphatic fistula after percutaneous lymphatic second-line interventions can be expected in less time compared with transpedal lymphangiography alone.