Novel Interventional Radiology for the Treatment of Various Lymphatic Leakages: Lymphatic Intervention and Embolization

Abstract

Little progress has been made in modern lymphatic medicine since Dr. Kinmonth first described pedal lymphangiography in the 1950s. The clinical need for an effective treatment modality for managing lymphatic leakage greatly increased only after intranodal lymphangiography, which enabled the depiction of the exact location of the leakage. This review introduces five hypotheses that have been proposed while addressing various clinical scenarios involving lymphatic leakage: (1) various embolization techniques can be used to prevent lymphatic leakage; (2) lymph node embolization can treat postoperative pelvic lymphoceles that are refractory to sclerotherapy; (3) the technical success rate of thoracic duct cannulation can be improved by using retrograde thoracic duct access as a bail-out method; (4) non-traumatic chylothorax can be managed by understanding the underlying pathophysiology; and (5) chylous ascites can be managed by understanding the underlying pathophysiology. Five retrospective observational studies, one randomized prospective clinical trial, and two case reports (letters to the editor) were published after the hypotheses were validated. We provide a new systematic approach to lymphatic intervention by describing the process of the current comprehensive research.

Keywords: Chylous; Lymph; Lymphangiography; Lymphatic system; Therapeutic embolization.

Fig. 1

A 61-year-old male patient underwent Lipiodol lymphangiography for a postoperative lymphocele after radical prostatectomy. (A) A volume rendering image from cone-beam computed tomography data of lymphangiography shows Lipiodol leaking into the lymphocele where a drainage catheter is installed through two bundles of lymphatic vessels (arrow and arrowhead) originating from a complex network of lymph nodes (dashed circle). (B) Only medial bundles of lymphatic vessels (arrowhead) were filled with glue (N-butyl cyanoacrylate: Lipiodol ratio=1:5) when the far most medial inguinal lymph node was accessed and embolized. (C) Glue was confirmed to reach the lateral bundles of lymphatic vessels (arrow) only after accessing the lymph node at a lower level in the digital subtraction angiography performed during glue injection. The drainage catheter could be removed eight days after the embolization.

Fig. 2

A 74-year-old male patient underwent Lipiodol lymphangiography for a persisting postoperative chylothorax (over 300 mL per day, lasting more than a week at medical treatment) after right upper lobectomy with mediastinal lymph node dissection. (A) Cisterna chyli is located behind the aorta, and the segment between the cisterna chyli and the upper part of the thoracic duct is a plexiform variation through which the catheter cannot pass. (B) A micro-guidewire was inserted into the thoracic duct retrogradely by fluoroscopically guided puncture of the cervical segment of the thoracic duct. (C) The lymphatic vessel leading to the right pulmonary hilum is selectively catheterized with a microcatheter, and a glue (N-butyl cyanoacrylate: Lipiodol ratio=1:3) was injected to embolize the vessel super-selectively while keeping the thoracic duct patent. The chylothorax stopped immediately, and the drainage tube could be removed three days after the procedure.

Fig. 3

(A) Non-traumatic chylothorax incidentally discovered on chest radiograph in a 29-year-old male. (B) A thoracic duct embolization was performed at another hospital, and the symptoms aggravated. (C) Dynamic contrast-enhanced Magnetic Resonance Lymphangiography performed at Seoul National University Hospital showed that the thoracic duct (dotted line) was occluded, and the contrast agent leaked into the thoracic cavity (arrowhead) through the collateral lymphatic vessel (arrows) in the retroperitoneal space. After selective lymphatic embolization of the collateral passage, the symptoms improved.

Fig. 4

Three different clinical scenarios of non-traumatic chylothorax in dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL). (A) A 41-year-old female with chylopericardium. Abnormal lymphatic perfusion of mediastinal structures is seen. Thoracic duct embolization successfully resolved the symptom. (B) A 14-year-old male with Noonan syndrome and related chylothorax. The parietal pleural lymphatic structure was enhanced through collateral lymphatic vessels in the body wall. Selective embolization of the collateral lymphatic vessels successfully resolved the symptom. (C) A 50-year-old female with idiopathic chylothorax. Computed tomography examination shows the presence of ascites. DCMRL shows a dilated and tortuous thoracic duct, but there is no clear sign of abnormal pulmonary perfusion. Even after thoracic duct embolization, the symptom was not resolved. The patient underwent pleurodesis to control the symptoms eventually.

Fig. 5

A 52-year-old male with postoperative chylous ascites after partial gastrectomy and lymph node dissection for stomach cancer. (A, B) Lymphangiography showed no leakage of lymph fluid. (C) In balloon-occluded retrograde transcatheter magnetic resonance lymphangiography performed after retrograde thoracic duct cannulation and blockade of drainage of the thoracic duct with a balloon catheter, a contrast agent traveled through the cisterna chyli and then through the mesenteric lymphatic vessel (white arrowheads), which was a reversed flow (dashed arrow line) from the normal lymphatic physiology. It finally leaks from damaged lymphatic vessels and spreads into the abdominal cavity (white arrow). Adapted from the article of Lee et al. (J Vasc Interv Radiol 2021;32:617-619) [28] with original copyright holder’s permission.

Fig. 6

A three-dimensional reconstructed image (A) and a schematic diagram (B) for a drainage tube directly inserted into a lymphocele (asterisk) generated in the retroperitoneal space after damage to the lymphatic system around the aorta. (A) Damaged lymphatic vessels (black arrows) from the thoracic duct (T) and cisterna chyli to the back of the retroperitoneal space, the lymphatic vessels of the peri-aortic retroperitoneal space (white arrow) coming up from the bottom are all connected to the lymphocele (asterisk). (B) After chylous lymphatic fluid (large black arrow) originating from the cisterna chyli (CC) and clear lymph fluid (small black arrow) ascending from the legs and pelvis are all collected to a lymphocele (asterisk) and flow into the abdominal cavity along the defect in the wall of the lymphocele, it becomes chylous ascites (white arrows). Data from the article of Kwon et al. (Korean J Radiol 2021;22:376-383) [31].