Intranodal Lymphangiography

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CXR Thickened septa and large cardiac silhouette.

CT; Perivascular and peribronchial tissue thickening, pericardial effusion.

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Indications

• ​Lymphatic leaks (effusions, ascites).
• CCLA, KLA

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Contraindication

• None absolute.
• Allergies to agents used.
• If right to left shunt, then do not use ethiodized oil for contrast.

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Pre-procedure

• Review cross-sectional imaging.
• Echocardiography if suspected right to left shunt. 

• ​Antibiotics only if embolization is considered
  
  • Cefazolin and metronidazole
  • Alternative clindamycin and gentamicin

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Technique

Supplies

• Needles: 25G hypodermic and 21/22G Chiba needles.
• Short connecting tubes, 10 ml and 3 ml syringes.
• Lipiodol dose: 0.25 ml/kg, not to exceed 10 ml.
• If embolizing, 70 cm Rapid Transit microcatheter, V18 guidewire, microcoils (e.g. 2-3 mm Interlock coils), histoacryl glue (1:1 mixture with lipiodol)

 
Prep

• Consent for lymphangiography, drainage, bilateral upper extremity venography
• Head first supine
• Prep: Bilateral inguinal regions and upper thighs are prepped. The left upper chest and neck are also prepped to allow sonographic evaluation of the terminal portion of the thoracic duct. If there is potential for cannulation of the thoracic duct, the entire abdomen should be prepped
• Remove/reposition catheters over expected location of thoracic duct.

 
Technique

• Connect needle via two short connecting tubes to 3 ml syringe with lipiodol
• Initial snapshot images to cover from neck to upper thighs.

• Using a high-frequency transducer, access inguinal lymph nodes along the long axis bilaterally.  Advance needle to at least the junction of node cortex and medulla. Avoid through and through puncture.
• Stabilize the needles with Steri‐Strip and avoid manipulation of needles once inserted into node.
• Inject lipiodol at a slow rate to avoid extravasation. Average 1 ml every 5-10 minutes.
• Access new node if evidence of extravasation. 
• Intermittent fluoroscopy to confirm progression of contrast. 
• If maximum dose reached or slow transit, then flush with saline. Abdominal massage can also be used to propagate contrast.

• Record abnormal signs: ectasia, reflux, crossing, collateralization, lymphaticovenous shunts, obstruction, leak, slow flow, poor peristalsis of thoracic duct and drainage via the cervical potion. 
• Sonography of terminal portion (usually at venous angle between left internal jugular and subclavian veins) is useful to confirm emptying and identify reflux.

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Complications

• Hypersensitivity reactions
• Oil embolization - usually to lungs. Cerebral embolization is rare in the absence of right to left intra-cardiac shunt

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Thoracic Duct Embolization

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Technique

• Angle image identifier at 15-20 degrees craniocaudal to provide an end-on view.
• 21-gauge Chiba needle advanced into the cisterna chyli or another targeted duct.
• Curving needle can sometimes be helpful in gaining access.
• Consider pre-loading with guidewire.
• If difficulty accessing try different levels (sometimes maceration of thoracic duct may be enough to terminate leak).
• Advance guidewire (typically V18, (Boston Scientific, Natick, MA) ) to cranial portion of thoracic duct to ensure secure access.
• Exchange needle for microcatheter (most commonly Rapid Transit)
• If leak identified, place 1-2 coils in cranial portion of thoracic duct (Interlock, 0.018", (Boston Scientific, Natick, MA)).
• Follow with injection of histoacryl (1;1 with lipiodol). Diluting beyond 1:2 risks venous embolization as polymerization in chyle is slower than in blood.
• Withdraw catheter rapidly while aspirating.

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Complications

• Hematoma
• Bile leak
• Shearing of wire or catheter
• Non-target embolization

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References

• ​Stecker MS, Fan CM. Lymphangiography for Thoracic Duct Interventions. Tech Vasc Interv Radiol. 2016;19(4):277-285. 
• Itkin M, Chen EH. Thoracic duct embolization. Semin Intervent Radiol. 2011;28(2):261-266.
• Chaudry G. Complex Lymphatic Anomalies and Therapeutic Options. Tech Vasc Interv Radiol. 2019;22(4):100632.