淋巴管造影

1207R.S.Dieteretal.(eds.),EndovascularInterventions,DOI10.1007/978-1-4614-7312-1_98,©SpringerScience+BusinessMediaNewYork2014IntroductionThelymphaticsystemiscomplex;itsimagingremainschal-lengingbecauseitlinksdifferentstructurestogetherthatcanbeinvolvedinawidevarietyofcongenital,neoplastic,andinfectiousdiseases[1].Lymphangiographyistheradio-graphicdemonstrationofthelymphaticsystembyinjectionofcontrastmaterial[2].Theearliestattemptsatindirectlymphangiographyweremadebyinjectionofradiopaquematerialintosubcutaneoustissuewithuptakeintheadjacentnodes[3].Directinjectionintolargepalpablenodes,orlymphadenography,wasalsodemonstrated[4].In1955,thetechniqueoflymphangiographywasdevelopedtostudylymphedemaoflowerextremities[5].Giventotheimportantroleoflymphangiographyinlymphaticinterventions,suchasthoracicductembolization[6],aswellasdevelopmentofnewcontrastagentsandimagingtechniquessuchasmag-neticresonance(MR)lymphangiography,contrast-enhancedultrasound,andpositronemissiontomography,thefieldoflymphaticimagingisgrowing[1].Thepurposeofthischap-teristoreviewtheproceduralelementsoftraditionalbipedallymphangiographywithstepwiseillustrationoftheinterven-tionalradiologictechnique.DiagnosticLymphangiographyKhairuddinMemon,RiadSalem,andRonC.Gaba98K.Memon,MD•R.Salem,MD,MBADepartmentofRadiology,SectionofInterventionalRadiology,NorthwesternUniversity,251EastHuronStreet,Chicago,IL60611,USAR.C.Gaba,MD(*)DepartmentofRadiology,InterventionalRadiologySection,UniversityofIllinoisatChicagoMedicalCenter,1740WestTaylorStreet,MC931,Chicago,IL60612,USAContentsIntroduction.................................................................................1207DiagnosticLymphangiography:AnnotatedStep-by-StepInterventionalApproach.....................................1209Discussion.....................................................................................1212References....................................................................................12131208K.Memonetal.CaseA73-year-oldwomanwithahistoryofchroniclympho-cyticleukemiaunderwentchestradiographfordiagnosticevaluationofdyspnea.Theradiographrevealedaleft-sidedpleuraleffusion(Fig.98.1),andultrasound-guidedthoracentesisyieldedmilkywhitefluid(Fig.98.2).Fluidanalysisshowedatriglyceridelevelof909mgperdL,indicatingalymphaticsource.Lymphaticinvasionbytumorwithsecondarychylothoraxwassuspected,andthepatientwasinitiallymanagedwithdietaryfatrestrictionfor3weeks.However,radiographicevaluationdemon-stratednoresolutionofthechylothorax,indicatingfailureofconservativetherapy.Thepatientremainedsymptomaticandwasthereforereferredtointerventionalradiology(IR)forlymphangiographyandpossiblethoracicductembolization.Fig.98.1Frontalchestradiographdemonstratesmoderate-sizedleftpleuraleffusion(arrowheads)Fig.98.2Photographofevacuatedpleuralfluidrevealsmilkywhitecolorcompatiblewithdiagnosisofchylothorax120998DiagnosticLymphangiographyDiagnosticLymphangiography:AnnotatedStep-by-StepInterventionalApproachInjectionofcontrastmaterialforlymphaticimagingcanbeaccomplishedbyfollowingmethods[1]:directendolym-phaticinjectionwherecontrastisinjecteddirectlyintodis-tallylocatedlymphvessels,indirectinterstitialcontrastinjectionwhereitistakenupbythesurroundinglymphves-sels,andindirectintravascularinjectionwherecontrastaccu-mulatesinorgansbelongingtoreticuloendothelialsystemandconsequentlypassesthroughthelymphaticsystem.Herein,wedescribedirectendolymphaticinjection,whichmaybeperformedonanoutpatientbasis[7].1.Bluedyeinjection:Amixtureof3mLof2%lidocaineand2mLofmethylenebluedye(2.5%patentblueVdye;GuerbetLaboratories,Aulnay-sous-BoisFrance)isinjectedintothesubdermaltissuesonthedorsalaspectofthefootbetweenthetoesusinga25-or27-gaugeneedle.Approximately0.1–0.2mLisinjectedperwebspace.2.Lymphaticchannelidentification:Thelymphaticchannelisvisuallyidentifiedalongthedorsumofthefootafteritfillswithdye(Fig.98.3).Thistypicallyoccurs10minafterbluedyeinjection.3.Lymphaticchanneldissection:Alymphaticchannelisselected,andaparallelincisionismade.Theductisexposedusingbluntdissection(Fig.98.4),andfatandlooseareolartissuearestrippedfromthelymphaticchan-nel.Theductispreparedforcannulationbysecuringitwithsutureandadhesivestrips(Fig.98.5).4.Lymphaticchannelcannulation:Thevesseliscannulatedusinga30-gaugeneedle(RabinovSialographyCatheter;CookMedical,BloomingtonIN)(Fig.98.6).Thecath-eterandneedlearesecuredwithadhesivestrips.Ifthefirstcannulationattemptisunsuccessful,amorecentralductupneartheanklemaybechosenandtheprocessrepeated.5.Contrastinjection:Thestandardmaterialusedforlymphangiographyisethiodizedoil(Lipiodol;GuerbetLaboratories,Villepinte,France).Thisoilmayremaininlymphnodesformonthsandsometimesyears,allow-ingonetoevaluatetheeffectsoftreatmentorprogres-sionofthedisease.Afterlymphaticductcannulation,slowintra-lymphaticinjectionofthecontrastagentisperformedusingamechanicalinjector(PHDUltrasyringepump;HarvardApparatus,HollistonMA).Thenormaldoseis6–7mLofcontrastmediuminjectedFig.98.3Photographtaken10minaftersubdermalmethylenebluedyeinjectionbetweenwebspacesoftoe