Assistant professor Interventional and Musculoskeletal Radiology University Hospitals Cleveland Medical Center Case Western University School of Medicine, United States
Case: Discuss management of difficult-to-treat post-traumatic lymphatic leak of left groin.
Material and Methods: Eighty-Six year old man presenting 4 weeks after resection of metastatic GIST to left pelvis with 14 cm collection within surgical bed , felt to represent lymphatic leak.
Day 1: Intra-nodal access obtained into left groin lymph node with 25G spinal needle using US guidance. Lymphangiogram demonstrates active extravesation into left groin collection, confirmed by aspirating lipiodol contrast via catheter placed into collection at suspected source of leak. Embolization performed via 25G needle using 3:1 lipiodol:NBCA dilution. Note made of abnormal localization of embolic, ultimately realized to be intravascular (left common femoral vein). Embolization stopped at this point. Minimal embolic noted in lymphatic vessels supplying leak. Collection also treated with doxycycline (600 mg, 25mg/mL in 50% Isoview 370) after placing 10 Fr pigtail drain. Doxycycline allowed to dwell 1 hour prior to opening to drainage bag. Patient reported no decrease in fluid volumem ( >500 cc/day, although exact volume uncertain due to significant leakage at catheter entry sites. Left femoral venogram showed patency of the left femoral vein in region of non-target embolization.
Day 3: Repeat Doxycycline sclerotherapy. No decrease in drain outputs. IVUS evaluation of left common femoral vein showed ~50% occlusion of lumen due to previous non-target glue embolization. High grade stenosis immediately central to glue also noted, of uncertain etiology. Patient placed on enoxaparin DVT prophylaxis.
Day9: Repeat doxycycline sclerotherapy as well as foamed STS (4 cc reconstituted 2 cc Isoview 370 and 6 cc room air). No decrease in drain outputs on follow up Day 11.
Day 11: Repeat lymphangiogram with active leak identified in same location. Repeat treatment with 2 cc lipiodol: NBCA 3:1 ratio (Figure).
Results: Drain output nil and dressings dry prior to patient discharge home after 1 hour observation following final embolization Day 11. Lack of persistent drain output or leakage around drains immediately following procedure is encouraging, since persistent ouput was noted following all prior interventions. Short-term follow-up in one week pending. Images of final embolization show NBCA occluding area of active leak and feeding lymphatics (Figure).
Conclusions: Repeat intra-nodal lymphatic embolization may be effective after initial unsuccessful lymphatic embolization and sclerotherapy.
.jpg "Salim Abboud, MD photo")