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Miyakawa Y, Ihara S, Ishii S, Rui Y, Yajima S, Hayakawa Y, Tsuji Y, Okazaki M, Seto Y, Fujishiro M. First case report of intestinal lymphangiectasia with refractory bleeding from the duodenum, successfully treated by intra-abdominal lymphaticovenous anastomosis with venous ligation. Clin J Gastroenterol 2024:10.1007/s12328-024-02021-x. [PMID: 39017991 DOI: 10.1007/s12328-024-02021-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 07/09/2024] [Indexed: 07/18/2024]
Abstract
Intestinal lymphangiectasia (IL) is a protein-losing enteropathy (PLE) that occasionally leads to gastrointestinal bleeding (GIB). We encountered a 41-year-old female with a 9-year history of duodenal IL with PLE and GIB that progressively worsened. Despite a diet, supplemented with medium-chain triglycerides, antiplasmin therapy, oral corticosteroids, octreotides, sirolimus, and repeated endoscopic hemostasis, her symptoms remained uncontrolled, leading to blood transfusion dependence. Lymphangiography revealed significant leakage from abnormal abdominal lymph vessels into the duodenal lumen. The patient subsequently underwent an abdominal-level lymphaticovenous anastomosis combined with local venous ligation. This approach resulted in a dramatic improvement and sustained resolution of both the PLE and GIB. More than 6 months after surgery, the patient remained free of symptoms and blood transfusion dependence.
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Affiliation(s)
- Yu Miyakawa
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Sozaburo Ihara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-Ku, Tokyo, 113-8655, Japan.
| | - Saaya Ishii
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, The University of Tokyo Hongo, Hongo 7-3-1, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yang Rui
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, The University of Tokyo Hongo, Hongo 7-3-1, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Shoh Yajima
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yoku Hayakawa
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Mutsumi Okazaki
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, The University of Tokyo Hongo, Hongo 7-3-1, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-Ku, Tokyo, 113-8655, Japan
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Smood B, Smith C, Dori Y, Mavroudis CD, Fuller S, Gaynor JW, Maeda K. Lymphatic failure and lymphatic interventions: Knowledge gaps and future directions for a new frontier in congenital heart disease. Semin Pediatr Surg 2024; 33:151426. [PMID: 38820801 PMCID: PMC11229519 DOI: 10.1016/j.sempedsurg.2024.151426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Lymphatic failure is a broad term that describes the lymphatic circulation's inability to adequately transport fluid and solutes out of the interstitium and into the systemic venous circulation, which can result in dysfunction and dysregulation of immune responses, dietary fat absorption, and fluid balance maintenance. Several investigations have recently elucidated the nexus between lymphatic failure and congenital heart disease, and the associated morbidity and mortality is now well-recognized. However, the precise pathophysiology and pathogenesis of lymphatic failure remains poorly understood and relatively understudied, and there are no targeted therapeutics or interventions to reliably prevent its development and progression. Thus, there is growing enthusiasm towards the development and application of novel percutaneous and surgical lymphatic interventions. Moreover, there is consensus that further investigations are needed to delineate the underlying mechanisms of lymphatic failure, which could help identify novel therapeutic targets and develop innovative procedures to improve the overall quality of life and survival of these patients. With these considerations, this review aims to provide an overview of the lymphatic circulation and its vasculature as it relates to current understandings into the pathophysiology and pathogenesis of lymphatic failure in patients with congenital heart disease, while also summarizing strategies for evaluating and managing lymphatic complications, as well as specific areas of interest for future translational and clinical research efforts.
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Affiliation(s)
- Benjamin Smood
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America.
| | - Christopher Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104 United States of America
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104 United States of America
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America; Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Laje P, Dori Y, Smith C, Maeda K. Surgical management of thoracic duct anomalies. Semin Pediatr Surg 2024; 33:151421. [PMID: 38796973 DOI: 10.1016/j.sempedsurg.2024.151421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
The development of new imaging techniques for the study of the central lymphatic system allows us to understand the anatomy and pathophysiology of all the disorders of the thoracic duct. With the help of catheters placed percutaneously in the thoracic duct, we can do now complex operations on the thoracic duct to restore its functionality. Advance imaging, expert percutaneous skills, and expert microsurgical skills are critical to the success of these interventions.
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Affiliation(s)
- Pablo Laje
- Center for Lymphatic Disorders, Children's Hospital of Philadelphia, University of Pennsylvania.
| | - Yoav Dori
- Center for Lymphatic Disorders, Children's Hospital of Philadelphia, University of Pennsylvania
| | - Christopher Smith
- Center for Lymphatic Disorders, Children's Hospital of Philadelphia, University of Pennsylvania
| | - Katsuhide Maeda
- Center for Lymphatic Disorders, Children's Hospital of Philadelphia, University of Pennsylvania
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Garlisi Torales LD, Sempowski BA, Krikorian GL, Woodis KM, Paulissen SM, Smith CL, Sheppard SE. Central conducting lymphatic anomaly: from bench to bedside. J Clin Invest 2024; 134:e172839. [PMID: 38618951 PMCID: PMC11014661 DOI: 10.1172/jci172839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Central conducting lymphatic anomaly (CCLA) is a complex lymphatic anomaly characterized by abnormalities of the central lymphatics and may present with nonimmune fetal hydrops, chylothorax, chylous ascites, or lymphedema. CCLA has historically been difficult to diagnose and treat; however, recent advances in imaging, such as dynamic contrast magnetic resonance lymphangiography, and in genomics, such as deep sequencing and utilization of cell-free DNA, have improved diagnosis and refined both genotype and phenotype. Furthermore, in vitro and in vivo models have confirmed genetic causes of CCLA, defined the underlying pathogenesis, and facilitated personalized medicine to improve outcomes. Basic, translational, and clinical science are essential for a bedside-to-bench and back approach for CCLA.
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Affiliation(s)
- Luciana Daniela Garlisi Torales
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Benjamin A. Sempowski
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Georgia L. Krikorian
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Kristina M. Woodis
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Scott M. Paulissen
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Christopher L. Smith
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah E. Sheppard
- Unit on Vascular Malformations, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
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Jona N, Majdalany BS, Klein AM. Thoracic Duct Occlusion Leading to Intermittent Left Supraclavicular Swelling and Pancreatitis. Laryngoscope 2024; 134:1313-1315. [PMID: 37462348 DOI: 10.1002/lary.30898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 07/04/2023] [Indexed: 02/17/2024]
Abstract
Intermittent left supraclavicular swelling is an uncommon and elusive condition that can lead to extensive diagnostic workups to determine the etiology and treatment. One potential cause is partial, intermittent, or complete thoracic duct occlusion (TDO). We report on a patient who presented with chronic, intermittent left supraclavicular swelling and abdominal pain that was relieved by thoracic duct angioplasty. Thoracic duct occlusion should be included in the differential diagnosis of left supraclavicular swelling. Lymphatic imaging can facilitate the diagnosis and allows for potential percutaneous treatment. Laryngoscope, 134:1313-1315, 2024.
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Affiliation(s)
- Nikitha Jona
- Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Bill S Majdalany
- Department of Radiology, University of Vermont Medical Center, Burlington, Vermont, U.S.A
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Jayathungage Don TD, Safaei S, Maso Talou GD, Russell PS, Phillips ARJ, Reynolds HM. Computational fluid dynamic modeling of the lymphatic system: a review of existing models and future directions. Biomech Model Mechanobiol 2024; 23:3-22. [PMID: 37902894 PMCID: PMC10901951 DOI: 10.1007/s10237-023-01780-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/02/2023] [Indexed: 11/01/2023]
Abstract
Historically, research into the lymphatic system has been overlooked due to both a lack of knowledge and limited recognition of its importance. In the last decade however, lymphatic research has gained substantial momentum and has included the development of a variety of computational models to aid understanding of this complex system. This article reviews existing computational fluid dynamic models of the lymphatics covering each structural component including the initial lymphatics, pre-collecting and collecting vessels, and lymph nodes. This is followed by a summary of limitations and gaps in existing computational models and reasons that development in this field has been hindered to date. Over the next decade, efforts to further characterize lymphatic anatomy and physiology are anticipated to provide key data to further inform and validate lymphatic fluid dynamic models. Development of more comprehensive multiscale- and multi-physics computational models has the potential to significantly enhance the understanding of lymphatic function in both health and disease.
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Affiliation(s)
| | - Soroush Safaei
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Gonzalo D Maso Talou
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Peter S Russell
- School of Biological Sciences, The University of Auckland, Auckland, New Zealand
- Surgical and Translational Research Centre, Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Anthony R J Phillips
- School of Biological Sciences, The University of Auckland, Auckland, New Zealand
- Surgical and Translational Research Centre, Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Hayley M Reynolds
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand.
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Laje P, Dori Y, Smith C, Pinto E, Taha D, Maeda K. Surgical Management of Central Lymphatic Conduction Disorders: A Review. J Pediatr Surg 2024; 59:281-289. [PMID: 37953163 DOI: 10.1016/j.jpedsurg.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023]
Abstract
AIM Recent advances in lymphatic imaging allow understanding the pathophysiology of lymphatic central conduction disorders with great accuracy. This new imaging data is leading to a wide range of novel surgical interventions. We present here the state-of-the-art imaging technology and current spectrum of surgical procedures available for patients with these conditions. METHOD Descriptive report of the newest lymphatic imaging technology and surgical procedures and retrospective review of outcome data. RESULTS There are currently two high-resolution imaging modalities for the central lymphatic system: multi-access dynamic contrast-enhanced MR lymphangiogram (DCMRL) and central lymphangiography (CL). DCMRL is done by accessing percutaneously inguinal and mesenteric lymph nodes and periportal lymphatics vessels. DCMRL provides accurate anatomical and dynamic data on the progression, or lack thereof, of the lymphatic fluid throughout the central lymphatic system. CL is done by placing a catheter percutaneously in the thoracic duct (TD). Pleural effusions are managed by pleurectomy and intraoperative lymphatic glue embolization guided by CL. Anomalies of the TD are managed by TD-to-vein anastomosis and/or ligation of aberrant TD branches. Chylous ascites and organ-specific chylous leaks are managed by intraoperative glue embolization, surgical lymphocutaneous fistulas, and ligation of aberrant peripheral lymphatic channels, among several other procedures. CONCLUSION The surgical management of lymphatic conduction disorders is a new growing field within pediatric general surgery. Pediatric surgeons should be familiar with the newest imaging modalities of the lymphatic system and with the surgical options available for patients with these complex surgical conditions to provide prompt treatment or referral. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Pablo Laje
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA.
| | - Yoav Dori
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Christopher Smith
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Erin Pinto
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Dalal Taha
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Katsuhide Maeda
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
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Grünherz L, Weinzierl A, Puippe GD, von Reibnitz D, Barbon C, Schneider MA, Giovanoli P, Gutschow CA, Lindenblatt N. First-in-human Use of a Microsurgical Robotic System for Central Lymphatic Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5484. [PMID: 38115836 PMCID: PMC10730044 DOI: 10.1097/gox.0000000000005484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/24/2023] [Indexed: 12/21/2023]
Abstract
Advances in the development of robotic systems have recently enabled the use of robotic technology in reconstructive lymphatic surgery. Although the advantages of microsurgical robots must be weighed carefully against the costs, their use may allow for smaller surgical approaches and easier access to anatomically deeper structures or even smaller vessels. We report on a case of a patient with central lymphatic dilation causing abdominal pain and severely reduced physical capacity. Sonography-assisted intranodal injection of indocyanine green allowed for localization of the lymphatic cyst and anastomosis with the left ovarian vein, applying robotic-assisted microsurgery for the first time on the central lymphatic system. Following the successful reconstruction of lymphatic drainage and decompression of the cyst, the patient reported a complete regression of her preoperative symptoms. From a surgical point of view, the Symani Surgical System improved precision and allowed significantly smaller surgical access. Considering the high morbidity and rarity of pathologies of the central lymphatic system, central lymphatic surgery is to date rarely performed. With improved precision and significantly smaller surgical access, robotic-assisted microsurgery has great potential to expand the treatment options for central lymphatic lesions.
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Affiliation(s)
- Lisanne Grünherz
- From the Department of Plastic and Reconstructive Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Andrea Weinzierl
- From the Department of Plastic and Reconstructive Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Gilbert Dominique Puippe
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Donata von Reibnitz
- From the Department of Plastic and Reconstructive Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Carlotta Barbon
- From the Department of Plastic and Reconstructive Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Marcel André Schneider
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- From the Department of Plastic and Reconstructive Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Nicole Lindenblatt
- From the Department of Plastic and Reconstructive Surgery, University Hospital Zurich, Zurich, Switzerland
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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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Xu J, Du Y, Han T, Zhu N, Zhu S. Protein@Cyanine-Based NIR-II Lymphography Enables the Supersensitive Visualization of Lymphedema and Tumor Lymphatic Metastasis. Adv Healthc Mater 2023; 12:e2301051. [PMID: 37264990 DOI: 10.1002/adhm.202301051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/24/2023] [Indexed: 06/03/2023]
Abstract
Visualization of the lymphatic system is clinically indispensable for the diagnosis and/or treatment of lymphatic diseases. Although indocyanine green (ICG) lymphography becomes an alternate imaging modality compared to traditional lymphoscintigraphy, it is still far from ideal due to the insufficient detection depth and low spatiotemporal resolution. Herein, protein@cyanine probes are rationally developed to solve the limitations of the current near-infrared-I (NIR-I) lymphography. The protein@cyanine probes are synthesized following a chlorine-containing dye-labeling strategy based on structure-selectivity (facile covalent binding between the dye and protein with a 1:1 molar ratio). As expected, the probes display exceptional NIR-II imaging ability with much-improved imaging contrast/resolution and controllable pharmacokinetics, superior to the clinical ICG. The protein@cyanine probes locate lymph nodes and delineate lymphatic vessels with super-high sensitivity and signal-to-background ratio, enabling real-time diagnosing lymphatic diseases such as lymphedema and tumor lymphatic metastasis. In particular, the NIR-II lymphography provides an opportunity to discover the disparate morbidity rate of primary lymphedema in different types of mice. Given the fact of lacking clinically transferable NIR-II probes, this work not only provides a promising strategy for enriching of the current library of NIR-II probes, but also promotes the clinical translation of NIR-II lymphography technology.
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Affiliation(s)
- Jiajun Xu
- Joint Laboratory of Opto-Functional Theranostics in Medicine and Chemistry, First Hospital of Jilin University, Changchun, 130021, P. R. China
- State Key Laboratory of Supramolecular Structure and Materials, Center for Supramolecular Chemical Biology, College of Chemistry, Jilin University, Changchun, 130012, P. R. China
| | - Yijing Du
- Joint Laboratory of Opto-Functional Theranostics in Medicine and Chemistry, First Hospital of Jilin University, Changchun, 130021, P. R. China
- State Key Laboratory of Supramolecular Structure and Materials, Center for Supramolecular Chemical Biology, College of Chemistry, Jilin University, Changchun, 130012, P. R. China
| | - Tianyang Han
- Joint Laboratory of Opto-Functional Theranostics in Medicine and Chemistry, First Hospital of Jilin University, Changchun, 130021, P. R. China
- State Key Laboratory of Supramolecular Structure and Materials, Center for Supramolecular Chemical Biology, College of Chemistry, Jilin University, Changchun, 130012, P. R. China
| | - Ningning Zhu
- Joint Laboratory of Opto-Functional Theranostics in Medicine and Chemistry, First Hospital of Jilin University, Changchun, 130021, P. R. China
- State Key Laboratory of Supramolecular Structure and Materials, Center for Supramolecular Chemical Biology, College of Chemistry, Jilin University, Changchun, 130012, P. R. China
| | - Shoujun Zhu
- Joint Laboratory of Opto-Functional Theranostics in Medicine and Chemistry, First Hospital of Jilin University, Changchun, 130021, P. R. China
- State Key Laboratory of Supramolecular Structure and Materials, Center for Supramolecular Chemical Biology, College of Chemistry, Jilin University, Changchun, 130012, P. R. China
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11
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Pieper CC. Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions. Invest Radiol 2023; 58:610-640. [PMID: 37058335 DOI: 10.1097/rli.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
ABSTRACT Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.
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Affiliation(s)
- Claus C Pieper
- From the Division for Minimally Invasive Lymphatic Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn; and Center for Rare Congenital Lymphatic Diseases, Center of Rare Diseases Bonn, Bonn, Germany
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12
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Choe J, Koo HJ, Ahn Y, Lee GD, Yang DH, Kang JW, Lee JE, Shin JH. Evaluation of Chylothorax Using Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography After Lung Cancer Surgery. Lymphat Res Biol 2023; 21:343-350. [PMID: 36880884 DOI: 10.1089/lrb.2022.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Background: To determine the role of dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) in the management of postoperative chylothorax after lung cancer surgery. Methods and Results: Between July 2017 and November 2021, patients who developed postoperative chylothorax following pulmonary resection and mediastinal lymph node dissection were assessed and those who underwent DCMRL for the evaluation of chyle leak were evaluated. The findings of DCMRL and conventional lymphangiography were compared. The incidence of postoperative chylothorax was 0.9% (50/5587). Among the patients with chylothorax, a total of 22 patients (44.0% [22/50]; mean age, 67.6 ± 7.9 years; 15 men) underwent DCMRL. Treatment outcomes were compared between patients with conservative management (n = 10) and those with intervention (n = 12). The patients demonstrated unilateral pleural effusion, ipsilateral to the operation site, and showed right-sided dominance. The most frequent site of thoracic duct injury showing contrast media leakage was visualized at the subcarinal level. No DCMRL-related complication occurred. DCMRL showed comparable performance to conventional lymphangiography in visualizing the central lymphatics, including cisterna chyli (DCMRL vs. conventional lymphangiography, 72.7% vs. 45.5%, p = 0.25) and thoracic duct (90.9% vs. 54.5%, p = 0.13), and in localizing thoracic duct injury (90.9% vs. 54.5%, p = 0.13). On follow-up, the amount of chest tube drainage after lymphatic intervention showed a significant difference over time from that after medical treatment only (p = 0.02). Conclusion: DCMRL can provide detailed information about the leak site and the central lymphatic anatomy in patients with chylothorax after lung cancer surgery. The findings of DCMRL can guide subsequent treatment planning for optimal outcomes.
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Affiliation(s)
- Jooae Choe
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Hyun Jung Koo
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Yura Ahn
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong Hyun Yang
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Joon-Won Kang
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Ja Eun Lee
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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13
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Trivedi A, Reed HO. The lymphatic vasculature in lung function and respiratory disease. Front Med (Lausanne) 2023; 10:1118583. [PMID: 36999077 PMCID: PMC10043242 DOI: 10.3389/fmed.2023.1118583] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/23/2023] [Indexed: 03/18/2023] Open
Abstract
The lymphatic vasculature maintains tissue homeostasis via fluid drainage in the form of lymph and immune surveillance due to migration of leukocytes through the lymphatics to the draining lymph nodes. Lymphatic endothelial cells (LECs) form the lymphatic vessels and lymph node sinuses and are key players in shaping immune responses and tolerance. In the healthy lung, the vast majority of lymphatic vessels are found along the bronchovascular structures, in the interlobular septa, and in the subpleural space. Previous studies in both mice and humans have shown that the lymphatics are necessary for lung function from the neonatal period through adulthood. Furthermore, changes in the lymphatic vasculature are observed in nearly all respiratory diseases in which they have been analyzed. Recent work has pointed to a causative role for lymphatic dysfunction in the initiation and progression of lung disease, indicating that these vessels may be active players in pathologic processes in the lung. However, the mechanisms by which defects in lung lymphatic function are pathogenic are understudied, leaving many unanswered questions. A more comprehensive understanding of the mechanistic role of morphological, functional, and molecular changes in the lung lymphatic endothelium in respiratory diseases is a promising area of research that is likely to lead to novel therapeutic targets. In this review, we will discuss our current knowledge of the structure and function of the lung lymphatics and the role of these vessels in lung homeostasis and respiratory disease.
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Affiliation(s)
- Anjali Trivedi
- Weill Cornell Medical Center, New York, NY, United States
| | - Hasina Outtz Reed
- Weill Cornell Medical Center, New York, NY, United States
- Graduate School of Medical Sciences, Weill Cornell Medicine, New York, NY, United States
- *Correspondence: Hasina Outtz Reed,
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14
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Singhal D, Börner K, Chaikof EL, Detmar M, Hollmén M, Iliff JJ, Itkin M, Makinen T, Oliver G, Padera TP, Quardokus EM, Radtke AJ, Suami H, Weber GM, Rovira II, Muratoglu SC, Galis ZS. Mapping the lymphatic system across body scales and expertise domains: A report from the 2021 National Heart, Lung, and Blood Institute workshop at the Boston Lymphatic Symposium. Front Physiol 2023; 14:1099403. [PMID: 36814475 PMCID: PMC9939837 DOI: 10.3389/fphys.2023.1099403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/20/2023] [Indexed: 02/09/2023] Open
Abstract
Enhancing our understanding of lymphatic anatomy from the microscopic to the anatomical scale is essential to discern how the structure and function of the lymphatic system interacts with different tissues and organs within the body and contributes to health and disease. The knowledge of molecular aspects of the lymphatic network is fundamental to understand the mechanisms of disease progression and prevention. Recent advances in mapping components of the lymphatic system using state of the art single cell technologies, the identification of novel biomarkers, new clinical imaging efforts, and computational tools which attempt to identify connections between these diverse technologies hold the potential to catalyze new strategies to address lymphatic diseases such as lymphedema and lipedema. This manuscript summarizes current knowledge of the lymphatic system and identifies prevailing challenges and opportunities to advance the field of lymphatic research as discussed by the experts in the workshop.
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Affiliation(s)
- Dhruv Singhal
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Katy Börner
- Department of Intelligent Systems Engineering, Luddy School of Informatics, Computing, and Engineering, Indiana University Bloomington, Bloomington, IN, United States
| | - Elliot L. Chaikof
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Michael Detmar
- Institute of Pharmaceutical Sciences, Swiss Federal Institute of Technology (ETH) Zürich, Zürich, Switzerland
| | - Maija Hollmén
- MediCity Research Laboratory, University of Turku, Turku, Finland
| | - Jeffrey J. Iliff
- VISN 20 Mental Illness Research, Education and Clinical Center (MIRECC), VA Puget Sound Healthcare System, Department of Psychiatry and Behavioral Science, Department of Neurology, University of Washington School of Medicine, Seattle, WA, United States
| | - Maxim Itkin
- Center for Lymphatic Imaging and Interventions, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Taija Makinen
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Guillermo Oliver
- Center for Vascular and Developmental Biology, Feinberg School of Medicine, Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL, United States
| | - Timothy P. Padera
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Ellen M. Quardokus
- Department of Intelligent Systems Engineering, Luddy School of Informatics, Computing, and Engineering, Indiana University Bloomington, Bloomington, IN, United States
| | - Andrea J. Radtke
- Lymphocyte Biology Section and Center for Advanced Tissue Imaging, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Hiroo Suami
- Department of Clinical Medicine, Australian Lymphoedema Education, Research and Treatment Centre, Macquarie University, Sydney, NSW, Australia
| | - Griffin M. Weber
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Ilsa I. Rovira
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Selen C. Muratoglu
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Zorina S. Galis
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, United States
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15
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Harris NR, Bálint L, Dy DM, Nielsen NR, Méndez HG, Aghajanian A, Caron KM. The ebb and flow of cardiac lymphatics: a tidal wave of new discoveries. Physiol Rev 2023; 103:391-432. [PMID: 35953269 PMCID: PMC9576179 DOI: 10.1152/physrev.00052.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 06/16/2022] [Accepted: 07/18/2022] [Indexed: 12/16/2022] Open
Abstract
The heart is imbued with a vast lymphatic network that is responsible for fluid homeostasis and immune cell trafficking. Disturbances in the forces that regulate microvascular fluid movement can result in myocardial edema, which has profibrotic and proinflammatory consequences and contributes to cardiovascular dysfunction. This review explores the complex relationship between cardiac lymphatics, myocardial edema, and cardiac disease. It covers the revised paradigm of microvascular forces and fluid movement around the capillary as well as the arsenal of preclinical tools and animal models used to model myocardial edema and cardiac disease. Clinical studies of myocardial edema and their prognostic significance are examined in parallel to the recent elegant animal studies discerning the pathophysiological role and therapeutic potential of cardiac lymphatics in different cardiovascular disease models. This review highlights the outstanding questions of interest to both basic scientists and clinicians regarding the roles of cardiac lymphatics in health and disease.
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Affiliation(s)
- Natalie R Harris
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - László Bálint
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Danielle M Dy
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Natalie R Nielsen
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hernán G Méndez
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Amir Aghajanian
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kathleen M Caron
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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16
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de Lange C, Möller T, Hebelka H. Fontan-associated liver disease: Diagnosis, surveillance, and management. Front Pediatr 2023; 11:1100514. [PMID: 36937979 PMCID: PMC10020358 DOI: 10.3389/fped.2023.1100514] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
The Fontan operation is a lifesaving procedure for patients with functional single-ventricle congenital heart disease, where hypoplastic left heart syndrome is the most frequent anomaly. Hemodynamic changes following Fontan circulation creation are now increasingly recognized to cause multiorgan affection, where the development of a chronic liver disease, Fontan-associated liver disease (FALD), is one of the most important morbidities. Virtually, all patients with a Fontan circulation develop liver congestion, resulting in fibrosis and cirrhosis, and most patients experience childhood onset. FALD is a distinctive type of congestive hepatopathy, and its pathogenesis is thought to be a multifactorial process driven by increased nonpulsatile central venous pressure and decreased cardiac output, both of which are inherent in the Fontan circulation. In the advanced stage of liver injury, complications of portal hypertension often occur, and there is a risk of developing secondary liver cancer, reported at young age. However, FALD develops with few clinical symptoms, a surprisingly variable degree of severity in liver disease, and with little relation to poor cardiac function. The disease mechanisms and modifying factors of its development are still not fully understood. As one of the more important noncardiac complications of the Fontan circulation, FALD needs to be diagnosed in a timely manner with a structured monitoring scheme of disease development, early detection of malignancy, and determination of the optimal time point for transplantation. There is also a clear need for consensus on the best surveillance strategy for FALD. In this regard, imaging plays an important role together with clinical scoring systems, biochemical workups, and histology. Patients operated on with a Fontan circulation are generally followed up in cardiology units. Ultimately, the resulting multiorgan affection requires a multidisciplinary team of healthcare personnel to address the different organ complications. This article discusses the current concepts, diagnosis, and management of FALD, with special emphasis on the role of different imaging techniques in the diagnosis and monitoring of disease progression, as well as current recommendations for liver disease surveillance.
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Affiliation(s)
- Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas Möller
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hanna Hebelka
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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17
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Thoracic Duct Lymphovenous Bypass: A Preliminary Case Series, Surgical Techniques, and Expected Physiologic Outcomes. Plast Reconstr Surg Glob Open 2022; 10:e4695. [PMID: 36530853 PMCID: PMC9746772 DOI: 10.1097/gox.0000000000004695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/29/2022] [Indexed: 12/15/2022]
Abstract
In patients with recalcitrant mechanical thoracic duct obstruction, microsurgical lymphovenous bypass is an emerging therapeutic option. We herein discuss the preoperative workup, share our current operative technique, and evaluate preliminary outcomes with an emphasis on changes in physiology. Methods A retrospective review of adult patients who underwent thoracic duct lymphovenous bypass by a single surgeon and interventional radiologist from 2019 to 2022 was performed. Demographics, comorbidities, perioperative data, and postoperative outcomes were collected. Results Nine patients were included in the study. Immediate postoperative heart rate increased significantly among this heterogeneous patient population, but within 4-6 hours the change in heart rate was no longer significant. Mean arterial pressure and oxygen requirement were not significantly different before and after bypass. Conclusions Thoracic duct lymphovenous bypass seem to be well tolerated in the short-term even in patients with cardiopulmonary comorbidities. Further data are necessary to continue to better understand the resulting physiologic changes and to optimize patient outcomes.
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18
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Crawford D, Guevara CJ, Kim SK. Thoracic Duct Embolization Using Transabdominal Antegrade and Transcervical Retrograde Accesses. J Vasc Interv Radiol 2022; 33:1536-1541. [PMID: 36028207 DOI: 10.1016/j.jvir.2022.08.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/25/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To evaluate the technical success and clinical outcomes of thoracic duct embolization (TDE) using transabdominal antegrade and transcervical retrograde accesses to treat patients with chyle leak. MATERIALS AND METHODS This study was a retrospective, nonblinded, single-institution chart review of all patients aged 18 years or older over a 6-year time frame who underwent lymphangiography with attempted TDE for iatrogenic or spontaneous chyle leaks using transabdominal antegrade and/or transcervical retrograde accesses. RESULTS Ninety-nine patients underwent 113 procedures. Eighty-five patients underwent 1 procedure, and 14 patients required 2 procedures. The technical success rate of TDE was 68% (72/106) with transabdominal antegrade access and 44% (15/34) with transcervical retrograde access. The overall technical success rate of TDE, including both the access methods, was 77% (87/113). The most common reasons for transabdominal access failure were small caliber of the cisterna chyli and thoracic duct (TD) occlusion. Five patients were lost to follow-up. Overall clinical success, defined as resolution of the chyle leak, was achieved in 83% (78/94) of the patients. There were 6 Society of Interventional Radiology (SIR) level 1 adverse events (AEs), 5 SIR level 2 AEs, and 2 SIR level 3 AEs. Nontarget embolization occurred in 2 patients. CONCLUSIONS Although transcervical retrograde TDE is a challenging procedure, with a lower technical success rate than transabdominal antegrade access, retrograde access improved the technical and clinical success rates of the treatment of chyle leaks in cases of thoracic duct occlusion, small cisterna chyli, and leaks located in the abdomen.
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Affiliation(s)
- Daniel Crawford
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, Missouri
| | - Carlos J Guevara
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, Missouri
| | - Seung Kwon Kim
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, Missouri.
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19
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Moazzam S, O'Hagan LA, Clarke AR, Itkin M, Phillips ARJ, Windsor JA, Mirjalili SA. The cisterna chyli: a systematic review of definition, prevalence, and anatomy. Am J Physiol Heart Circ Physiol 2022; 323:H1010-H1018. [PMID: 36206050 DOI: 10.1152/ajpheart.00375.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The cisterna chyli is a lymphatic structure found at the caudal end of the thoracic duct that receives lymph draining from the abdominal and pelvic viscera and lower limbs. In addition to being an important landmark in retroperitoneal surgery, it is the key gateway for interventional radiology procedures targeting the thoracic duct. A detailed understanding of its anatomy is required to facilitate more accurate intervention, but an exhaustive summary is lacking. A systematic review was conducted, and 49 published human studies met the inclusion criteria. Studies included both healthy volunteers and patients and were not restricted by language or date. The detectability of the cisterna chyli is highly variable, ranging from 1.7 to 98%, depending on the study method and criteria used. Its anatomy is variable in terms of location (vertebral level of T10 to L3), size (ranging 2-32 mm in maximum diameter and 13-80 mm in maximum length), morphology, and tributaries. The size of the cisterna chyli increases in some disease states, though its utility as a marker of disease is uncertain. The anatomy of the cisterna chyli is highly variable, and it appears to increase in size in some disease states. The lack of well-defined criteria for the structure and the wide variation in reported detection rates prevent accurate estimation of its natural prevalence in humans.
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Affiliation(s)
- Sara Moazzam
- School of Medicine, The University of Auckland, Auckland, New Zealand
| | - Lomani A O'Hagan
- School of Medicine, The University of Auckland, Auckland, New Zealand
| | - Alys R Clarke
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Maxim Itkin
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anthony R J Phillips
- Applied Surgery and Metabolism Laboratory, School of Biological Sciences, The University of Auckland, Auckland, New Zealand
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - S Ali Mirjalili
- Department of Anatomy and Medical Imaging, The University of Auckland, Auckland, New Zealand
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20
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Jenner ZB, Li P, Kang L, Goldner BW, Brown CN, Raff GW, Kaufman J. Pediatric Intranodal CT Lymphangiography with Water-Soluble Contrast Medium. J Vasc Interv Radiol 2022; 33:1440-1443. [PMID: 35970504 DOI: 10.1016/j.jvir.2022.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 07/26/2022] [Accepted: 08/08/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Zachary B Jenner
- Department of Radiology, University of California, Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA 95817.
| | - Peter Li
- Department of Interventional Radiology, Oregon Health & Science University, Portland, OR
| | - Lisa Kang
- Department of Radiology, University of California, Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA 95817
| | - Brian W Goldner
- Department of Radiology, Mercy Radiology Group, Sacramento, CA
| | - Colin N Brown
- Department of Radiology, University of California, Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA 95817
| | - Gary W Raff
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Sacramento, CA
| | - John Kaufman
- Department of Interventional Radiology, Oregon Health & Science University, Portland, OR
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21
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Kariya S, Yamamoto S, Nakatani M, Ono Y, Maruyama T, Tanigawa N. The role of lymphatic interventional radiology for postoperative lymphorrhea. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Shuji Kariya
- Department of Radiology, Kansai Medical University, Osaka, Japan
| | | | - Miyuki Nakatani
- Department of Radiology, Kansai Medical University, Osaka, Japan
| | - Yasuyuki Ono
- Department of Radiology, Kansai Medical University, Osaka, Japan
| | - Takuji Maruyama
- Department of Radiology, Kansai Medical University, Osaka, Japan
| | - Noboru Tanigawa
- Department of Radiology, Kansai Medical University, Osaka, Japan
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22
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Zurcher KS, Huynh KN, Khurana A, Majdalany BS, Toskich B, Kriegshauser JS, Patel IJ, Naidu SG, Oklu R, Alzubaidi SJ. Interventional Management of Acquired Lymphatic Disorders. Radiographics 2022; 42:1621-1637. [PMID: 36190865 DOI: 10.1148/rg.220032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The lymphatic system is a complex network of tissues, vessels, and channels found throughout the body that assists in fluid balance and immunologic function. When the lymphatic system is disrupted related to idiopathic, iatrogenic, or traumatic disorders, lymphatic leaks can result in substantial morbidity and/or mortality. The diagnosis and management of these leaks is challenging. Modern advances in lymphatic imaging and interventional techniques have made radiology critical in the multidisciplinary management of these disorders. The authors provide a review of conventional and clinically relevant variant lymphatic anatomy and recent advances in diagnostic techniques such as MR lymphangiography. A detailed summary of technical factors related to percutaneous lymphangiography and lymphatic intervention is presented, including transpedal and transnodal lymphangiography. Traditional transabdominal access and retrograde access to the central lymph nodes and thoracic duct embolization techniques are outlined. Newer techniques including transhepatic lymphangiography and thoracic duct stent placement are also detailed. For both diagnostic and interventional radiologists, an understanding of lymphatic anatomy and modern diagnostic and interventional techniques is vital to the appropriate treatment of patients with acquired lymphatic disorders. ©RSNA, 2022.
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Affiliation(s)
- Kenneth S Zurcher
- From the Division of Vascular and Interventional Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (K.S.Z., J.S.K., I.J.P., S.G.N., R.O., S.J.A.); Department of Radiological Sciences, University of California, Irvine, Orange, Calif (K.N.H.); Department of Radiology, Mayo Clinic, Rochester, Minn (A.K.); Department of Radiology, University of Vermont, Burlington, VT (B.S.M.); and Division of Vascular and Interventional Radiology, Mayo Clinic Jacksonville, Jacksonville, Fla (B.T.)
| | - Kenneth N Huynh
- From the Division of Vascular and Interventional Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (K.S.Z., J.S.K., I.J.P., S.G.N., R.O., S.J.A.); Department of Radiological Sciences, University of California, Irvine, Orange, Calif (K.N.H.); Department of Radiology, Mayo Clinic, Rochester, Minn (A.K.); Department of Radiology, University of Vermont, Burlington, VT (B.S.M.); and Division of Vascular and Interventional Radiology, Mayo Clinic Jacksonville, Jacksonville, Fla (B.T.)
| | - Aditya Khurana
- From the Division of Vascular and Interventional Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (K.S.Z., J.S.K., I.J.P., S.G.N., R.O., S.J.A.); Department of Radiological Sciences, University of California, Irvine, Orange, Calif (K.N.H.); Department of Radiology, Mayo Clinic, Rochester, Minn (A.K.); Department of Radiology, University of Vermont, Burlington, VT (B.S.M.); and Division of Vascular and Interventional Radiology, Mayo Clinic Jacksonville, Jacksonville, Fla (B.T.)
| | - Bill S Majdalany
- From the Division of Vascular and Interventional Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (K.S.Z., J.S.K., I.J.P., S.G.N., R.O., S.J.A.); Department of Radiological Sciences, University of California, Irvine, Orange, Calif (K.N.H.); Department of Radiology, Mayo Clinic, Rochester, Minn (A.K.); Department of Radiology, University of Vermont, Burlington, VT (B.S.M.); and Division of Vascular and Interventional Radiology, Mayo Clinic Jacksonville, Jacksonville, Fla (B.T.)
| | - Beau Toskich
- From the Division of Vascular and Interventional Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (K.S.Z., J.S.K., I.J.P., S.G.N., R.O., S.J.A.); Department of Radiological Sciences, University of California, Irvine, Orange, Calif (K.N.H.); Department of Radiology, Mayo Clinic, Rochester, Minn (A.K.); Department of Radiology, University of Vermont, Burlington, VT (B.S.M.); and Division of Vascular and Interventional Radiology, Mayo Clinic Jacksonville, Jacksonville, Fla (B.T.)
| | - J Scott Kriegshauser
- From the Division of Vascular and Interventional Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (K.S.Z., J.S.K., I.J.P., S.G.N., R.O., S.J.A.); Department of Radiological Sciences, University of California, Irvine, Orange, Calif (K.N.H.); Department of Radiology, Mayo Clinic, Rochester, Minn (A.K.); Department of Radiology, University of Vermont, Burlington, VT (B.S.M.); and Division of Vascular and Interventional Radiology, Mayo Clinic Jacksonville, Jacksonville, Fla (B.T.)
| | - Indravadan J Patel
- From the Division of Vascular and Interventional Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (K.S.Z., J.S.K., I.J.P., S.G.N., R.O., S.J.A.); Department of Radiological Sciences, University of California, Irvine, Orange, Calif (K.N.H.); Department of Radiology, Mayo Clinic, Rochester, Minn (A.K.); Department of Radiology, University of Vermont, Burlington, VT (B.S.M.); and Division of Vascular and Interventional Radiology, Mayo Clinic Jacksonville, Jacksonville, Fla (B.T.)
| | - Sailendra G Naidu
- From the Division of Vascular and Interventional Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (K.S.Z., J.S.K., I.J.P., S.G.N., R.O., S.J.A.); Department of Radiological Sciences, University of California, Irvine, Orange, Calif (K.N.H.); Department of Radiology, Mayo Clinic, Rochester, Minn (A.K.); Department of Radiology, University of Vermont, Burlington, VT (B.S.M.); and Division of Vascular and Interventional Radiology, Mayo Clinic Jacksonville, Jacksonville, Fla (B.T.)
| | - Rahmi Oklu
- From the Division of Vascular and Interventional Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (K.S.Z., J.S.K., I.J.P., S.G.N., R.O., S.J.A.); Department of Radiological Sciences, University of California, Irvine, Orange, Calif (K.N.H.); Department of Radiology, Mayo Clinic, Rochester, Minn (A.K.); Department of Radiology, University of Vermont, Burlington, VT (B.S.M.); and Division of Vascular and Interventional Radiology, Mayo Clinic Jacksonville, Jacksonville, Fla (B.T.)
| | - Sadeer J Alzubaidi
- From the Division of Vascular and Interventional Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (K.S.Z., J.S.K., I.J.P., S.G.N., R.O., S.J.A.); Department of Radiological Sciences, University of California, Irvine, Orange, Calif (K.N.H.); Department of Radiology, Mayo Clinic, Rochester, Minn (A.K.); Department of Radiology, University of Vermont, Burlington, VT (B.S.M.); and Division of Vascular and Interventional Radiology, Mayo Clinic Jacksonville, Jacksonville, Fla (B.T.)
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23
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Banerjee P, Roy S, Chakraborty S. Recent advancement of imaging strategies of the lymphatic system: Answer to the decades old questions. Microcirculation 2022; 29:e12780. [PMID: 35972391 DOI: 10.1111/micc.12780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 07/22/2022] [Accepted: 08/10/2022] [Indexed: 12/30/2022]
Abstract
The role of the lymphatic system in maintaining tissue homeostasis and a number of different pathophysiological conditions has been well established. The complex and delicate structure of the lymphatics along with the limitations of conventional imaging techniques make lymphatic imaging particularly difficult. Thus, in-depth high-resolution imaging of lymphatic system is key to understanding the progression of lymphatic diseases and cancer metastases and would greatly benefit clinical decisions. In recent years, the advancement of imaging technologies and development of new tracers suitable for clinical applications has enabled imaging of the lymphatic system in both clinical and pre-clinical settings. In this current review, we have highlighted the advantages and disadvantages of different modern techniques such as near infra-red spectroscopy (NIRS), positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI) and fluorescence optical imaging, that has significantly impacted research in this field and has led to in-depth insights into progression of pathological states. This review also highlights the use of current imaging technologies, and tracers specific for immune cell markers to identify and track the immune cells in the lymphatic system that would help understand disease progression and remission in immune therapy regimen.
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Affiliation(s)
- Priyanka Banerjee
- Department of Medical Physiology, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas, USA
| | - Sukanya Roy
- Department of Medical Physiology, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas, USA
| | - Sanjukta Chakraborty
- Department of Medical Physiology, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas, USA
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24
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Gupta A, Naranje P, Vora Z, Sharma R, Jana M, Bhalla AS, Sinha P, Malik R, Goel P, Dhua A, Kandasamy D. Intranodal lipiodol injection for the treatment of chyle leak in children - a preliminary experience. Br J Radiol 2022; 95:20211270. [PMID: 35856789 PMCID: PMC10996956 DOI: 10.1259/bjr.20211270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 06/24/2022] [Accepted: 07/18/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of intranodal lymphangiography using ethiodised oil (Lipiodol; Guerbet Japan, Tokyo, Japan) for the treatment of refractory cases of chylothorax and chylous ascites in the paediatric population. METHODS Between 2016 and 2020, eight children having chyle leak resistant to conservative management underwent intranodal lymphangiography using lipiodol injection. After ethical approval by the Institutional Review Board, these patients' data were retrospectively analysed. Technical success was defined by opacification of inguinal and retroperitoneal lymphatics while injection on fluoroscopy. Clinical success was defined as progressively decreasing drain output and eventual cessation of output within a week after the procedure. Long-term follow up was done as feasible. RESULTS Technical success was achieved in all the patients. Complete cessation of drain output was noted within 1 week of procedure in all patients indicating clinical success. One patient had recurrence of chylous leakage after an interval of 1 month and intranodal lymphangiography was repeated for that patient. The child had technical as well as clinical success after the repeat procedure. Hence a total of 9 procedures were performed in 8 patients. CONCLUSION Intranodal lymphangiography may prove to be a valuable minimally invasive therapeutic tool in cases of refractory chylous leakage in paediatric patients with minimal risk of complications. ADVANCES IN KNOWLEDGE Intranodal lymphangiography using lipiodol may prove to be a minimally invasive alternative in paediatric patients with refractory lymphatic leaks.
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Affiliation(s)
- Amit Gupta
- Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, New
Delhi, India
| | - Priyanka Naranje
- Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, New
Delhi, India
| | - Zainab Vora
- Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, New
Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, New
Delhi, India
| | - Manisha Jana
- Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, New
Delhi, India
| | - Ashu Seith Bhalla
- Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, New
Delhi, India
| | - Pallavi Sinha
- Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, New
Delhi, India
| | - Rohan Malik
- Department of Pediatrics, All India Institute of Medical
Sciences, New Delhi,
India
| | - Prabudh Goel
- Department of Pediatric Surgery, All India Institute of Medical
Sciences, New Delhi,
India
| | - Anjan Dhua
- Department of Pediatric Surgery, All India Institute of Medical
Sciences, New Delhi,
India
| | - Devasenathipathy Kandasamy
- Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, New
Delhi, India
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25
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Ramirez-Suarez KI, Tierradentro-Garcia LO, Stern JA, Dori Y, Escobar FA, Otero HJ, Rapp JB, Smith CL, Krishnamurthy G, Biko DM. State-of-the-art imaging for lymphatic evaluation in children. Pediatr Radiol 2022:10.1007/s00247-022-05469-6. [PMID: 35980463 DOI: 10.1007/s00247-022-05469-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/22/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022]
Abstract
The lymphatic system has been poorly understood and its importance neglected for decades. Growing understanding of lymphatic flow pathophysiology through peripheral and central lymphatic flow imaging has improved diagnosis and treatment options in children with lymphatic diseases. Flow dynamics can now be visualized by different means including dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL), the current standard technique to depict central lymphatics. Novel imaging modalities including intranodal, intrahepatic and intramesenteric DCMRL are quickly evolving and have shown important advances in the understanding and guidance of interventional procedures in children with intestinal lymphatic leaks. Lymphatic imaging is gaining importance in the radiologic and clinical fields and new techniques are emerging to overcome its limitations.
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Affiliation(s)
- Karen I Ramirez-Suarez
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | | | - Joseph A Stern
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Yoav Dori
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fernando A Escobar
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher L Smith
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
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26
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MR lymphangiography of lymphatic abnormalities in children and adults with Noonan syndrome. Sci Rep 2022; 12:11164. [PMID: 35778409 PMCID: PMC9249771 DOI: 10.1038/s41598-022-13806-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 05/27/2022] [Indexed: 11/09/2022] Open
Abstract
Noonan syndrome is associated with complex lymphatic abnormalities. We report dynamic-contrast enhanced MR lymphangiography (DCMRL) findings in children and adults with Noonan syndrome to further elucidate this complex disease spectrum. A retrospective evaluation of patients with confirmed Noonan syndrome and clinical signs of lymphatic dysfunction undergoing DCMRL between 01/2019 and 04/2021 was performed. MRL included T2-weighted imaging (T2w) and DCMRL. Clinical history/presentation and genetic variants were recorded. T2w-imaging was evaluated for central lymphatic abnormalities and edema distribution. DCMRL was evaluated regarding the presence of cisterna chyli/thoracic duct, lymphatic leakages, pathological lymphatic reflux and abnormal lymphatic perfusion. The time from start of contrast-injection to initial enhancement of the thoracic duct venous junction was measured to calculate the speed of contrast propagation. Eleven patients with Noonan syndrome with lymphatic abnormalities (5 female, 6 male; 7 infants, 4 adults; mean age 10.8 ± 16.4 years) were identified (PTPN11 n = 5/11 [45.5%], RIT1 n = 5/11 [45.5%], KRAS n = 1/11 [9%]). Patients had a chylothorax (n = 10/11 [91%]) and/or pulmonary lymphangiectasia [dilated pulmonary lymph vessels] (n = 9/11 [82%]). Mediastinal/pulmonary edema was depicted in 9/11 (82%) patients. The thoracic duct (TD) was (partially) absent in 10/11 (91%) cases. DCMRL showed lymphatic reflux into intercostal (n = 11/11 [100%]), mediastinal (n = 9/11 [82%]), peribronchial (n = 8/11 [73%]), peripheral (n = 5/11 [45.5%]) and genital lymphatics (n = 4/11 [36%]). Abnormal pulmonary/pleural lymphatic perfusion was seen in 8/11 patients (73%). At infancy peripheral/genital edema was more prevalent in patients with RIT1 than PTPN11 (n = 3/5 vs. n = 0/5). Compared to patients with PTPN11 who had fast lymphatic enhancement in 4/5 patients, enhancement took markedly longer in 4/5 patients with RIT1-mutations. Thoracic duct dysplasia, intercostal reflux and pulmonary/pleural lymphatic perfusion are characteristic findings in patients with Noonan syndrome presenting with chylothorax and/or pulmonary lymphangiectasia. Central lymphatic flow abnormalities show possible phenotypical differences between PTPN11 and RIT1-mutations.
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27
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Optical Coherence Tomography Angiography and Attenuation Imaging for Label-Free Observation of Functional Changes in the Intestine after Sympathectomy: A Pilot Study. PHOTONICS 2022. [DOI: 10.3390/photonics9050304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We present in this study optical coherence tomography angiography (OCTA) and OCT attenuation imaging (OCTAI) for in vivo non-destructive visualization of intramural blood and lymphatic vessels of the intestine wall. Rabbit small intestine in the norm and after thoracolumbar sympathectomy served as the object of the intraoperative study. Compared to OCTA real-time imaging, OCTAI takes several minutes and can be termed as “nearly real time”. OCTAI signal processing was modified to take into account the signal-to-noise ratio and the final thickness of the intestine wall. The results showed that, after sympathectomy, changes in functioning of intramural blood and lymphatic vessels were observed with a high statistical significance. The occurrence of trauma-induced constriction of the blood and lymphatic vessels led to an especially pronounced decrease in the length of small-caliber (<30 µm) blood vessels (p < 10−5), as well as in the volumetric density of lymphatic vessels (on average by ~50%) compared to their initial state. Remarkably, OCTA/OCTAI modalities provide the unique ability for “nearly-instant detection” of changes in functional status of the tissues, long before they become visible on histology. The proposed approach can be used in further experiments to clarify the mechanisms of changes in intestinal blood and lymph flows in response to trauma of the nervous system. Furthermore, potentially it can be used intraoperatively in patients requiring express diagnosis of the state of intramural blood and lymph circulation.
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28
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Windsor JA, Trevaskis NL, Phillips AJ. The Gut-Lymph Model Gives New Treatment Strategies for Organ Failure. JAMA Surg 2022; 157:540-541. [PMID: 35442412 DOI: 10.1001/jamasurg.2022.0654] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical Health Sciences, University of Auckland, Auckland, New Zealand
| | - Natalie L Trevaskis
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Anthony J Phillips
- Surgical and Translational Research Centre, Faculty of Medical Health Sciences, University of Auckland, Auckland, New Zealand.,School of Biological Sciences, Faculty of Science, University of Auckland, Auckland, New Zealand
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29
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van Schaik CJ, Boer LL, Draaisma JMT, van der Vleuten CJM, Janssen JJ, Fütterer JJ, Schultze Kool LJ, Klein WM. The lymphatic system throughout history: From hieroglyphic translations to state of the art radiological techniques. Clin Anat 2022; 35:701-710. [PMID: 35383381 PMCID: PMC9542037 DOI: 10.1002/ca.23867] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/22/2022] [Accepted: 03/24/2022] [Indexed: 11/07/2022]
Abstract
A comprehensive lymphatic system is indispensable for a well-functioning body; it is integral to the immune system and is also interrelated with the digestive system and fluid homeostasis. The main difficulty in examining the lymphatic system is its fine-meshed structure. This remains a challenge, leaving patients with uninterpreted symptoms and a dearth of potential therapies. We review the history of the lymphatic system up to the present with the aim of improving current knowledge. Several findings described throughout history have made fundamental contributions to elucidating the lymphatic system. The first contributions were made by the ancient Egyptians and the ancient Greeks. Vesalius obtained new insights by dissecting corpses. Thereafter, Ruysch (1638-1731) gained an understanding of lymphatic flow. In 1784, Mascagni published his illustration of the whole lymphatic network. The introduction of radiological lymphography revolutionized knowledge of the lymphatic system. Pedal lymphangiography was first described by Monteiro (1931) and Kinmonth (1952). Lymphoscintigraphy (nuclear medicine), magnetic resonance imaging, and near-infrared fluorescence lymphography further improved visualization of the lymphatic system. The innovative dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) transformed understanding of the central lymphatic system, enabling central lymphatic flow disorders in patients to be diagnosed and even allowing for therapeutic planning. From the perspective of the history of lymph visualization, DCMRL has ample potential for identifying specific causes of debilitating symptoms in patients with central lymphatic system abnormalities and even allows for therapeutic planning.
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Affiliation(s)
- Caroline J van Schaik
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lucas L Boer
- Department of Medical Imaging, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jos M T Draaisma
- Department of General Pediatrics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Jan Jaap Janssen
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jurgen J Fütterer
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leo J Schultze Kool
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willemijn M Klein
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
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30
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O'Leary C, Itkin M, Roshkovan L, Katz S, Cao Q, Hershman M, Galperin-Aizenberg M. CT Features of Lymphatic Plastic Bronchitis in Adults: Correlation with Multimodality Lymphatic Imaging. Radiol Cardiothorac Imaging 2022; 4:e210048. [PMID: 35506131 DOI: 10.1148/ryct.210048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 12/05/2021] [Accepted: 03/24/2022] [Indexed: 11/11/2022]
Abstract
Purpose To distinguish CT patterns of lymphatic and nonlymphatic causes of plastic bronchitis (PB) through comparison with lymphatic imaging. Materials and Methods In this retrospective study, chest CT images acquired prior to lymphatic workup were assessed in 44 patients with PB from January 2014 to August 2020. The location and extent of ground-glass opacity (GGO) was compared with symptoms and lymphatic imaging. Statistical analysis was performed using descriptive statistics, logistic regression, Pearson correlation coefficient, and unweighted κ coefficient for interobserver agreement. Sensitivity and specificity of GGO for lymphatic PB were calculated. Results Lymphatic imaging was performed in 44 patients (median age, 52 years ± 21 [IQR]; 23 women): 35 with lymphatic PB and nine with nonlymphatic PB. GGO was more frequently observed in patients with lymphatic PB than in those with nonlymphatic PB (91% [32 of 35] vs 33% [three of nine]; P < .001). Univariate logistic regression confirmed this result by showing that GGO was a significant predictor of lymphatic PB (odds ratio, 21 (95% CI: 3.8, 159.7). The model areas under the receiver operating characteristic curve (AUCs) of GGO unadjusted and adjusted for demographics were 0.79 and 0.86, respectively. The location of GGO correlated with lymphatic imaging and bronchoscopic findings. Overall sensitivity and specificity of GGO for lymphatic PB were 91% (32 of 35; 95% CI: 76, 98) and 67% (six of nine; 95% CI: 30, 93), respectively. Conclusion Patients with lymphatic PB predominantly had multifocal GGO with or without a "crazy paving" pattern; identification of GGO should prompt lymphatic workup in this frequently misdiagnosed condition.Keywords: Lymphography, Lymphatic, CT, Tracheobronchial Tree, Thorax© RSNA, 2022See also commentary by Kligerman and White in this issue.
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Affiliation(s)
- Cathal O'Leary
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Maxim Itkin
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Leonid Roshkovan
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Sharyn Katz
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Quy Cao
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Michelle Hershman
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
| | - Maya Galperin-Aizenberg
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104-6243 (C.O., L.R.); Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa (M.I., S.K., M.H., M.G.A.); and Department of Biostatistics, University of Pennsylvania, Philadelphia, Pa (Q.C.)
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31
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Neonatal vascular anomalies manifesting as soft-tissue masses. Pediatr Radiol 2022; 52:786-801. [PMID: 34374837 DOI: 10.1007/s00247-021-05149-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/25/2021] [Accepted: 06/28/2021] [Indexed: 01/19/2023]
Abstract
The broad and heterogeneous spectrum of vascular anomalies ranges from an innocuous localized cutaneous discoloration to complex, extensive and life-threatening diagnoses. While many of these lesions are present at birth, smaller and deeper lesions might be clinically occult for months or years. Certain vascular anomalies commonly manifest in the prenatal or neonatal period and often have suggestive clinical and imaging features that can aid the radiologist in making a correct diagnosis. The characteristics of such lesions presenting very early in life, particularly those manifesting as soft-tissue masses, are the focus of this review.
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32
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Ultrasound-guided needle positioning for nodal dynamic contrast-enhanced MR lymphangiography. Sci Rep 2022; 12:3621. [PMID: 35256625 PMCID: PMC8901837 DOI: 10.1038/s41598-022-07359-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/10/2022] [Indexed: 11/15/2022] Open
Abstract
The aim of the study was to assess injection needle positioning for contrast-enhanced MR-lymphangiography (MRL) by ultrasound-guided injection of saline-solution. 80 patients (33 male, mean age 43.1 years) were referred for MRL. The injection needle position was assessed by injection of saline-solution. Consecutive lymph node distension was observed on sonography followed by MRL. Transpedal MRL was performed when no inguinal lymph nodes could be identified. The inguinal lymph node detection rate was recorded. MR-lymphangiograms were assessed regarding primary (i.e. enhancement of draining lymph vessels) and secondary technical success (i.e. lymph vessel enhancement after repositioning of the needle). MRL was considered as clinically successful if enhancement of the central lymphatic system and/or a lymphatic pathologies were observed. For a total of 92 MRLs 177 groins were evaluated sonographically. In 171/177 groins (96.6%) lymph nodes were identified. After needle placement lymph node distension was observed in 171/171 cases (100%) on saline injection. MR-contrast injection demonstrated enhancement of draining lymph vessels in 163/171 cases (95.3%). In 6/171 cases (3.5%) in-bore needle retraction lead to lymphatic enhancement. In one patient [2/171 nodes (1.1%)] no lymphatic enhancement was seen despite repeated needle repositioning. Overall contrast application was technically successful in 169/171 cases (98.8%). In the 6 groins in which no nodes were identifiable, transpedal MRL was successful. So overall 91/92 MRLs (98.9%) were clinically successful. No complications were recorded. Confirmation of the needle position for nodal MRL by sonographically controlled saline injection is a reliable technique with a high success rate of MRL.
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33
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Lee E, Biko DM, Sherk W, Masch WR, Ladino-Torres M, Agarwal PP. Understanding Lymphatic Anatomy and Abnormalities at Imaging. Radiographics 2022; 42:487-505. [PMID: 35179984 DOI: 10.1148/rg.210104] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Lymphatic abnormalities encompass a wide range of disorders spanning solitary common cystic lymphatic malformations (LMs) to entities involving multiple organ systems such as lymphangioleiomyomatosis. Many of these disorders are rare, yet some, such as secondary lymphedema from the treatment of malignancy (radiation therapy and/or lymph node dissection), affect millions of patients worldwide. Owing to complex and variable anatomy, the lymphatics are not as well understood as other organ systems. Further complicating this is the variability in the description of lymphatic disease processes and their nomenclature in the medical literature. In recent years, medical imaging has begun to facilitate a deeper understanding of the physiology and pathologic processes that involve the lymphatic system. Radiology is playing an important and growing role in the diagnosis and treatment of many lymphatic conditions. The authors describe both normal and common variant lymphatic anatomy. Various imaging modalities including nuclear medicine lymphoscintigraphy, conventional lymphangiography, and MR lymphangiography used in the diagnosis and treatment of lymphatic disorders are highlighted. The authors discuss imaging many of the common and uncommon lymphatic disorders, including primary LMs described by the International Society for the Study of Vascular Anomalies 2018 classification system (microcystic, mixed, and macrocystic LMs; primary lymphedema). Secondary central lymphatic disorders are also detailed, including secondary lymphedema and chylous leaks, as well as lymphatic disorders not otherwise easily classified. The authors aim to provide the reader with an overview of the anatomy, pathology, imaging findings, and treatment of a wide variety of lymphatic conditions. ©RSNA, 2022.
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Affiliation(s)
- Elizabeth Lee
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - David M Biko
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - William Sherk
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - William R Masch
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - Maria Ladino-Torres
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
| | - Prachi P Agarwal
- From the Department of Radiology, Divisions of Cardiothoracic Imaging (E.L., P.P.A.), Interventional Radiology (W.S.), and Body Imaging (W.R.M.), University of Michigan, University Hospital Floor B1, Reception C, 1500 E Medical Center Dr, SPC 5030, Ann Arbor, MI 48109; University of Pennsylvania Perelman School of Medicine, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pa (D.M.B.); and Department of Radiology, Division of Pediatric Radiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich (M.L.T.)
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Dynamic contrast-enhanced magnetic resonance lymphangiography. Pediatr Radiol 2022; 52:285-294. [PMID: 33830292 DOI: 10.1007/s00247-021-05051-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/25/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
Lymphatic flow disorders include a broad spectrum of abnormalities that can originate in the lymphatic or the venous system. The development of these disorders is multifactorial and is most commonly associated with congenital heart diseases and palliative surgeries that these patients undergo. Central lymphatic disorders might be secondary to traumatic leaks, lymphatic overproduction, conduction abnormalities or lymphedema, and they can progress to perfusion anomalies. Several imaging modalities have been used to visualize the lymphatic system. However, the imaging of central lymphatic flow has always been challenging. Dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) allows for visualization of central lymphatic flow disorders and has been recently applied for the assessment of plastic bronchitis, protein-losing enteropathy, chylothorax and chylopericardium, among other lymphatic disorders. The hepatic and mesenteric accesses are innovative and promising techniques for better identification and understanding of these abnormalities. The main objectives of this review are to discuss the physiology and anatomy of the lymphatic system and review the current uses of DCMRL in the diagnosis and management of lymphatic flow disorders.
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Alali M, Park R, Shin JH, Chen C, Shin JI. Lipiodol Lymphangiography and Glue Embolization for Vulvar and Vaginal Lymphorrhea. THE ARAB JOURNAL OF INTERVENTIONAL RADIOLOGY 2022. [DOI: 10.1055/s-0042-1750106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractA 26-year-old woman patient had an 18-year long history of vulvar and vaginal lymphorrhea and multiple millet-like lesions on her vulva. On magnetic resonance image, multiple T2 high signal intensities were noted at the bilateral vulvar areas and pelvic cavity. Conventional lipiodol lymphangiography showed lymphatic reflux to the vulvar areas, possibly originating from prominent tubular lymphatics in the right lower abdominal wall. After percutaneous puncture of this tubular lymphatic structure, its distal portion was embolized using microcoils to prevent upward glue propagation; this was followed by glue embolization of the tubular lymphatic structure. The patient was without skin lesions or symptoms at follow-up of 1 year after the procedure.
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Affiliation(s)
- Meshari Alali
- Department of Radiology, Majmaah University, Almajmaah, Saudi Arabia
| | - Rohee Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji H. Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chengshi Chen
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Jeoung I. Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
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36
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Li AA, Raghu P, Chen A, Triadafilopoulos G, Park W. Sticky Situation: Bleeding Duodenal Lymphangiectasias Treated with Lymphatic Glue Embolization. Dig Dis Sci 2022; 67:71-74. [PMID: 33638090 DOI: 10.1007/s10620-021-06898-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Andrew A Li
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Preethi Raghu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Anne Chen
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Walter Park
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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37
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Patel S, Hur S, Khaddash T, Simpson S, Itkin M. Intranodal CT Lymphangiography with Water-soluble Iodinated Contrast Medium for Imaging of the Central Lymphatic System. Radiology 2021; 302:228-233. [PMID: 34698570 DOI: 10.1148/radiol.2021210294] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Dynamic contrast-enhanced MR lymphangiography (DCMRL) is the reference standard used to diagnose various thoracic lymphatic disorders, such as traumatic chylothorax and plastic bronchitis. However, accessibility and logistical challenges have prevented the wide dissemination of this technology. Purpose To evaluate the feasibility of intranodal CT lymphangiography (ICTL) in the diagnosis and planning of subsequent intervention in patients with thoracic lymphatic disorders. Materials and Methods In this retrospective review, five women suspected of having lymphatic abnormalities (ranging from traumatic chylothorax to plastic bronchitis) and with contraindications to MRI underwent ICTL from September 2019 to May 2020. Needles (25 gauge) were placed in the bilateral inguinal lymph nodes with US guidance, and water-soluble iodinated contrast material was injected. CT fluoroscopy was used to monitor the opacification of the cisterna chyli to determine the timing of CT. After ICTL, the thoracic duct was catheterized, and lymphangiography was performed through the thoracic duct catheter. The ICTL and subsequent lymphangiographic findings were then visually compared by using three-dimensional reconstructions. Results Intranodal injection of water-soluble contrast medium was successful in all patients evaluated (five women; mean age, 68 years ± 11 [standard deviation]; range, 53-83 years). The central lymphatics were opacified in four of the five women, demonstrating abnormal pulmonary lymphatic flow from the thoracic duct into the lung parenchyma. In one of the five women, thoracic duct injection showed successful ligation of the thoracic duct. The time elapsed from injection of contrast medium to visualization of the thoracic duct ranged from 2 to 27 minutes. ICTL and lymphangiographic findings matched well. Conclusion Intranodal CT lymphangiography sufficiently depicted central lymphatic anatomy in patients with lymphatic abnormalities, thereby demonstrating its use as a feasible alternative to more technically challenging methods, such as dynamic contrast-enhanced MR lymphangiography. © RSNA, 2021.
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Affiliation(s)
- Suhag Patel
- From the Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.P., T.K., S.S., M.I.); Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.H.); and Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea (S.H.)
| | - Saebeom Hur
- From the Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.P., T.K., S.S., M.I.); Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.H.); and Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea (S.H.)
| | - Tamim Khaddash
- From the Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.P., T.K., S.S., M.I.); Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.H.); and Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea (S.H.)
| | - Scott Simpson
- From the Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.P., T.K., S.S., M.I.); Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.H.); and Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea (S.H.)
| | - Maxim Itkin
- From the Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.P., T.K., S.S., M.I.); Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea (S.H.); and Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea (S.H.)
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38
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Brouillard P, Witte MH, Erickson RP, Damstra RJ, Becker C, Quéré I, Vikkula M. Primary lymphoedema. Nat Rev Dis Primers 2021; 7:77. [PMID: 34675250 DOI: 10.1038/s41572-021-00309-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/09/2022]
Abstract
Lymphoedema is the swelling of one or several parts of the body owing to lymph accumulation in the extracellular space. It is often chronic, worsens if untreated, predisposes to infections and causes an important reduction in quality of life. Primary lymphoedema (PLE) is thought to result from abnormal development and/or functioning of the lymphatic system, can present in isolation or as part of a syndrome, and can be present at birth or develop later in life. Mutations in numerous genes involved in the initial formation of lymphatic vessels (including valves) as well as in the growth and expansion of the lymphatic system and associated pathways have been identified in syndromic and non-syndromic forms of PLE. Thus, the current hypothesis is that most cases of PLE have a genetic origin, although a causative mutation is identified in only about one-third of affected individuals. Diagnosis relies on clinical presentation, imaging of the structure and functionality of the lymphatics, and in genetic analyses. Management aims at reducing or preventing swelling by compression therapy (with manual drainage, exercise and compressive garments) and, in carefully selected cases, by various surgical techniques. Individuals with PLE often have a reduced quality of life owing to the psychosocial and lifelong management burden associated with their chronic condition. Improved understanding of the underlying genetic origins of PLE will translate into more accurate diagnosis and prognosis and personalized treatment.
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Affiliation(s)
- Pascal Brouillard
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Marlys H Witte
- Department of Surgery, Neurosurgery, and Pediatrics, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Robert P Erickson
- Department of Pediatrics, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Robert J Damstra
- VASCERN PPL European Reference Centre; Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, Drachten, Netherlands
| | | | - Isabelle Quéré
- Department of Vascular Medicine, Centre de référence des Maladies Lymphatiques et Vasculaires Rares, Inserm IDESP, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium. .,VASCERN VASCA European Reference Centre; Center for Vascular Anomalies, Division of Plastic Surgery, University Clinics Saint-Luc, University of Louvain, Brussels, Belgium. .,Walloon Excellence in Lifesciences and Biotechnology (WELBIO), de Duve Institute, University of Louvain, Brussels, Belgium.
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Martin-Almedina S, Mortimer PS, Ostergaard P. Development and physiological functions of the lymphatic system: insights from human genetic studies of primary lymphedema. Physiol Rev 2021; 101:1809-1871. [PMID: 33507128 DOI: 10.1152/physrev.00006.2020] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Primary lymphedema is a long-term (chronic) condition characterized by tissue lymph retention and swelling that can affect any part of the body, although it usually develops in the arms or legs. Due to the relevant contribution of the lymphatic system to human physiology, while this review mainly focuses on the clinical and physiological aspects related to the regulation of fluid homeostasis and edema, clinicians need to know that the impact of lymphatic dysfunction with a genetic origin can be wide ranging. Lymphatic dysfunction can affect immune function so leading to infection; it can influence cancer development and spread, and it can determine fat transport so impacting on nutrition and obesity. Genetic studies and the development of imaging techniques for the assessment of lymphatic function have enabled the recognition of primary lymphedema as a heterogenic condition in terms of genetic causes and disease mechanisms. In this review, the known biological functions of several genes crucial to the development and function of the lymphatic system are used as a basis for understanding normal lymphatic biology. The disease conditions originating from mutations in these genes are discussed together with a detailed clinical description of the phenotype and the up-to-date knowledge in terms of disease mechanisms acquired from in vitro and in vivo research models.
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Affiliation(s)
- Silvia Martin-Almedina
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
| | - Peter S Mortimer
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St. George's Universities NHS Foundation Trust, London, United Kingdom
| | - Pia Ostergaard
- Molecular and Clinical Sciences Institute, St. George's University of London, London, United Kingdom
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40
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Fudim M, Salah HM, Sathananthan J, Bernier M, Pabon-Ramos W, Schwartz RS, Rodés-Cabau J, Côté F, Khalifa A, Virani SA, Patel MR. Lymphatic Dysregulation in Patients With Heart Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:66-76. [PMID: 34210416 DOI: 10.1016/j.jacc.2021.04.090] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/13/2021] [Indexed: 11/29/2022]
Abstract
The lymphatic system is an integral part of the circulatory system and plays an important role in the volume homeostasis of the human body. The complex anatomy and physiology paired with a lack of simple diagnostic tools to study the lymphatic system have led to an underappreciation of the contribution of the lymphatic system to acute and chronic heart failure (HF). Herein, we discuss the physiological role of the lymphatic system in volume management and the evidence demonstrating the dysregulation of the lymphatic system in HF. Further, we discuss the opportunity to target the lymphatic system in the management of HF and different potential approaches to accessing the lymphatic system.
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Affiliation(s)
- Marat Fudim
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Husam M Salah
- Department of Medicine, University of Arkansas for Medical Sciences, Arkansas, USA
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation and Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mathieu Bernier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Waleska Pabon-Ramos
- Department of Radiology, Division of Interventional Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Hospital Clinic of Barcelona, Barcelona, Spain
| | - François Côté
- Interventional Radiology Department, CHU de Quebec, Laval University, Quebec City, Quebec, Canada
| | - Abubaker Khalifa
- Department of Medicine, Joseph Brant Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Sean A Virani
- Centre for Cardiovascular Innovation and Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Manesh R Patel
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
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41
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Intranodal lymphangiography and interstitial lymphatic embolization to treat chyluria caused by a lymphatic malformation in a pediatric patient. Pediatr Radiol 2021; 51:1762-1765. [PMID: 33638694 DOI: 10.1007/s00247-021-05007-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/27/2020] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
Chyluria is characterized by chyle in the urinary tract and often presents as milky-white urine. We present a case of chyluria from a lymphatic malformation in a 13-year-old boy diagnosed using dynamic intranodal contrast-enhanced magnetic resonance (MR) lymphangiography. This report demonstrates the utility of intranodal lymphangiography and interstitial lymphatic embolization to treat a pediatric patient presenting with persistent chyluria. Glue migration into the urinary collecting system is a potential complication of this procedure that can be mitigated by adjusting the n-butyl cyanoacrylate dilution with Lipiodol.
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42
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Abstract
Lymphedema is a common, complex, and inexplicably underappreciated human disease. Despite a history of relative neglect by health care providers and by governmental health care agencies, the last decade has seen an explosive growth of insights into, and approaches to, the problem of human lymphedema. The current review highlights the significant advances that have occurred in the investigative and clinical approaches to lymphedema, particularly over the last decade. This review summarizes the progress that has been attained in the realms of genetics, lymphatic imaging, and lymphatic surgery. Newer molecular insights are explored, along with their relationship to future molecular therapeutics. Growing insights into the relationships among lymphedema, obesity, and other comorbidities are important to consider in current and future responses to patients with lymphedema.
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Affiliation(s)
- Stanley G Rockson
- Allan and Tina Neill Professor of Lymphatic Research and Medicine, Stanford University School of Medicine, Stanford, CA
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43
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Othman S, Azoury SC, DiBardino D, Adams DM, Itkin M, Kovach SJ. Respiratory Failure in Noonan Syndrome Treated by Microsurgical Thoracic Duct-Venous Anastomosis. Ann Thorac Surg 2021; 113:e219-e221. [PMID: 34116002 DOI: 10.1016/j.athoracsur.2021.05.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/26/2021] [Accepted: 05/08/2021] [Indexed: 11/01/2022]
Abstract
Noonan Syndrome is a disorder characterized by central and peripheral lymphatic conducting anomalies, leading to chylothorax, chylous ascites, and metabolic derangement. Novel imaging modalities including dynamic contrast magnetic resonance lymphangiography (DCMRL) and intranodal lymphangiography have allowed for increased visualization of lymphatic pathology. We describe the first study of a 61-year-old male with Noonan syndrome who developed severe pulmonary insufficiency and chylothoraces. DCMRL and intranodal lymphangiography demonstrated central thoracic duct (TD) occlusion. The patient's condition significantly improved following microsurgical TD-venous anastomosis assisted by TD catherization for imaging guidance, resulting in decompression of the lymphatic system and resolution of the pulmonary symptoms.
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Affiliation(s)
- Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - David DiBardino
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care, Department of Medicine, University of Pennsylvania
| | - Denise M Adams
- Director, Comprehensive Vascular Anomalies Program, Children's Hospital of Philadelphia
| | - Maxim Itkin
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania.
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44
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O'Leary CN, Khaddash T, Nadolski G, Itkin M. Abnormal Pulmonary Lymphatic Flow on Novel Lymphangiographic Imaging Supports a Common Etiology of Lymphatic Plastic Bronchitis and Nontraumatic Chylothorax. Lymphat Res Biol 2021; 20:153-159. [PMID: 34077679 DOI: 10.1089/lrb.2021.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: This study evaluates whether dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) and thoracic duct lymphangiography (TDL) findings in adults with lymphatic plastic bronchitis (PB) and/or nontraumatic chylothorax (NTC) support a shared pathophysiology. Materials and Results: Retrospective review of clinical and imaging findings in patients who underwent DCMRL and TDL at a single institution from March 2017 to March 2019. Categorical variables were compared with Fisher's exact test. Twenty-eight patients (median age 61 ± 21 years, 15 women) presenting with lymphatic PB (n = 13), NTC (n = 10), or both (n = 5) were included. Lymphatic imaging demonstrated pulmonary lymphatic perfusion (PLP) in all patients. A patent thoracic duct (TD) with retrograde flow was seen in 53.4% (7/13) of patients with PB, 60% (6/10) of patients with NTC, and 20% (1/5) of patients with both (p = 0.69). An occluded TD with retrograde flow was seen in 30.8% (4/13) of patients with PB, 30% (3/10) of patients with NTC, and 80% (4/5) of patients with both (p = 0.12). Similar patterns of PLP between DCMRL and TDL were seen in 96.2% (25/26) of patients. Conclusions: DCMRL and TDL demonstrated similar findings in patients with lymphatic PB and/or NTC, supporting a common etiology. This supports the hypothesis that the clinical presentation depends on the proximity of abnormal lymphatic vessels to the pleural cavity, resulting in chylothorax, or bronchial mucosa, resulting in PB.
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Affiliation(s)
- Cathal N O'Leary
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Tamim Khaddash
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Gregory Nadolski
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Maxim Itkin
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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45
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Maldonado-Zimbron VE, Hong J, Russell P, Trevaskis NL, Windsor JA, Phillips ARJ. Methods for studying pulmonary lymphatics. Eur Respir J 2021; 57:13993003.04106-2020. [PMID: 33863740 DOI: 10.1183/13993003.04106-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/04/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Victor E Maldonado-Zimbron
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand .,Applied Surgery and Metabolism Laboratory, School of Biological Science, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Jiwon Hong
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Applied Surgery and Metabolism Laboratory, School of Biological Science, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Peter Russell
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Applied Surgery and Metabolism Laboratory, School of Biological Science, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Natalie L Trevaskis
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - John Albert Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Applied Surgery and Metabolism Laboratory, School of Biological Science, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Anthony Ronald John Phillips
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Applied Surgery and Metabolism Laboratory, School of Biological Science, Faculty of Science, University of Auckland, Auckland, New Zealand
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46
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Sato Y, Tanaka Y, Imai T, Kawada H, Okumura N, Matsuhashi N, Takahashi T, Matsuo M, Yoshida K. Chylothorax after esophagectomy treated with inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization. Clin J Gastroenterol 2021; 14:969-974. [PMID: 33974188 PMCID: PMC8298363 DOI: 10.1007/s12328-021-01429-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
Chylothorax after esophagectomy is a serious complication that is associated with major morbidity due to dehydration and malnutrition. Reoperation with ligation of the thoracic duct is considered for patients with high-output chyle leaks that have failed conservative management. In this report, we present the treatment options for chylothorax after esophagectomy: inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization. A 74-year-old man with esophageal cancer had been operated with thoracoscopic esophagectomy. Six days after surgery, he presented with high-output chyle leaks. Conservative treatment did not result in a significant improvement. Inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization were performed 13 days after surgery and were technically and clinically successful. Inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization are an effective treatment option, especially for patients after esophagectomy with reconstruction performed via the posterior mediastinal route, without the potential for damage the gastric tube and omentum.
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Affiliation(s)
- Yuta Sato
- Department of Surgical Oncology, Gifu university, graduate school of Medicine, 1-1 Yanagido, Gifu city, 501-1194, Japan
| | - Yoshihiro Tanaka
- Department of Surgical Oncology, Gifu university, graduate school of Medicine, 1-1 Yanagido, Gifu city, 501-1194, Japan.
| | - Takeharu Imai
- Department of Surgical Oncology, Gifu university, graduate school of Medicine, 1-1 Yanagido, Gifu city, 501-1194, Japan
| | - Hiroshi Kawada
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Naoki Okumura
- Department of Surgical Oncology, Gifu university, graduate school of Medicine, 1-1 Yanagido, Gifu city, 501-1194, Japan
| | - Nobuhisa Matsuhashi
- Department of Surgical Oncology, Gifu university, graduate school of Medicine, 1-1 Yanagido, Gifu city, 501-1194, Japan
| | - Takao Takahashi
- Department of Surgical Oncology, Gifu university, graduate school of Medicine, 1-1 Yanagido, Gifu city, 501-1194, Japan
| | - Masayuki Matsuo
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Kazuhiro Yoshida
- Department of Surgical Oncology, Gifu university, graduate school of Medicine, 1-1 Yanagido, Gifu city, 501-1194, Japan
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47
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Wagenpfeil J, Attenberger U, Pieper CC. Unusual Left Periclavicular Cutaneous Lymphatic Fistula After Port Explantation Without Lymph Vessel Injury: Imaging and Interventional Treatment. Cardiovasc Intervent Radiol 2021; 44:1279-1281. [PMID: 33928406 PMCID: PMC8249259 DOI: 10.1007/s00270-021-02840-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/02/2021] [Indexed: 11/18/2022]
Abstract
Complex oncological treatment can be associated with lymphatic vascular injury that is burdened by considerable morbidity. Lymphatic imaging and interventional techniques offer new minimally invasive treatment options. We report the case of a 59-year-old woman with an unusual lympho-veno-cutaneous fistula, diagnosed by magnetic resonance lymphangiography and treated by minimally invasive embolization therapy and venous recanalization.
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Affiliation(s)
- Julia Wagenpfeil
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Ulrike Attenberger
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Claus Christian Pieper
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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48
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Refractory Hepatic Lymphorrhea: Percutaneous Transhepatic Lymphangiography and Embolization with n-Butyl-2-Cyanoacrylate Glue. Cardiovasc Intervent Radiol 2021; 44:1127-1130. [PMID: 33723667 DOI: 10.1007/s00270-021-02802-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
Hepatic lymphorrhea is a leakage from the liver's lymphatic ducts into the abdominal cavity and an extremely rare complication associated with injury of the hepatoduodenal ligament, which can lead to refractory ascites. Hepatic lymphorrhea is constituted by non-chylous ascites and can be visualized by transhepatic lymphangiography instead of pedal or intranodal lymphangiography. To date, only a few successfully treated cases using interventional procedures have been reported. Although n-butyl-2-cyanoacrylate (NBCA) glue is widely used in various cases of vascular embolization and other lymphatic leak treatments, there have been no reports of its use for post-surgical hepatic lymphorrhea. The NBCA glue embolization described in this case report may be one of the treatment options to control the refractory ascites derived from hepatic lymphorrhea.
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49
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Itkin M, Rockson SG, Witte MH, Burkhoff D, Phillips A, Windsor JA, Kassab GS, Hur S, Nadolski G, Pabon-Ramos WM, Rabinowitz D, White SB. Research Priorities in Lymphatic Interventions: Recommendations from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol 2021; 32:762.e1-762.e7. [PMID: 33610432 DOI: 10.1016/j.jvir.2021.01.269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/06/2021] [Accepted: 01/16/2021] [Indexed: 11/26/2022] Open
Abstract
Recognizing the increasing importance of lymphatic interventions, the Society of Interventional Radiology Foundation brought together a multidisciplinary group of key opinion leaders in lymphatic medicine to define the priorities in lymphatic research. On February 21, 2020, SIRF convened a multidisciplinary Research Consensus Panel (RCP) of experts in the lymphatic field. During the meeting, the panel and audience discussed potential future research priorities. The panelists ranked the discussed research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were prioritized by RCP: lymphatic decompression in patients with congestive heart failure, detoxification of thoracic duct lymph in acute illness, development of newer agents for lymphatic imaging, characterization of organ-based lymph composition, and development of lymphatic interventions to treat ascites in liver cirrhosis. The RCP priorities underscored that the lymphatic system plays an important role not only in the intrinsic lymphatic diseases but in conditions that traditionally are not considered to be lymphatic such as congestive heart failure, liver cirrhosis, and critical illness. The advancement of the research in these areas will lead the field of lymphatic interventions to the next level.
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Affiliation(s)
- Maxim Itkin
- Penn Center for Lymphatic Disorders, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Stanley G Rockson
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Marlys H Witte
- University of Arizona College of Medicine Tucson Arizona, International Society of Lymphology, Tuscon, Arizona
| | | | - Anthony Phillips
- Applied Surgery and Metabolism Laboratory, Surgical and Translational Research Centre, School of Biological Sciences & Dept. of Surgery, Auckland University, Auckland, New Zealand
| | - John A Windsor
- Surgery and Director Surgical and Translational Research Centre, University of Auckland, New Zealand
| | | | - Saebeom Hur
- Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
| | - Gregory Nadolski
- Penn Center for Lymphatic Disorders, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Waleska M Pabon-Ramos
- Pediatric Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Debbie Rabinowitz
- Department of Medical Imaging, Division of Interventional Radiology, Nemours/duPont Hospital for Children, Radiology and Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, Delaware
| | - Sarah B White
- Clinical Research and Registries Division, SIR Foundation, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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50
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Usman AA, Horak J, Wang G, Nadolski GA, Desai N, Gutsche J, Itkin M. Development of intractable ascites due to thoracic duct hypertension. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:189-192. [PMID: 33997551 PMCID: PMC8093308 DOI: 10.1016/j.jvscit.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/21/2021] [Indexed: 11/29/2022]
Abstract
We describe a 69-year-old dialysis-dependent patient who developed intractable ascites after zone 2 aortic reconstruction for a type IA thoracic endovascular aneurysm repair endoleak. Investigation as to the cause of ascites revealed a unique set of clinical circumstances leading to intractable bloody ascites. Investigation included imaging and invasive testing to diagnose the culprit mechanism. Ultimately, interventional catherization of the left subclavian vein illustrated an abnormally elevated pressure in the left subclavian vein. It was thus determined that, owing to the combination of a left brachiocephalic (innominate) vein occlusion after surgical ligation and in situ left brachiobasilic arteriovenous dialysis graft, there was overcirculation through the thoracic duct. Retrograde flow through the pop-off thoracic duct led to hematogenous ascites. Ligation of the left brachiobasilic arteriovenous dialysis graft resulted in near instantaneous and complete resolution of the ascites.
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Affiliation(s)
- Asad A Usman
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Grace Wang
- Division of Vascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Gregory A Nadolski
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Nimesh Desai
- Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Maxim Itkin
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pa
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