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Thamkittikun C, Tovichien P. Clinical approach for pulmonary lymphatic disorders. World J Clin Cases 2024; 12:6020-6026. [PMID: 39328863 PMCID: PMC11326095 DOI: 10.12998/wjcc.v12.i27.6020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/20/2024] [Accepted: 06/25/2024] [Indexed: 07/29/2024] Open
Abstract
In this editorial, we discuss the clinical implications of the article "Lymphatic plastic bronchitis and primary chylothorax: A study based on computed tomography lymphangiography" published by Li et al. Pulmonary lymphatic disorders involve abnormalities in the lymphatic tissues within the thoracic cavity. Specifically, pulmonary lymphatic perfusion syndrome describes a condition where the flow of lymphatic fluid in the lungs is redirected towards abnormally widened lymphatic vessels. Clinically, individuals with this syndrome may experience symptoms such as chyloptysis, plastic bronchitis (PB), chylothorax, chylopericardium, and interstitial lung disease. These disorders can be caused by various factors, including PB, chylothorax, and complex lymphatic malformations. Advancements in lymphatic imaging techniques, such as intranodal lymphangiography, computed tomography lymphangiography, and dynamic contrast-enhanced magnetic resonance lymphangiography, have enabled the detection of abnormal lymphatic flow. This has enhanced our understanding of the pathophysiology of these conditions. Additionally, innovative minimally invasive treatments, such as thoracic duct embolization, selective embolization of lymphatic channels, and surgical procedures aim to improve clinical condition of patients and address their dietary needs.
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Affiliation(s)
- Chalisa Thamkittikun
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Prakarn Tovichien
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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2
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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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Schaffner D, Perez MH, Duran R, Pretre R, Di Bernardo S. Case Report: Transcatheter interventional procedure to innominate vein turn-down procedure for failing fontan circulation. Front Pediatr 2024; 12:1341443. [PMID: 38379912 PMCID: PMC10876887 DOI: 10.3389/fped.2024.1341443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Fontan physiology creates a chronic state of decreased cardiac output and systemic venous congestion, leading to liver cirrhosis/malignancy, protein-losing enteropathy, chylothorax, or plastic bronchitis. Creating a fenestration improves cardiac output and relieves some venous congestion. The anatomic connection of the thoracic duct to the subclavian-jugular vein junction exposes the lymphatic system to systemic venous hypertension and could induce plastic bronchitis. To address this complication, two techniques have been developed. A surgical method that decompresses the thoracic duct by diverting the innominate vein to the atrium, and a percutaneous endovascular procedure that uses a covered stent to create an extravascular connection between the innominate vein and the left atrium. We report a novel variant transcatheter intervention of the innominate vein turn-down procedure without creating an extravascular connection in a 39-month-old patient with failing Fontan circulation complicated by plastic bronchitis and a 2-year post-intervention follow-up.
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Affiliation(s)
- Damien Schaffner
- Pediatric Cardiology Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Maria-Helena Perez
- Pediatric Intensive Care Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Rafael Duran
- Department of Radiology and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - René Pretre
- Department of Cardiac Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Stefano Di Bernardo
- Pediatric Cardiology Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
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4
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Negm AS, Collins JD, Bendel EC, Takahashi E, Knavel Koepsel EM, Gehling KJ, Burke CE, Barker DR, Stenzel WS, Bathke AM, Polites SF, Abcejo AS, Morris JM, Favazza C, Lu A, François CJ, Young P, Thompson SM. MR Lymphangiography in Lymphatic Disorders: Clinical Applications, Institutional Experience, and Practice Development. Radiographics 2024; 44:e230075. [PMID: 38271257 DOI: 10.1148/rg.230075] [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: 01/27/2024]
Abstract
Lymphatic flow and anatomy can be challenging to study, owing to variable lymphatic anatomy in patients with diverse primary or secondary lymphatic pathologic conditions and the fact that lymphatic imaging is rarely performed in healthy individuals. The primary components of the lymphatic system outside the head and neck are the peripheral, retroperitoneal, mesenteric, hepatic, and pulmonary lymphatic systems and the thoracic duct. Multiple techniques have been developed for imaging components of the lymphatic system over the past century, with trade-offs in spatial, temporal, and contrast resolution; invasiveness; exposure to ionizing radiation; and the ability to obtain information on dynamic lymphatic flow. More recently, dynamic contrast-enhanced (DCE) MR lymphangiography (MRL) has emerged as a valuable tool for imaging both lymphatic flow and anatomy in a variety of congenital and acquired primary or secondary lymphatic disorders. The authors provide a brief overview of lymphatic physiology, anatomy, and imaging techniques. Next, an overview of DCE MRL and the development of an MRL practice and workflow in a hybrid interventional MRI suite incorporating cart-based in-room US is provided, with an emphasis on multidisciplinary collaboration. The spectrum of congenital and acquired lymphatic disorders encountered early in an MRL practice is provided, with emphasis on the diversity of imaging findings and how DCE MRL can aid in diagnosis and treatment of these patients. Methods such as DCE MRL for assessing the hepatic and mesenteric lymphatic systems and emerging technologies that may further expand DCE MRL use such as three-dimensional printing are introduced. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Ahmed S Negm
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Jeremy D Collins
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Emily C Bendel
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Edwin Takahashi
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Erica M Knavel Koepsel
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Kathleen J Gehling
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Courtney E Burke
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Devin R Barker
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Wayne S Stenzel
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Angela M Bathke
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Stephanie F Polites
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Arnoley S Abcejo
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Jonathan M Morris
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Christopher Favazza
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Aiming Lu
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Christopher J François
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Phillip Young
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
| | - Scott M Thompson
- From the Department of Radiology, Division of Cardiovascular Imaging (A.S.N., J.D.C., E.T., D.R.B., W.S.S., C.F., A.L., C.J.F., P.Y., S.M.T.), Department of Radiology, Division of Vascular and Interventional Radiology (E.C.B., E.T., K.J.G., C.E.B., A.M.B., J.M.M., S.M.T.), Department of Surgery, Division of Pediatric Surgery (S.F.P.), and Department of Anesthesiology (A.S.A.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, Section of Interventional Radiology, University of Wisconsin, Madison, Wis (E.M.K.K.)
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Gipsman AI, Feld L, Johnson B, Needleman JP, Boas H, Lin N, DePasquale B, Pogoriler J, McDowell KM, Piccione JC. Eosinophilic plastic bronchitis: Case series and review of the literature. Pediatr Pulmonol 2023; 58:3023-3031. [PMID: 37606213 PMCID: PMC10928548 DOI: 10.1002/ppul.26650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 08/23/2023]
Abstract
Plastic bronchitis is a term used to describe group of life-threatening disorders characterized by the presence of large obstructing casts in the airways. Eosinophilic plastic bronchitis is a subtype of plastic bronchitis that occurs mainly in children and has not been well-described in the literature. Patients may have a history of asthma or atopy, but many do not. They often present with cough and wheezing, and frequently have complete collapse of one lung seen on imaging. The severity of presentation varies depending on the location of the casts, ranging from mild symptoms to severe airway obstruction and death. Bronchoscopy is often required to both diagnose and treat this condition. A variety of medical therapies have been used, although no formal studies have evaluated their efficacy. Symptoms may resolve after initial cast removal, but in some patients, cast formation recurs. Here, we report a case series of nine patients with eosinophilic plastic bronchitis and review the existing literature of this condition.
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Affiliation(s)
- Alexander I. Gipsman
- Division of Pulmonary and Sleep Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lance Feld
- Division of Pulmonary and Sleep Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brandy Johnson
- Division of Pulmonary and Sleep Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joshua P. Needleman
- Pediatric Pulmonary Medicine, Maimonides Medical Center, Brooklyn, New York, USA
| | - Heather Boas
- Division of Pulmonary and Sleep Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nancy Lin
- Division of Pulmonary and Sleep Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Jennifer Pogoriler
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Karen M. McDowell
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joseph C. Piccione
- Division of Pulmonary and Sleep Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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6
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Bauer C, Dori Y, Scala M, Tulzer A, Tulzer G. Current diagnostic and therapeutic strategies for the management of lymphatic insufficiency in patients with hypoplastic left heart syndrome. Front Pediatr 2023; 11:1058567. [PMID: 36911024 PMCID: PMC9999027 DOI: 10.3389/fped.2023.1058567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Children with hypoplastic left heart syndrome share unique hemodynamic features that alter lymphatic integrity at all stages of palliation. Lymphatic congestion is almost universal in this patient group to some extent. It may lead to reversal of lymphatic flow, the development of abnormal lymphatic channels and ultimately decompression and loss of protein rich lymphatic fluid into extra lymphatic compartments in prone individuals. Some of the most devastating complications that are associated with single ventricle physiology, notably plastic bronchitis and protein losing enteropathy, have now been proven to be lymphatic in origin. Based on the new pathophysiologic concept new diagnostic and therapeutic strategies have recently been developed. Dynamic contrast magnetic resonance lymphangiography is now mainstay in diagnosis of lymphatic insufficiency and allows a thorough assessment of anatomy and function of the main lymphatic compartments through intranodal, intrahepatic and intramesenteric lymphatic imaging. Contrast enhanced ultrasound can evaluate thoracic duct patency and conventional fluoroscopic lymphangiography has been refined for evaluation of patients where magnetic resonance imaging cannot be performed. Novel lymphatic interventional techniques, such as thoracic duct embolization, selective lymphatic duct embolization and liver lymphatic embolization allow to seal abnormal lymphatic networks minimally invasive and have shown to resolve symptoms. Innominate vein turn-down procedures, whether surgical or interventional, have been designed to reduce lymphatic afterload and increase systemic preload effectively in the failing Fontan circulation. Outflow obstruction can now be managed with new microsurgical techniques that create lympho-venous anastomosis. Short term results for all of these new approaches are overall promising but evidence is sparse and long-term outcome still has to be defined. This review article aims to summarize current concepts of lymphatic flow disorders in single ventricle patients, discuss new emerging diagnostic and therapeutic strategies and point out lacks in evidence and needs for further research on this rapidly growing topic.
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Affiliation(s)
- Christoph Bauer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria
- Johannes Kepler University Linz, Linz, Austria
| | - Yoav Dori
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Mario Scala
- Johannes Kepler University Linz, Linz, Austria
- Central Radiology Institute, Kepler University Hospital GmbH, Linz, Austria
| | - Andreas Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria
- Johannes Kepler University Linz, Linz, Austria
| | - Gerald Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria
- Johannes Kepler University Linz, Linz, Austria
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7
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Computed tomography of the airways and lungs in congenital heart disease. Pediatr Radiol 2022; 52:2529-2537. [PMID: 34562108 DOI: 10.1007/s00247-021-05186-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/21/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
The presence of airway and lung disease in children with congenital heart disease is commonly observed with both cardiac CT angiography and routine chest CT. In this review we discuss abnormalities encountered on CT imaging of the chest beyond the heart and central vasculature, focusing on the airways, lung parenchyma and peripheral vasculature. Preoperative and postoperative findings are reviewed as well.
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8
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Ramirez-Suarez KI, Tierradentro-García LO, Biko DM, Otero HJ, White AM, Dori Y, Smith CL, Vatsky S, Rapp JB. Lymphatic anomalies in congenital heart disease. Pediatr Radiol 2022; 52:1862-1876. [PMID: 35840695 DOI: 10.1007/s00247-022-05449-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 05/16/2022] [Accepted: 06/30/2022] [Indexed: 10/17/2022]
Abstract
Congenital heart disease can lead to various lymphatic complications including traumatic leaks, lymphatic overproduction, conduction abnormalities or lymphedema. Advancements in the imaging of central lymphatics and guided interventions have improved outcomes in these children. Dynamic contrast-enhanced magnetic resonance (MR) lymphangiography allows for the assessment of abnormal lymphatic drainage. This technique is preferred for evaluating lymphatic conditions such as plastic bronchitis, chylothorax, chyloptysis, chylopericardium, protein-losing enteropathy and chylous ascites, among other lymphatic disorders. In this review, we discuss lymphatic abnormalities encountered on MRI in children with congenital heart disease. We also briefly review treatment options.
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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
| | | | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, 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, University of Pennsylvania, Philadelphia, PA, USA
| | - Ammie M White
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yoav Dori
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher L Smith
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Seth Vatsky
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, 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, University of Pennsylvania, Philadelphia, PA, USA.
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9
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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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10
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Sun JD, Shum T, Behzadi F, Hammer MM. Imaging Findings of Thoracic Lymphatic Abnormalities. Radiographics 2022; 42:1265-1282. [PMID: 35960666 DOI: 10.1148/rg.220040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The lymphatic system plays an important role in balancing fluid compartments in the body. It is disrupted by various disease processes in the thorax, including injury to the thoracic lymphatic duct after surgery, as well as malignancy and heart failure. Because of the small size of lymphatic vessels, imaging of the lymphatics is relatively difficult, and effective imaging methods are still being optimized and developed. The standard of reference for lymphatic imaging has been conventional lymphangiography for several decades. Other modalities such as CT, noncontrast or contrast-enhanced MRI, and lymphoscintigraphy can also demonstrate lymphatic abnormalities and help in treatment planning. Imaging findings associated with lymphatic abnormalities can be seen in the pulmonary parenchyma, pleural space, and mediastinum. In the pulmonary parenchyma, common findings include interlobular septal thickening as well as reversal of lymphatic flow with intravasation of contrast material into pulmonary lymphatics. In the pleural space, findings include chylous pleural effusion and occasionally nonchylous pleural effusion. In the mediastinum, thoracic duct leak, plexiform thoracic duct, lymphatic malformations, and lymphangiectasis may occur. Management of chylothorax includes conservative or medical treatment, surgery, and interventional radiology procedures. The authors discuss thoracic lymphatic anatomy, imaging manifestations of lymphatic abnormalities in the various anatomic compartments, and interventional radiology treatment of chylothorax. Radiologists should be familiar with these imaging findings for diagnosis and to help guide appropriate management. ©RSNA, 2022.
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Affiliation(s)
- Jingshuo Derek Sun
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Thomas Shum
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Fardad Behzadi
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Mark M Hammer
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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11
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Nakano TA, Dori Y, Gumer L, Liptzin DR, Hill LRS, Kulungowski AM. How we approach pediatric congenital chylous effusions and ascites. Pediatr Blood Cancer 2022; 69 Suppl 3:e29246. [PMID: 36070215 DOI: 10.1002/pbc.29246] [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: 04/23/2021] [Revised: 06/19/2021] [Accepted: 06/27/2021] [Indexed: 11/10/2022]
Abstract
Congenital lymphatic leak may develop in patients with maldeveloped lymphatics and result in life-threatening fluid and electrolyte imbalance, protein deficiency, and immunodeficiency. Rapid diagnosis and therapy are necessary to prevent these complications; however, the field lacks clinical trials to support standardized diagnostic treatment guidelines. We present our current multidisciplinary approach to the diagnosis and management of congenital lymphatic leak including chylous pleural effusions and ascites. Depending on the rate of lymphatic leak, therapy can range from observation with nutritional modifications to surgical and interventional procedures aimed to reduce lymphatic drainage. Modalities to image central and peripheral lymphatics have advanced considerably. Genetic variants and subsequent targets that drive lymphatic maldevelopment have expanded the repertoire of possible pharmacotherapeutic options.
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Affiliation(s)
- Taizo A Nakano
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Yoav Dori
- Division of Cariology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lindsey Gumer
- Division of Pediatric Gastroenterology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Deborah R Liptzin
- Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lauren R S Hill
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Ann M Kulungowski
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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12
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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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13
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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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14
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Hosokawa T, Uchiyama M, Tanami Y, Sato Y, Wakabayashi Y, Oguma E. Insufficient hepatic uptake in pediatric patients on lymphoscintigraphy. Pediatr Int 2022; 64:e15156. [PMID: 35510682 DOI: 10.1111/ped.15156] [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: 11/10/2021] [Revised: 01/03/2022] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND To demonstrate the association between pediatric outcomes and tracer hepatic uptake as a marker of systemic circulation in lymphoscintigraphy. METHODS We included 31 initial lymphoscintigraphic studies. We compared the presence or absence of hepatic uptake between deceased and survived patients in both early and delayed images using Fisher's exact test. Kaplan-Meier survival analysis was performed based on imaging results, and these curves were compared using the log-rank test. The primary endpoint was death and the survival period was defined from the day of examination to the day of the last visit or death. RESULTS Of 31 patients, six died. Hepatic uptake was significantly different in both early and delayed images (early images, died [with/without visualization] vs. survived [with/without visualization], 0/6 vs. 13/12, P = 0.028; delayed images, died [with/without visualization] vs. survived [with/without visualization], 2/4 vs. 22/3, P = 0.014) between deceased and survived patients. Survival periods were significantly different between the two groups with and without hepatic uptake in early and delayed images (with/without visualization in early imags = 1,177.1 ± 773.8 days/426.7 ± 419.8 days, P = 0.008 and with/without visualization in delayed images = 821.3 ± 738.0 days/467.4 ± 452.4 days, P = 0.003). CONCLUSIONS Visualization of hepatic uptake in both early and delayed lymphoscintigraphy is associated with patient outcomes. Hepatic uptake could represent tracer inflow into the systemic circulation, indicating preservation of the connection between the lymphatic system and the systemic circulation. Physicians should evaluate these findings carefully on lymphoscintigraphy.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Mayuki Uchiyama
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yasuharu Wakabayashi
- Division of Radiological Technology, Saitama Prefectural Children's Medical Center, Saitama, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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15
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Pałyga-Bysiecka I, Polewczyk AM, Polewczyk M, Kołodziej E, Mazurek H, Pogorzelski A. Plastic Bronchitis—A Serious Rare Complication Affecting Children Only after Fontan Procedure? J Clin Med 2021; 11:jcm11010044. [PMID: 35011785 PMCID: PMC8745351 DOI: 10.3390/jcm11010044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Plastic bronchitis (PB) may occur not only in children following palliative Fontan procedure but also in those without underlying heart disease. We aim to assess the clinical course, therapeutic measures, outcome, and follow-up of PB in children with congenital heart disease (CHD) and children without cardiac problems. Methods: This retrospective case series assessed children with PB admitted to hospital between 2015 and 2019. Parents or guardians of patients were contacted by e-mail or telephone between September 2017 and June 2019 to enquiry about recurrence of PB and strategy of treatment. The diagnosis of PB was based on the expectoration (spontaneous or during bronchoscopy) of endobronchial plugs. Results: This study delineated the clinical, histological, and laboratory features of plastic bronchitis in children following Fontan procedure (Group A) and in those without heart defects (Group B, non-CHD children). The main symptoms were cough accompanied by dyspnea, and hypoxemia with a decrease in oxygen saturation, often leading to acute respiratory failure. In children with CHD, the first episode of PB occurred at a relatively young age. Although chronic, i.e., lasting more than 3 weeks, inhaled therapy was implemented in both groups of patients, the recurrences of PB were observed. The mean time to PB recurrence after the first episode in Group A was longer than that in Group B (1.47 vs. 0.265 years, p = 0.2035). There was no re-episode with recurrence of PB in 3 cases out of 10 in total in Group A (30%) and 1 case out of 4 in total in Group B (25%). While the majority of children in Group A usually developed bronchial casts on the right side, the patients in Group B (without CHD) suffered from bronchial casts located only on the left side. Conclusions: Despite many similarities, clinical, histological, and laboratory studies in the children with plastic bronchitis after Fontan’s surgery and in children without heart defects suggest that there are differences in the course of the disease in patients without CHD, such as a more advanced age of the first episode of PB, the location of plastic casts on the left side, and a stronger role of inflammatory factors and mechanisms. Further research is needed to understand the pathophysiology of PB and choose the most appropriate therapy.
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Affiliation(s)
- Ilona Pałyga-Bysiecka
- First Department of Pediatrics, Swietokrzyskie Pediatric Center, 25-736 Kielce, Poland; (A.M.P.); (E.K.)
- Collegium Medicum, Jan Kochanowski University, 25-736 Kielce, Poland;
- Correspondence: ; Tel.: +48-413303326
| | - Aneta Maria Polewczyk
- First Department of Pediatrics, Swietokrzyskie Pediatric Center, 25-736 Kielce, Poland; (A.M.P.); (E.K.)
- Collegium Medicum, Jan Kochanowski University, 25-736 Kielce, Poland;
| | - Maciej Polewczyk
- Collegium Medicum, Jan Kochanowski University, 25-736 Kielce, Poland;
| | - Elżbieta Kołodziej
- First Department of Pediatrics, Swietokrzyskie Pediatric Center, 25-736 Kielce, Poland; (A.M.P.); (E.K.)
| | - Henryk Mazurek
- Department of Pneumology and Cystic Fibrosis, Institute of Tuberculosis and Lung Diseases, 03-700 Rabka-Zdrój, Poland; (H.M.); (A.P.)
| | - Andrzej Pogorzelski
- Department of Pneumology and Cystic Fibrosis, Institute of Tuberculosis and Lung Diseases, 03-700 Rabka-Zdrój, Poland; (H.M.); (A.P.)
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16
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Hubrechts J, Wåhlander H, Kjellberg-Olofsson C, Maleux G, Gewillig M. Case Report: Disseminated Systemic Embolism of Lipiodol After Lymphography for Plastic Bronchitis After Fontan Repair. Front Pediatr 2020; 8:584185. [PMID: 33194917 PMCID: PMC7652765 DOI: 10.3389/fped.2020.584185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/24/2020] [Indexed: 11/26/2022] Open
Abstract
Lipiodol-based lymphangiography is not only a diagnostic tool for visualization of lymphatic disorders such as plastic bronchitis (PB), but also aims a therapeutic effect by embolizing lymph leakages. We performed such percutaneous lymphatic embolization for PB in a Fontan patient with proven absence of right-to-left shunt, and demonstrated important lymphatic abnormalities in the mediastinum. Shortly after the procedure, the patient developed severe convulsive seizures, revealing multiple cerebral embolisms of Lipiodol. Radiological images were impressive, yet the clinical neurological outcome was favorable. Lipiodol-based lymphography in Fontan patients with plastic bronchitis should be avoided as this subgroup is more likely to have developed lympho-pulmonary venous connections which allow systemic emboli.
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Affiliation(s)
- Jelena Hubrechts
- Department of Pediatric and Congenital Cardiology, Leuven University Hospital, Leuven, Belgium
| | - Håkan Wåhlander
- Pediatric Heart Center, The Queen Silvia Children's Hospital, Gothenburg, Sweden.,Department of Pediatrics, Institute for Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | | | - Geert Maleux
- Interventional Radiology, Leuven University Hospital, Leuven, Belgium
| | - Marc Gewillig
- Department of Pediatric and Congenital Cardiology, Leuven University Hospital, Leuven, Belgium
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