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Venkatesh P, Gao H, Abudayyeh I, Pai RG, Varadarajan P. Contemporary Management of the Failing Fontan. J Clin Med 2024; 13:3049. [PMID: 38892760 PMCID: PMC11172880 DOI: 10.3390/jcm13113049] [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: 04/17/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Adult patients with congenital heart disease have now surpassed the pediatric population due to advances in surgery and improved survival. One such complex congenital heart disease seen in adult patients is the Fontan circulation. These patients have complex physiology and are at risk for several complications, including thrombosis of the Fontan pathway, pulmonary vascular disease, heart failure, atrial arrhythmias, atrioventricular valve regurgitation, and protein-losing enteropathy. This review discusses the commonly encountered phenotypes of Fontan circulatory failure and their contemporary management.
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Affiliation(s)
- Prashanth Venkatesh
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (P.V.); (H.G.)
| | - Hans Gao
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (P.V.); (H.G.)
| | | | - Ramdas G. Pai
- California University of Science and Medicine, Colton, CA 92324, USA;
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2
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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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3
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Tomasulo CE, Dori Y, Smith CL. Understanding the next circulation: lymphatics and what the future holds. Curr Opin Cardiol 2023; 38:369-374. [PMID: 37195304 DOI: 10.1097/hco.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
PURPOSE OF REVIEW The lymphatic system was previously considered the forgotten circulation because of an absence of adequate options for imaging and intervention. However, recent advances over the last decade have improved management strategies for patients with lymphatic disease, including chylothorax, plastic bronchitis, ascites, and protein-losing enteropathy. RECENT FINDINGS New imaging modalities have enabled detailed visualization of lymphatic vessels to allow for a better understanding of the cause of lymphatic dysfunction in a variety of patient subsets. This sparked the development of multiple transcatheter and surgery-based techniques tailored to each patient based on imaging findings. In addition, the new field of precision lymphology has added medical management options for patients with genetic syndromes, who have global lymphatic dysfunction and typically do not respond as well to the more standard lymphatic interventions. SUMMARY Recent developments in lymphatic imaging have given insight into disease processes and changed the way patients are managed. Medical management has been enhanced and new procedures have given patients more options, leading to better long-term results.
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Affiliation(s)
| | - Yoav Dori
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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4
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Benjamin J, O'Leary C, Hur S, Gurevich A, Klein WM, Itkin M. Imaging and Interventions for Lymphatic and Lymphatic-related Disorders. Radiology 2023; 307:e220231. [PMID: 36943078 DOI: 10.1148/radiol.220231] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The lymphatic system is critical in fluid balance homeostasis. Yet, until recently, lymphatic imaging has been outside of mainstream medicine due to a lack of robust imaging and interventional options. However, during the last 20 years, both clinical lymphatic imaging and interventions have shown dramatic advancement. The key to imaging advancement has been the interstitial delivery of contrast agents through lymphatic-rich tissues. These techniques include intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography. These methods provide the ability to image and recognize lymphatic anatomy and pathologic conditions. Percutaneous thoracic duct catheterization and embolization became the first widely accepted interventional technique for the management of chyle leaks. Advances in interstitial lymphatic embolization, as well as liver and mesenteric lymphatic interventions, have broadened the scope of possible lymphatic interventions. Also, recent techniques of lymphatic decompression allow for the treatment of a variety of lymphatic disorders. Finally, immunologic studies of central lymphatic fluid reveal the potential of lymphatic interventions on immunity. These advances herald an exciting new chapter for lymphatic imaging and interventions in the coming years.
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Affiliation(s)
- Jamaal Benjamin
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Cathal O'Leary
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Saebeom Hur
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Alexey Gurevich
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Willemijn M Klein
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Maxim Itkin
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
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5
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Hur S, Kim J, Ratnam L, Itkin M. Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part II. Classification and Treatment of the Lymphatic Disorders. Korean J Radiol 2023; 24:109-132. [PMID: 36725353 PMCID: PMC9892215 DOI: 10.3348/kjr.2022.0689] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/03/2022] [Accepted: 11/14/2022] [Indexed: 01/28/2023] Open
Abstract
Lymphatic disorders encompass a broad spectrum of diseases involving the lymphatic system, ranging from traumatic lymphatic leaks to lymphatic malformations. Lymphatic disorders can be categorized into traumatic and non-traumatic disorders according to their etiology. These two categories may be further divided into subgroups depending on the anatomical location of the lymphatic pathology and their association with clinical syndromes. Thoracic duct embolization was a milestone in the field of lymphatic intervention that encouraged the application of percutaneous embolization techniques to treat leaks and reflux disorders in the lymphatic system. Additional access routes for embolization, including retrograde thoracic duct and transhepatic lymphatic access, have also been developed. This article comprehensively reviews a variety of options for the treatment of lymphatic disorders, from conservative management to the most recent embolization techniques.
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Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jinoo Kim
- Department of Radiology, Ajou University Hospital, Suwon, Korea.
| | - Lakshmi Ratnam
- Department of Radiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Maxim Itkin
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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6
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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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7
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Rabinowitz D, Dysart K, Itkin M. Neonatal lymphatic flow disorders: central lymphatic flow disorder and isolated chylothorax, diagnosis and treatment using novel lymphatic imaging and interventions technique. Curr Opin Pediatr 2022; 34:191-196. [PMID: 35102115 DOI: 10.1097/mop.0000000000001109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Neonatal lymphatic disorders (NLDs) are conditions that are relatively rare and difficult to treat. The recent development of lymphatic imaging, such as Dynamic Contrast-Enhanced MR Lymphangiography and Intranodal Lymphangiography has led to a new, better understanding of the anatomical substrate and pathophysiological mechanisms of the diseases. Consequently, this has allowed the development of new targeted therapeutic interventions as well as prognostication for this population with lymphatic flow disorders. RECENT FINDINGS The underlying causes of all NLD is an obstruction or altered flow of the central lymphatic flow. Two types of NLD have been described: isolated neonatal chylothorax and central lymphatic flow disorder (CLFD). Isolated neonatal chylothorax can be treated successfully with oil-based contrast (lipiodol) embolization. CLFD secondary to obstruction of the thoraco-venous junction can be successfully treated with surgical thoracic duct-venous anastomosis. CLFD caused by elevated central pressure and/or thoracic duct dysplasia can be treated medically, including with new systemic therapies such as mammalian target of rapamycin inhibitors. SUMMARY New diagnostic and interventional tools have recently allowed for classification, prognostication, and targeted interventions for neonatal patients with lymphatic flow disorders. Further research will build on these discoveries.
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Affiliation(s)
- Deborah Rabinowitz
- Division of Interventional Radiology, Department of Medical Imaging, Nemours Children's Hospital, Delaware, Wilmington, Delaware
- Department of Radiology and Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kevin Dysart
- Division of Neonatal-Perinatal Medicine, Department of Neonatology, Nemours Children's Hospital, Delaware, Wilmington, Delaware
| | - Maxim Itkin
- Center for Lymphatic Imaging, Penn Medicine, Hospital of the University of Pennsylvania
- Department of Radiology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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8
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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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Ngeow AJH, Chan MY, Teoh OH, Sanamandra SK, Chan DKL. Non-immune hydrops fetalis secondary to congenital chylothorax with diffuse interstitial lung disease: a diagnostic conundrum. BMJ Case Rep 2021; 14:14/4/e240688. [PMID: 33863770 PMCID: PMC8055142 DOI: 10.1136/bcr-2020-240688] [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: 11/03/2022] Open
Abstract
A Chinese male infant was born at 35 weeks weighing 2935 g to a mother with polyhydramnios and prenatal hydrops fetalis. He developed marked respiratory distress secondary to bilateral congenital chylothorax and required pleural drainage, high frequency oscillation and inhaled nitric oxide therapy. He was extubated to non-invasive ventilation by day 14. There was no bacterial or intrauterine infection, haematologic, chromosomal or cardiac disorder. He was exclusively fed medium-chain triglyceride formula. High-resolution CT showed diffuse interstitial lung disease. He received a dexamethasone course for chronic lung disease to facilitate supplemental oxygen weaning. A multidisciplinary team comprising neonatology, pulmonology, haematology, interventional radiology and thoracic surgery considered congenital pulmonary lymphangiectasia as the most likely diagnosis and advised open lung biopsy, lymphangiography or scintigraphy for diagnostic confirmation should symptoms of chylothorax recur. Fortunately, he was weaned off oxygen at 5 months of life, and tolerated human milk challenge at 6 months of life and grew well.
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Affiliation(s)
- Alvin Jia Hao Ngeow
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
| | - Mei Yoke Chan
- Haematology/Oncology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Oon Hoe Teoh
- Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | | | - Daisy Kwai Lin Chan
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
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Itkin M, Pizarro C, Radtke W, Spurrier E, Rabinowitz DA. Lymphatic Management in Single-Ventricle Patients. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 23:41-47. [PMID: 32354546 DOI: 10.1053/j.pcsu.2020.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/01/2020] [Accepted: 03/05/2020] [Indexed: 01/04/2023]
Abstract
Lymphatic complications in patients with single ventricle include plastic bronchitis, protein-losing enteropathy, and chylous pleural effusion are a source of significant morbidity and mortality with historically limited therapeutic options. Novel lymphatic imaging techniques such as intranodal lymphangiography, dynamic contrast enhanced magnetic resonance lymphangiography and liver lymphangiography have allowed visualization of the lymphatic system and discovery of the pathophysiological mechanism of these conditions. This mechanism includes the combination of 2 factors: increased lymphatic flow in patients with elevated central venous pressure and presence of the lymphatic anatomical variant that allows the lymph to flow in close proximity to the serous (pleural space in chylothorax) or mucosal (plastic bronchitis and protein losing enteropathy) surfaces. Novel minimally invasive lymphatic interventional techniques, such as thoracic duct embolization, interstitial embolization and liver lymphatic embolization have allowed the obliteration of these abnormal lymphatic networks, resulting in resolution of the symptoms. Further refinement of the imaging techniques and interventional methods have subsequently allowed better patient selection and improved long term outcome of these procedures.
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Affiliation(s)
- Maxim Itkin
- Neours/Dupont Children's Hospital, Wilmington, Delaware; Penn Medicine, Perelman School of Medicine, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania.
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11
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Neonatal lymphatic flow disorders: impact of lymphatic imaging and interventions on outcomes. J Perinatol 2021; 41:494-501. [PMID: 32879418 DOI: 10.1038/s41372-020-00771-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 07/16/2020] [Accepted: 08/03/2020] [Indexed: 11/09/2022]
Abstract
UNLABELLED Neonatal chylothorax (NCTx) and central lymphatic flow disorder (CLFD) are historically challenging neonatal disorders with high morbidity and mortality. METHODS We conducted a retrospective study of 35 neonates with pulmonary lymphatic abnormalities at our institution who underwent lymphatic evaluation between December 2015 and September 2018. Patients with only pulmonary lymphatic perfusion syndrome were classified as NCTx and those with multiple flow abnormalities were classified as CLFD. Demographics, clinical characteristics, and outcomes were compared using t-tests/Wilcoxon rank sum tests and Fisher's exact tests. RESULTS All 35 patients had intranodal MR lymphangiography and 14 (40%) also had conventional fluoroscopic lymphangiography. Fifteen (42.8%) patients were diagnosed with NCTx and 20 (57.1%) were diagnosed with CLFD. Thirty-four (97.1%) patients had pleural effusions. None of the NCTx group had ascites, anasarca, or dermal backflow compared to 17 (85%) (p < 0.001), 8 (42.1%) (p: 0.004), and 20 (100%) (p < 0.001) of the CLFD group, respectively. In the NCTx group, 11 (73.3%) had ethiodized oil embolization and 4 (26.7%) received conservative therapy. Ten (50%) of the CLFD patients had an intervention; of those, two (10%) had ethiodized oil-only embolization. Eight had non-ethiodized oil embolizations (two (25%) had embolization with glue, three (37.5%) underwent surgical lymphovenous anastomosis, two (25%) underwent thoracic duct (TD) externalization, and one (12.5%) had a non-TD lymphatic channel drain placed). Complete resolution of pleural effusions was achieved in all 15 NCTx patients, whereas 9 (45%) of 20 CLFD patients had resolution of chylothorax (p: 0.001). CONCLUSIONS Establishing a diagnosis of NCTx or CLFD is paramount in selecting treatment options and providing prognostic information. Development of lymphatic interventions represents a paradigm shift in our understanding of neonatal lymphatic flow disorders and may be associated with improved survival.
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12
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Neville JJ, Chacon CS, Jordan S, Roberton B, Semple T, Padley S, Clarke SA. Use of lymphangiography in neonates prior to thoracic duct ligation. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2020.101699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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13
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Lymphatic Disorders and Management in Patients with Congenital Heart Disease. Ann Thorac Surg 2020; 113:1101-1111. [PMID: 33373590 DOI: 10.1016/j.athoracsur.2020.10.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/11/2020] [Accepted: 10/05/2020] [Indexed: 11/20/2022]
Abstract
Congenital heart disease can lead to significant lymphatic complications such as chylothorax, plastic bronchitis, protein losing enteropathy and ascites. Recent improvements in lymphatic imaging and the development of new lymphatic procedures can help alleviate symptoms and improve outcomes.
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14
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Barrera CA, Victoria T, Escobar FA, Krishnamurthy G, Smith CL, Moldenhauer JS, Biko DM. Imaging of fetal lymphangiectasias: prenatal and postnatal imaging findings. Pediatr Radiol 2020; 50:1872-1880. [PMID: 33252755 DOI: 10.1007/s00247-020-04673-6] [Citation(s) in RCA: 4] [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: 12/13/2019] [Revised: 02/25/2020] [Accepted: 03/31/2020] [Indexed: 12/22/2022]
Abstract
Lymphangiectasias are lymphatic malformations characterized by the abnormal dilation and morphology of the lymphatic channels. The classification and treatment of these disorders can be challenging given the limited amount of literature available in children. Various imaging modalities are used to confirm suspected diagnosis, plan the most appropriate treatment, and estimate a prognosis. Prenatal evaluation is performed using both prenatal US imaging and fetal MRI. These modalities are paramount for appropriate parental counseling and planning of perinatal care. During the neonatal period, chest US imaging is a useful modality to evaluate pulmonary lymphangiectasia because other modalities such as conventional radiography and CT display nonspecific findings. Finally, the recent breakthroughs in lymphatic imaging with MRI have allowed us to better classify lymphatic disorders. Dynamic contrast-enhanced lymphangiography, conventional lymphangiography and percutaneous lymphatic procedures offer static and dynamic evaluation of the central conducting lymphatics in children, with excellent spatial resolution and the possibility to provide treatment. The purpose of this review is to discuss the normal and abnormal development of the fetal lymphatic system and how to best depict it by imaging during the prenatal and postnatal life.
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Affiliation(s)
- Christian A Barrera
- Department of Radiology, Children's Hospital of Philadelphia,, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Teresa Victoria
- Department of Radiology, Children's Hospital of Philadelphia,, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Fernando A Escobar
- Department of Radiology, Section of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- Department of Radiology, Section of Interventional Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher L Smith
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julie S Moldenhauer
- Center for Fetal Diagnosis and Treatment,, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine,, University of Pennsylvania, Philadelphia, PA, USA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia,, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
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Itkin M, Chidekel A, Ryan KA, Rabinowitz D. Abnormal pulmonary lymphatic flow in patients with paediatric pulmonary lymphatic disorders: Diagnosis and treatment. Paediatr Respir Rev 2020; 36:15-24. [PMID: 32792289 DOI: 10.1016/j.prrv.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023]
Abstract
Pulmonary lymphatic disorders are characterized by the presence of the abnormal lymphatic tissues in the thoracic cavity, presenting clinically as chylothorax, chylopericardium, chyloptysis, interstitial lung disease and plastic bronchitis. These conditions include: neonatal chylothorax, cardiac and non-cardiac plastic bronchitis, non-traumatic chylothorax, post congenital cardiac surgery chylothorax and complex lymphatic malformations. Recently developed lymphatic imaging techniques, such as intranodal lymphangiography and dynamic contrast enhanced magnetic resonance lymphangiography demonstrated abnormal pulmonary lymphatic flow from thoracic duct into pulmonary parenchyma as a pathophysiological mechanism of these diseases. Novel minimally invasive lymphatic interventions, such as thoracic duct embolization, interstitial lymphatic embolization and surgical lympho-venous anastomosis, provide an effective treatment of these conditions.
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Affiliation(s)
- Maxim Itkin
- Center for Lymphatic Imaging, Penn Medicine, United States; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
| | - Aaron Chidekel
- Department of Pediatrics, Division of Pulmonology and Sleep Medicine, Nemours/duPont Hospital for Children, Wilmington, DE, United States; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Kelly A Ryan
- Cardiac Center, Nemours/duPont Hospital for Children, Wilmington, DE, United States; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Deborah Rabinowitz
- Dept of Medical Imaging, Division of Interventional Radiology, Nemours/duPont Hospital for Children, Wilmington, DE, United States; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
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16
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Rabinowitz D, Itkin M. Pediatric Lymphatics Review: Current State and Future Directions. Semin Intervent Radiol 2020; 37:414-419. [PMID: 33041488 DOI: 10.1055/s-0040-1715876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Deborah Rabinowitz
- Division of Interventional Radiology, Department of Medical Imaging, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.,Department of Radiology and Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Maxim Itkin
- Center for Lymphatic Imaging, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia Pennsylvania
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17
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Pieper CC. Nodal and Pedal MR Lymphangiography of the Central Lymphatic System: Techniques and Applications. Semin Intervent Radiol 2020; 37:250-262. [PMID: 32773950 DOI: 10.1055/s-0040-1713442] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Novel lymphatic imaging and interventional techniques are increasingly used in the diagnostic workup and treatment of pathologies of the central lymphatic system and have opened a new field of interventional radiology. The mainstay of lymphatic imaging today is magnetic resonance lymphangiography (MRL). It provides information on the anatomy of the central lymphatic system, lymphatic flow, as well as lymphatic pathologies and therefore is a valuable tool for treatment planning. There are two techniques to perform contrast-enhanced MRL: nodal dynamic contrast-enhanced MRL (nodal DCE-MRL) and interstitial transpedal MRL (tMRL). Nodal DCE-MRL yields superior information on lymphatic flow dynamics and is therefore best suited for suspected lymphatic flow pathologies and lymphatic malformations. tMRL is a technically simpler alternative for central lymphatic visualization without the need for sonographically guided lymph node cannulation. This review article describes current MRL techniques with a focus on contrast-enhanced MRL, their specific advantages, and possible clinical applications in patients suffering from pathologies of the central lymphatic system.
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Affiliation(s)
- Claus Christian Pieper
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University Hospital Bonn, Bonn, Germany
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18
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Chavhan GB, Lam CZ, Greer MLC, Temple M, Amaral J, Grosse-Wortmann L. Magnetic Resonance Lymphangiography. Radiol Clin North Am 2020; 58:693-706. [PMID: 32471538 DOI: 10.1016/j.rcl.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Dynamic contrast-enhanced magnetic resonance lymphangiography is a novel technique to image central conducting lymphatics. It is performed by injecting contrast into groin lymph nodes and following passage of contrast through lymphatic system using T1-weighted MR images. Currently, it has been successfully applied to image and plan treatment of thoracic duct pathologies, lymphatic leaks, and other lymphatic abnormalities such as plastic bronchitis. It is useful in the assessment of chylothorax and chyloperitoneum. Its role in other areas such as intestinal lymphangiectasia and a variety of lymphatic anomalies is likely to increase.
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Affiliation(s)
- Govind B Chavhan
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Christopher Z Lam
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Michael Temple
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Image Guided Therapy (IGT), Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joao Amaral
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Image Guided Therapy (IGT), Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lars Grosse-Wortmann
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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19
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Itkin M, Rabinowitz DA, Nadolski G, Stafler P, Mascarenhas L, Adams D. Abnormal Pulmonary Lymphatic Flow in Patients With Lymphatic Anomalies and Respiratory Compromise. Chest 2020; 158:681-691. [PMID: 32220591 DOI: 10.1016/j.chest.2020.02.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/09/2020] [Accepted: 02/15/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Pulmonary involvement in lymphatic anomalies (LA) is associated with significant morbidity and mortality. Dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) is capable of imaging the lymphatic system in a variety of pulmonary lymphatic disorders. RESEARCH QUESTION The objective of this study is to describe the central lymphatic anatomy in patients with LA and pulmonary involvement on DCMRL. STUDY DESIGN AND METHODS This prospective observational study enrolled 16 patients with LA (mean age, 17 years; range, 6-63 years; ratio of female to male patients, 9:7) with pulmonary involvement. All patients underwent DCMRL. The lymphatic system was assessed for the presence of mediastinal masses, interstitial lung disease, size and tortuosity of the thoracic duct (TD), and presence of abnormal pulmonary lymphatic flow. RESULTS T2-weighted imaging showed the following: mediastinal soft tissue masses in 10 patients, diffuse pulmonary interstitial thickening in 13 patients, and bone involvement in 15 patients. DCMRL revealed abnormal pulmonary lymphatic flow in 14 of 16 patients. Abnormal pulmonary lymphatic flow originated from the TD in three of 14 patients, the retroperitoneum in six of 14 patients, and both the TD and retroperitoneum in four of 14 patients. In nine of 16 patients, the TD was dilated and tortuous. In two patients the TD was not identified, and in five patients it was normal. INTERPRETATION Abnormal pulmonary lymphatic flow/perfusion from the TD or retroperitoneum into the lung parenchyma occurred in the majority of patients in this study. These findings can explain the interstitial lung disease and chylothorax resulting in deterioration of respiratory function in these patients. Future studies will determine whether mechanical cessation of this abnormal flow can improve pulmonary function and prolong survival in patients with LA. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov; No.: NCT02744027; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Maxim Itkin
- Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Radiology, Nemours/AI DuPont Children's Hospital, Wilmington, DE.
| | | | - Gregory Nadolski
- Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Patrick Stafler
- Pulmonary Institute, Schneider Children's Medical Center, Petach-Tikva, Israel
| | - Leo Mascarenhas
- Division of Oncology and Hematology, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Denise Adams
- Cancer and Blood Disorders Center, Boston Children's Hospital, Boston, MA
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Abstract
Lipiodol is an iodinated poppy seed oil first synthesized in 1901. Originally developed for therapeutic purposes, it has mainly become a diagnostic contrast medium since the 1920s. At the end of the 20th century, Lipiodol underwent a transition back to a therapeutic agent, as exemplified by its increasing use in lymphangiography and lymphatic interventions. Nowadays, indications for lymphangiography include chylothorax, chylous ascites, chyluria, and peripheral lymphatic fistula or lymphoceles. In these indications, Lipiodol alone has a therapeutic effect with clinical success in 51% to 100% of cases. The 2 main access sites to the lymphatic system for lymphangiography are cannulation of lymphatic vessels in the foot (transpedal) and direct puncture of (mainly inguinal) lymph nodes (transnodal). In case of failure of lymphangiography alone to occlude the leaking lymphatic vessel as well as in indications such as protein-losing enteropathy, postoperative hepatic lymphorrhea, or plastic bronchitis, lymphatic vessels can also be embolized directly by injecting a mixture of Lipiodol and surgical glues (most commonly in thoracic duct embolization). The aim of this article is to review the historical role of Lipiodol and the evolution of its clinical application in lymphangiography over time until the current state-of-the-art lymphatic imaging techniques and interventions.
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21
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Biko DM, Johnstone JA, Dori Y, Victoria T, Oliver ER, Itkin M. Recognition of Neonatal Lymphatic Flow Disorder: Fetal MR Findings and Postnatal MR Lymphangiogram Correlation. Acad Radiol 2018; 25:1446-1450. [PMID: 29580790 DOI: 10.1016/j.acra.2018.02.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 02/13/2018] [Accepted: 02/18/2018] [Indexed: 11/18/2022]
Abstract
RATIONALE AND OBJECTIVES This study aimed to describe prenatal and postnatal imaging features and outcomes of neonates with neonatal lymphatic disorders (NLDs). MATERIALS AND METHODS An institutional review board-approved search of the radiology database for patients with NLD identified five patients. Inclusion criteria include prenatal imaging (fetal magnetic resonance [MR] imaging and ultrasound) and postnatal three-dimensional T2 Sampling Perfection with Application optimized Contrasts using different flip angle Evolution (SPACE) and dynamic contrast-enhanced MR lymphangiography within 6 months of life. Chart review was undertaken to evaluate morbidity and mortality. RESULTS Prenatal finding of "nutmeg lung" or fetal pulmonary lymphatic disorder was identified in all five patients on fetal MR imaging, and in four of five patients on fetal ultrasound. Postnatal dynamic contrast-enhanced MR lymphangiography demonstrated abnormal lymphatic flow to the lungs in four of five patients, but absent in the single patient with coexisting hypoplastic left heart syndrome (HLHS). Dermal backflow was seen in one patient, also the only patient with prenatal body wall edema. Three patients with lymphatic flow to the lungs only were classified as neonatal chylothorax. The patient with dermal backflow and perfusion to the lungs was diagnosed with central lymphatic flow disorder (CLFD). The HLHS patient with normal lymphatic perfusion maintained the HLHS diagnosis. Of the five patients, the patient with CLFD and the one with HLHS expired because of respiratory distress. CONCLUSIONS NLDs can be recognized on prenatal and postnatal imaging and may be primary, as in neonatal chylothorax or CLFD, or secondary. In this small series, "nutmeg lung" was present in all patients. Prenatal imaging demonstrates that body wall edema may correlate with postnatal dermal backflow, which, in our small cohort, carried a poor prognosis.
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Affiliation(s)
- David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 190104.
| | | | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia
| | - Teresa Victoria
- Department of Radiology, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 190104
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 190104
| | - Maxim Itkin
- Department of Radiology, Hospital of the University of Pennsylvania, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
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22
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Jobes DR, Brown LA, Dori Y, Itkin M, Nicolson SC. Lymphatic imaging and intervention in a pediatric population: Anesthetic considerations. Paediatr Anaesth 2018; 28:507-512. [PMID: 29687529 DOI: 10.1111/pan.13385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2018] [Indexed: 11/29/2022]
Abstract
The recent adoption of an improved lymphatic access technique coupled with Dynamic Contrast-enhanced Magnetic Resonance Lymphangiography has introduced the ability to diagnose and treat severe lymphatic disorders unresponsive to other therapies. All pediatric patients presenting for lymphatic procedures require general anesthesia presenting challenges in managing highly morbid and comorbid conditions both from logistical as well as medical aspects. General anesthesia is used because of the procedural requirement for immobility to accurately place needles and catheters, treat pain secondary to contrast and glue injections, and to accommodate additional procedures. We reviewed a one-year cohort of all pediatric patients in a newly created Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for lymphatic procedures. The patients ranged in age from 4 days to 17 years and weighed from 2.5 to 92 kg. There were 106 anesthetics for 68 patients. Patients were functionally impaired (98% ASA 3 or 4) and included significant comorbidities (79.4%). Concurrent with lymphatic imaging and intervention additional procedures were frequently performed (76%). They included cardiac catheterization, bronchoscopy, endoscopy, and drain placement (thoracic or abdominal). Paralysis and controlled ventilation was used for all interventions. Reversal of paralysis and tracheal extubation occurred in all patients not previously managed by invasive respiratory support. All patients having an intervention were admitted to intensive care for observation where escalation of care or complications (fever, hypotension, bleeding, or stroke) occurred in 25% in the first 24 hours.
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Affiliation(s)
- David R Jobes
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lauren A Brown
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yoav Dori
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maxim Itkin
- Department of Radiology, Division of Interventional Radiology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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23
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Luo X, Zhang Z, Wang S, Gu X, Wang X. Chyloptysis with chylopericardium, a rare case and mini-review. BMC Pulm Med 2018; 18:21. [PMID: 29375033 PMCID: PMC5787927 DOI: 10.1186/s12890-018-0583-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 01/11/2018] [Indexed: 11/30/2022] Open
Abstract
Background Chyloptysis is reflux of chyle into the lungs and is a rare manifestation of primary chylous disorders. Case presentation Over 29 months, on the basis of x-rays, a 33-year-old female was repeatedly misdiagnosed with recurrent right-sided pneumonia; her symptoms included a recurrent cough, the appearance of cheese-like sputum, and diffuse pulmonary exudates. There was a history that abundant fluid in the pericardium was confirmed with echocardiography to have been present and asymptomatic for 4 years. Lymphangiography and surgery confirmed that the terminal portion of the thoracic duct was compressed by thick fibrous tissue and the vascular sheath of the internal jugular vein. Chyloptysis caused by high peribronchial lymphatic pressure was diagnosed and surgical intervention relieved the symptoms. Conclusion Chyloptysis is rare and easy to misdiagnose but is a typical symptom of chylous reflux syndrome.
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Affiliation(s)
- Xuming Luo
- Department of Respiratory Medicine, PutuoHospital, Shanghai University of Traditional Chinese Medicine, Shanghai, No.164, LanXi Road, Shanghai, 200062, China
| | - Zhuhua Zhang
- Department of Respiratory Medicine, PutuoHospital, Shanghai University of Traditional Chinese Medicine, Shanghai, No.164, LanXi Road, Shanghai, 200062, China
| | - ShiQiang Wang
- Department of Respiratory Medicine, PutuoHospital, Shanghai University of Traditional Chinese Medicine, Shanghai, No.164, LanXi Road, Shanghai, 200062, China
| | - XianDong Gu
- Department of Respiratory Medicine, PutuoHospital, Shanghai University of Traditional Chinese Medicine, Shanghai, No.164, LanXi Road, Shanghai, 200062, China
| | - Xiongbiao Wang
- Department of Respiratory Medicine, PutuoHospital, Shanghai University of Traditional Chinese Medicine, Shanghai, No.164, LanXi Road, Shanghai, 200062, China.
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Abstract
Congenital pulmonary lymphangiectasia (CPL) is a rare but fatal disease, usually having an onset from the first few hours to days after birth. Inconsistent nomenclatures were used for CPL in the past decades. Patients often present with intractable respiratory failure, hydrops fetalis and even sudden death. The etiologies of CPL remain unclear. Previous hypotheses suggested that CPL might be caused by conditions preventing normal regression of the lymphatics after the 18th-20th week of gestation. Up-to-date biological studies on lymphatic development, lymphatic valve formation and occurrence of hydrops fetalis revealed possible causative relations with mutations of genes of the vascular endothelial growth factor receptor (VEGFR), RAS/MAPK, PI3K/AKT and NF-κB signaling pathways. Lung biopsy with subsequent histological and immunohistochemical studies is a gold standard of CPL diagnosis. Apart from symptomatic and supportive treatments, novel regimens including sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, one of the inhibitors of the pertinent signaling pathways and ethiodized oil lymphatic embolization under ultrasound-guided intranodal lymphangiography have shown encouraging short-term therapeutic effects for lymphatic anomalies. Surgical operations (lobectomy or pneumonectomy) can be the treatment of choice for patients with CPL confined to one lobe or one lung. Patients with CPL usually have a poor prognosis and often die during the neonatal period. Their prognoses are expected to improve with the development of modern therapeutic agents.
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Chavhan GB, Amaral JG, Temple M, Itkin M. MR Lymphangiography in Children: Technique and Potential Applications. Radiographics 2017; 37:1775-1790. [DOI: 10.1148/rg.2017170014] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Govind B. Chavhan
- From the Department of Diagnostic Imaging (G.B.C., J.G.A., M.T.) and Division of Image Guided Therapy, Department of Diagnostic Imaging (J.G.A., M.T.), The Hospital for Sick Children, Medical Imaging, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Center for Lymphatic Imaging and Interventions, Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.I.)
| | - Joao G. Amaral
- From the Department of Diagnostic Imaging (G.B.C., J.G.A., M.T.) and Division of Image Guided Therapy, Department of Diagnostic Imaging (J.G.A., M.T.), The Hospital for Sick Children, Medical Imaging, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Center for Lymphatic Imaging and Interventions, Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.I.)
| | - Michael Temple
- From the Department of Diagnostic Imaging (G.B.C., J.G.A., M.T.) and Division of Image Guided Therapy, Department of Diagnostic Imaging (J.G.A., M.T.), The Hospital for Sick Children, Medical Imaging, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Center for Lymphatic Imaging and Interventions, Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.I.)
| | - Maxim Itkin
- From the Department of Diagnostic Imaging (G.B.C., J.G.A., M.T.) and Division of Image Guided Therapy, Department of Diagnostic Imaging (J.G.A., M.T.), The Hospital for Sick Children, Medical Imaging, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Center for Lymphatic Imaging and Interventions, Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia, Pa (M.I.)
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Itkin M. Magnetic Resonance Lymphangiography and Lymphatic Embolization in the Treatment of Pulmonary Complication of Lymphatic Malformation. Semin Intervent Radiol 2017; 34:294-300. [PMID: 28955119 DOI: 10.1055/s-0037-1604301] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Lymphatic malformations (LMs; especially those involving the central conducting lymphatic channels) are characterized by dysplastic and incompetent lymphatic channels in multiple tissues and organs. The major cause of mortality and morbidity in patients with thoracic LM is deterioration of pulmonary function due to chronic chylous effusions and progressive interstitial lung disease. The etiology of these pulmonary processes is unknown, although lymphatic involvement is certain. Understanding of the changes in the lymphatic anatomy in patients with LM has been hindered by difficulty of imaging of the lymphatic system. Recently developed dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) allows dynamic MR imaging of the lymphatic system by injecting gadolinium contrast agent in the groin lymph nodes. Using this technique, pathological lymphatic flow from the central lymphatic system and/or retroperitoneal and mediastinal masses into lung parenchyma ("pulmonary lymphatic perfusion syndrome") has been demonstrated in patients with LM. This abnormal lymphatic perfusion overflows pulmonary parenchyma and results in deterioration of pulmonary function due to interstitial process and/or compression effect of chylous effusions. Percutaneous thoracic duct embolization or lymphatic interstitial embolization of the lymphatic masses results in cessation of the pulmonary lymphatic overflow and significant improvement in pulmonary symptoms in these patients.
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Affiliation(s)
- Maxim Itkin
- Center for Lymphatic Imaging and Interventions, Children's Hospital of Philadelphia/Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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27
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Abstract
Congenital chylothorax (CC) results from multiple lymphatic vessel anomalies or thoracic cavity defects and may accompany other congenital anomalies. Fetal chylothorax may increase the risk of death and complications from pleural space lymphatic fluid accumulation, which compromises lung development, pulmonary, and cardiovascular function and from complications arising from the loss of drained lymphatic contents. Prenatal interventions might improve survival in severe cases of fetal chylothorax. The neonatal treatment strategy is generally supportive with interventions that include thoracostomy drainage and attempts to decrease chyle flow using a stepwise approach that begins with the least invasive means. Evidence-based treatment choices are lacking and are much needed. Most cases of CC resolve with time even without specific lymphatic system studies to identify the exact pathology. Expertise in performing lymphatic studies is not universally available. Data on both efficacy and safety of the various therapeutic options are needed to determine the best approach to the treatment of CC.
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Affiliation(s)
- Mohammad A Attar
- Department of Pediatrics and Communicable Diseases, Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Steven M Donn
- Department of Pediatrics and Communicable Diseases, Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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30
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Abstract
The thoracic lymphatic disorders are a heterogeneous group of uncommon conditions that are associated with thoracic masses, interstitial pulmonary infiltrates, and chylous complications. Accurate diagnosis of the thoracic lymphatic disorders has important implications for the newest approaches to management, including embolization and treatment with antilymphangiogenic drugs. New imaging techniques to characterize lymphatic flow, such as dynamic contrast-enhanced magnetic resonance lymphangiogram, are redefining approaches to disease classification and therapy.
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Affiliation(s)
- Maxim Itkin
- Interventional Radiology, Hospital of the University of Pennsylvania, Penn Medicine, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Francis X McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, MSB 6165, 231 Albert Sabin Way, Cincinnati, OH 45267-0564, USA
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31
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Dori Y, Keller MS, Rome JJ, Gillespie MJ, Glatz AC, Dodds K, Goldberg DJ, Goldfarb S, Rychik J, Itkin M. Percutaneous Lymphatic Embolization of Abnormal Pulmonary Lymphatic Flow as Treatment of Plastic Bronchitis in Patients With Congenital Heart Disease. Circulation 2016; 133:1160-70. [PMID: 26864093 DOI: 10.1161/circulationaha.115.019710] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/01/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Plastic bronchitis is a potentially fatal disorder occurring in children with single-ventricle physiology, and other diseases, as well, such as asthma. In this study, we report findings of abnormal pulmonary lymphatic flow, demonstrated by MRI lymphatic imaging, in patients with plastic bronchitis and percutaneous lymphatic intervention as a treatment for these patients. METHODS AND RESULTS This is a retrospective case series of 18 patients with surgically corrected congenital heart disease and plastic bronchitis who presented for lymphatic imaging and intervention. Lymphatic imaging included heavy T2-weighted MRI and dynamic contrast-enhanced magnetic resonance lymphangiogram. All patients underwent bilateral intranodal lymphangiogram, and most patients underwent percutaneous lymphatic intervention. In 16 of 18 patients, MRI or lymphangiogram or both demonstrated retrograde lymphatic flow from the thoracic duct toward lung parenchyma. Intranodal lymphangiogram and thoracic duct catheterization was successful in all patients. Seventeen of 18 patients underwent either lymphatic embolization procedures or thoracic duct stenting with covered stents to exclude retrograde flow into the lungs. One of the 2 patients who did not have retrograde lymphatic flow did not undergo a lymphatic interventional procedure. A total of 15 of 17(88%) patients who underwent an intervention had significant symptomatic improvement at a median follow-up of 315 days (range, 45-770 days). The most common complication observed was nonspecific transient abdominal pain and transient hypotension. CONCLUSIONS In this study, we demonstrated abnormal pulmonary lymphatic perfusion in most patients with plastic bronchitis. Interruption of the lymphatic flow resulted in significant improvement of symptoms in these patients and, in some cases, at least temporary resolution of cast formation.
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Affiliation(s)
- Yoav Dori
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.).
| | - Marc S Keller
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Jonathan J Rome
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Matthew J Gillespie
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Andrew C Glatz
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Kathryn Dodds
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - David J Goldberg
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Samuel Goldfarb
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Jack Rychik
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Maxim Itkin
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
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Blei F. Update December 2014. Lymphat Res Biol 2014. [DOI: 10.1089/lrb.2014.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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