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Kim C, Ali H, Tsai LL, Bulman J, Singhal D, Carroll B, Ahmed M, Weinstein J. Evaluation of Primary Lymphedema with Intranodal Lymphangiography. Cardiovasc Intervent Radiol 2024; 47:238-244. [PMID: 37985479 DOI: 10.1007/s00270-023-03605-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE There are limited existing data on the lymphatic anatomy of patients with primary lymphedema (LED), which is caused by aberrant development of lymphatic channels. In addition, there is a paucity of contemporary studies that use groin intranodal lymphangiography (IL) to evaluate LED anatomy. The purpose of this retrospective observational study was to better delineate the disease process and anatomy of primary LED using groin IL. MATERIALS AND METHODS We identified common groin IL findings in a cohort of 17 primary LED patients performed between 1/1/2017 and 1/31/2022 at a single institution. These patients were clinically determined to have primary lymphedema and demonstrated associated findings on lower extremity MR and lymphoscintigraphy. RESULTS Ten patients (59%) demonstrated irregular lymph node morphology or a paucity of lymph nodes on the more symptomatic laterality. Eight patients (47%) demonstrated lymphovenous shunting from pre-existing anastomoses between the lymphatic and venous systems. Eight patients (47%) demonstrated passage of contrast past midline to the contralateral lymphatics. Finally, 12 patients (71%) failed to opacify the cisterna chyli and thoracic duct on their initial lymphangiograms. Delayed computed tomography of 3 patients showed eventual central lymphatic opacification up to the renal veins, but none of these patients showed central lymphatic opacification to the thorax. CONCLUSION This descriptive, exploratory study demonstrates common central groin IL findings in primary LED to highlight patterns interventional radiologists should identify and report when addressing primary LED.
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Affiliation(s)
- Charissa Kim
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Hamza Ali
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Leo L Tsai
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Julie Bulman
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Dhruv Singhal
- Department of Surgery/Division of Plastic Surgery, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Brett Carroll
- Department of Cardiology, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA, 02215, USA
| | - Muneeb Ahmed
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA
| | - Jeffrey Weinstein
- Department of Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA, 02215, USA.
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Sun JM, Yamamoto T. Lymphovenous shunts in the treatment of lymphedema. J Chin Med Assoc 2024; 87:5-11. [PMID: 37962114 DOI: 10.1097/jcma.0000000000001016] [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: 11/15/2023] Open
Abstract
Lymphedema is a progressive disease with no known cure. Characterized by the accumulation of lymphatic fluid and subsequent swelling in the affected limbs, it often poses significant challenges to those living with it. Although various conservative treatments have been used to manage lymphedema, such as compression therapy and physical rehabilitation, surgical interventions have emerged as promising avenues for more substantial relief. Lymphovenous shunts have been described since the 1960s and have garnered much attention in the recent two decades due to technological advances in optics, imaging, and surgical instruments. This review article explores the use of different lymphovenous shunts such as lymphatic implantation, lymph node-to-vein anastomoses (LNVAs), dermal-adipose lymphatic flap venous wrapping (DALF-VW), and supermicrosurgical lymphovenous anastomoses (LVAs) as treatment modalities for lymphedema. We will discuss the underlying principles, indications, techniques, and potential benefits. By examining the current state of knowledge and ongoing research in the field, we aim to provide insights into the role of lymphovenous shunts in the comprehensive management of lymphedema and shed light on the prospects for this treatment option.
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Affiliation(s)
- Jeremy Mingfa Sun
- Department of Surgery, Plastic Reconstructive and Aesthetic Surgery Service, Changi General Hospital, Singapore, Singapore
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Hägerling R, Van Zanten M, Behncke RY, Ulferts S, Hansmeier NR, Märkl B, Witzel C, Ho B, Keeley V, Riches K, Mansour S, Gordon K, Ostergaard P, Mortimer PS. Erythematous capillary-lymphatic malformations mimicking blood vascular anomalies. JCI Insight 2023; 8:e172179. [PMID: 37698920 PMCID: PMC10619487 DOI: 10.1172/jci.insight.172179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023] Open
Abstract
Superficial erythematous cutaneous vascular malformations are assumed to be blood vascular in origin, but cutaneous lymphatic malformations can contain blood and appear red. Management may be different and so an accurate diagnosis is important. Cutaneous malformations were investigated through 2D histology and 3D whole-mount histology. Two lesions were clinically considered as port-wine birthmarks and another 3 lesions as erythematous telangiectasias. The aims were (i) to demonstrate that cutaneous erythematous malformations including telangiectasia can represent a lymphatic phenotype, (ii) to determine if lesions represent expanded but otherwise normal or malformed lymphatics, and (iii) to determine if the presence of erythrocytes explained the red color. Microscopy revealed all lesions as lymphatic structures. Port-wine birthmarks proved to be cystic lesions, with nonuniform lymphatic marker expression and a disconnected lymphatic network suggesting a lymphatic malformation. Erythematous telangiectasias represented expanded but nonmalformed lymphatics. Blood within lymphatics appeared to explain the color. Blood-lymphatic shunts could be detected in the erythematous telangiectasia. In conclusion, erythematous cutaneous capillary lesions may be lymphatic in origin but clinically indistinguishable from blood vascular malformations. Biopsy is advised for correct phenotyping and management. Erythrocytes are the likely explanation for color accessing lymphatics through lympho-venous shunts.
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Affiliation(s)
- René Hägerling
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Berlin, Germany
- Research Group Development and Disease, Max Planck Institute for Molecular Genetics, Berlin, Germany
| | - Malou Van Zanten
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Rose Yinghan Behncke
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
| | - Sascha Ulferts
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
| | - Nils R. Hansmeier
- Institute of Medical and Human Genetics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Berlin, Germany
- Research Group Development and Disease, Max Planck Institute for Molecular Genetics, Berlin, Germany
| | - Bruno Märkl
- Institute of Pathology and Molecular Diagnostics, University Clinic Augsburg, Augsburg, Germany
| | - Christian Witzel
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bernard Ho
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Vaughan Keeley
- Lymphoedema Clinic, Derby Hospitals Foundation NHS Trust, Derby, United Kingdom
| | - Katie Riches
- Lymphoedema Clinic, Derby Hospitals Foundation NHS Trust, Derby, United Kingdom
| | - Sahar Mansour
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- SW Thames Regional Centre for Genomics, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Kristiana Gordon
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Pia Ostergaard
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
| | - Peter S. Mortimer
- Molecular and Clinical Sciences Institute, St George’s University of London, London, United Kingdom
- Dermatology and Lymphovascular Medicine, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
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Lampejo AO, Ghavimi SAA, Hägerling R, Agarwal S, Murfee WL. Lymphatic/blood vessel plasticity: motivation for a future research area based on present and past observations. Am J Physiol Heart Circ Physiol 2023; 324:H109-H121. [PMID: 36459445 PMCID: PMC9829479 DOI: 10.1152/ajpheart.00612.2022] [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: 10/26/2022] [Revised: 11/23/2022] [Accepted: 11/23/2022] [Indexed: 12/04/2022]
Abstract
The lymphatic system plays a significant role in homeostasis and drainage of excess fluid back into venous circulation. Lymphatics are also associated with a number of diseases including lymphedema, tumor metastasis, and various lymphatic malformations. Emerging evidence suggests that lymphatics might have a bigger connection to the blood vascular system than originally presumed. As these two systems are often studied in isolation, several knowledge gaps exist surrounding what constitutes lymphatic vascular plasticity, under what conditions it arises, and where structures characteristic of plasticity can form. The objective of this review is to overview current structural, cell lineage-based, and cell identity-based evidence for lymphatic plasticity. These examples of plasticity will then be considered in the context of potential clinical and surgical implications of this evolving research area. This review details our current understanding of lymphatic plasticity, highlights key unanswered questions in the field, and motivates future research aimed at clarifying the role and therapeutic potential of lymphatic plasticity in disease.
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Affiliation(s)
- Arinola O Lampejo
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
| | | | - René Hägerling
- Institute of Medical and Human Genetics, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health Academy, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Shailesh Agarwal
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Walter L Murfee
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida
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