Clinical cases and publications

Lymphatic leak occurring after surgical lymph node dissection: a preliminary study
assessing the feasibility and outcome of lymphatic embolization⁽¹⁾

Embolization technique. For embolization, a 1:1 mixture of NBCA and Lipiodol^® was used for the first two techniques, while the mixture was between 1:6 and 1:8 for the third technique.

Outcome: Intranodal lymphangiography was successfully performed on both sides in 19 patients (90.5 %) […]
17 patients (81.0 %) showed initial response to treatment. Three patients underwent repeated embolization with successful results.
The overall success rate was 95.2 %.

LIPIODOL^® & NBCA – FOR LYMPHATIC LEAK

	A Technique 1: the leak (white arrow) was targeted under fluoroscopic guidance using a 22-gauge needle (black arrow) through which NBCA was injected.
	B Technique 2: the inflow vessel leading to the leak (white arrow) was puncturedusing a 22-gauge needle (black arrow) and NBCA was injected.
	C Technique 3: NBCA was injected into a pelvic lymph node (black arrows) to treat multifocal leaks (white arrows).

CT-guided injection of N-butyl cyanoacrylate glue for treatment of chylous leak after aorto-mesenteric bypass⁽²⁾

Embolization for thoracic duct collateral leakage in high-output chylothorax after thoracic surgery⁽³⁾
A 67-year-old man who had undergone esophagectomy for esophageal cancer. Despite conservative treatment, his postoperative chylous output was 2300 mL/day

Outcome: Clinical success was achieved in all patients […] No recurrence of chylous effusion was seen for any of the five patients in this period.No complications requiring treatment were encountered.

LIPIODOL^® & NBCA – FOR THORACIC DUCT COLLATERAL LEAKAGE

	A Lymphangiography. No rupture is evident in the thoracic duct (black arrows). Extravasation of lipiodol is apparent on the left of the thoracic duct, and rupture of a lymphatic duct (white arrow) forming a collateral route bypassing the thoracic duct is seen. The collateral routes comprise lymphatic ducts that form a reticulate network (black arrowheads) continuing to the lumbar lymphatics. The ruptured lymphatic duct is supplied with lipiodol from the lumbar lymphatics and cisterna chyli via the collateral routes.
	B Transcatheter thoracic ductography. Iodinated contrast agent is injected through a microcatheter inserted in the thoracic duct by a percutaneous transabdominal approach. The white arrowhead indicates the microcatheter tip. Similar to lymphangiography, a ruptured lymphatic duct (white arrow) is present, and extravasation of iodinated contrast agent is evident. Injection of a 5-mL bolus of iodinated contrast agent visualizes the ducts as far as collateral routes that communicate with the lumbar lymphatics (black arrowheads).
	C Thoracic duct embolization. This image represents a digital-subtraction image taken during injection of N-butyl cyanoacrylate mixed with Lipiodol® (N-butyl cyanoacrylate:lipiodol= 1:10) into the thoracic duct. The N-butyl cyanoacrylate reaches the rupture site (white arrow) in the lymphatic duct and travels via a collateral route that communicates with the lumbar lymphatics (black arrowhead).
	D Plain radiograph the day after thoracic duct embolization. N-butyl cyanoacrylate mixed with Lipiodol® was retained in the injected lymphatic vessel and embolization remained intact the day after TDE.

Risk factor analysis for massive lymphatic ascites after laparoscopic retroperitonal lymphadenectomy in gynecologic cancers and treatment using intranodal lymphangiography with glue embolization⁽⁴⁾

Direct lymphangiography as treatment option of lymphatic leakage:
indications, outcomes and role in patient’s management⁽⁵⁾

A 54-year-old patient with lymphatic fistula after inguinal lymphadenectomy due to metastasis in lymph nodes from cutaneous malignant melanoma. The daily
amount of drained lymph was 150 mL. Ten days after lymphography the lymphatic fistula was occluded.

Outcome: …Of 64 patients, 45 patients (70.3%) were treated and cured after lymphography. Based on the lymphography findings, 19 patients (29.7%) underwent surgical intervention with a completely occlusion of lymphatic leakage. The lymphatic leak could be completely occluded in 96.8% of patients…

LIPIODOL^® – FOR LYMPHATIC LEAKAGE

	CT of pelvis before lymphography. Documentation of the lymphatic fistula in the right inguinal region.
	X-ray image documenting contrasted lymph vessels of the right feet after injection of iodized oil.
	X-ray image documenting lymph leakage in the right inguinal region.
	CT of the pelvis one day after lymphography. Documentation of lymphatic leakage.

Therapeutic strategy for chylous leakage after esophagectomy: focusing on lymphangiography using Lipiodol^®(6)

A Main trunk type: the patient underwent esophagectomy with a combined resection of the thoracic duct. A chest radiograph shows that the thoracic duct was visualized in the lower mediastinum (black arrow). A large pooling of contrast medium leaked from the stump of thoracic duct (white arrow).

B Branch type: the patient underwent esophagectomy with the combined resection of thoracic duct. The black arrowhead shows the stump of the right-sided thoracic duct which was successfully ligated in the preceded esophagectomy. However, the leftsided thoracic duct (black arrow) was patent, and the segmental plexus formation of the lymphatic vessels was observed in the lower mediastinum. Pooled contrast medium was leaked from the plexus formation of the lymphatic vessels (white arrow)

Outcome:  In all 33 patients, the therapeutic management was determined after lymphangiography, and all patients were finally healed.

LIPIODOL^® – FOR REFRACTORY POST-ESOPHAGECTOMY CHYLOUS LEAKAGE

A novel algorithm proposed for determining the optimal therapeutic strategy for the treatment of refractory chylous leakage after esophagectomy, focusing on lymphangiography using Lipiodol^{® (7)}

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Ultrasound-guided intranodal lymphangiography with ethiodized oil to treat chylous ascites⁽⁷⁾

NBCA/Lipiodol^® ratio 1:1

Outcome: After the lymphangiography, the persistent abdominal pain was significantly reduced within a day. Moreover, the triglyceride level decreased to 21 mg/dL, and CA was resolved within 3 days…

LIPIODOL^® – FOR CHYLOUS ASCITES

	A Abdominal CT showing marked ascites.
	B Fluoroscopic image showing injected Lipiodol® through the bilateral inguinal lymph nodes.
	C The follow-up CT visualizing abdominal lymphatic vessels including cisterna chyli (arrow) without Lipiodol® leakage into the abdominal cavity.

Ultrasound-guided intranodal lipiodol^® lymphangiography from the groin is useful for assessment and treatment of post-esophagectomy chylothorax in three cases⁽⁸⁾

Outcome: …three cases of post-esophagectomy chylothorax in whom ultrasound-guided intranodal Lipiodol^® LAG from the groin we resuccessfully performed with no complications…

LIPIODOL^® – FOR POSTOPERATIVE CHYLOTHORAX

	A Ultrasound-guided intranodal LAG demonstrating Lipiodol® leakage behind the common hepatic arterial trunk (white arrow).
	B Plain CT image obtained after the intranodal Lipiodol® LAG providing more detailed information about the leak point (white arrow).
	C Plain CT image obtained 1 day after the intranodal Lipiodol® LAG showing that the leaked Lipiodol® near the leak point diffused to the surrounding (white arrow).
	D Ultrasound-guided intranodal LAG demonstrating Lipiodol® leakage at the level of the sixth thoracic vertebra (white arrow).
	E Plain CT image obtained after the intranodal Lipiodol® LAG providing more detailed information about the leak point (whitearrow).
	F Ultrasound-guided intranodal LAG demonstrating Lipiodol® leakage on the left side of the fifth thoracic vertebra level slightly higher than tracheal bifurcation (whitearrow).
	G Plain CT image obtained after the intranodal Lipiodol® LAG providing more detailed information about the leak point (white arrow).
	H Plain CT image obtained 2 days after the intranodal Lipiodol® LAG showing remained Lipiodol® near the leak point (white arrow).

Transnodal lymphangiography in the diagnosis and treatment of genital lymphedema⁽⁹⁾

Outcome: Sclerosing activity of Lipiodol is expected to gradually decrease the amount of leakage or the severity of inflammation. Genital lymphedema also progressively decreased, and the patient’s discomfort disappeared…

LIPIODOL^® –  FOR GENITAL LYMPHEDEMA

	A A Lymphangiography image at 30 min showing lymphatic hyperplasia in the pelvis (curved arrows) and lymphatic plevic fistula (arrowhead).
	B Lymphangiography image at 45 min demonstrating vaginal leak (arrow).
	C CT scan 24 h after lumphangiography depicting Lipiodol® within the parenchyma of the kidney indicating lymphatic pelvic fistula (arrow).
	D Coronal reconstruction of the same CT scan showing Lipiodol® within the kidney parenchyma due to lymphopelvic fistula (arrow) and lymphatic hyperplasia in the pelvic organs (curved arrows)

Interventional treatment of pulmonary lymphatic anomalies⁽¹⁰⁾

Outcome: Percutaneous embolization of these abnormal pulmonary lymphatic vessels results in alleviation of the symptoms of plastic bronchitis in close to 100% of the patients with minimal complications…

LIPIODOL^® –  FOR PULMONARY LYMPHATIC ANOMALIES

	A Dynamiccontrast–enhanced magnetic resonance lymphangiography (DCMRL) of the patient with neonatal chylothorax,demonstrating abnormal pulmonary lymphatic flow toward lung parenchyma (white arrows).
	B Fluoroscopy image of the chest again demonstrating abnormal flow of the Lipiodol® injected through groin lymph nodes toward lung parenchyma (black arrows).