Complications during Lymphangiography and Lymphatic Interventions

Abstract

Lymphangiography as a diagnostic procedure dates back to the 1950s and was widely performed for several decades until being supplanted by other advanced imaging techniques. With the advent of thoracic duct embolization to treat chylothorax, Constantin Cope ushered in a transition from lymphangiography as a diagnostic procedure to a precursor for lymphatic intervention. Subsequently, technical modifications and applications of lymphatic embolization to other medical conditions have greatly expanded the scope and application of lymphangiography and lymphatic intervention. Although there is increasing familiarity with lymphatic interventions, few interventionalists have performed a high enough volume to be aware of potential complications and their management. Potential complications of lymphangiography and those encountered while performing lymphatic interventions are discussed along with approaches to minimize their risk and management strategies should they occur.

Clinical Uses and Short-Term Safety Profile of Ethiodized Poppy Seed Oil Contrast Agent in the Diagnosis and Treatment of Vascular Anomalies and Tumors

“…The route of EPO is easily visualizable under fluoroscopy, but lymphangiography is a time-intense procedure, as the EPO flows very slowly in the lymphatic channels. Use of EPO should be avoided in patients with a history of sensitivity to other iodinated contrast agents because of an increased risk of a hypersensitivity reaction to Lipiodol [36][37][38]. Hypersensitivity reactions to Lipiodol can occur within half an hour and up to several days after administration, although as mentioned, none occurred in this cohort.…”

Back to the Future II—A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions

“…To avoid symptomatic pulmonary embolization, the injected amount of oil should be as low as possible, especially in patients with known pulmonary disease. A maximum dose of 20 mL ethiodized oil has therefore been recommended as the incidence of complications has been linked with oil dose 1,47,48 . It has further been recommended according to the packaging insert in the United States to monitor the propagation of ethiodized oil during application and to stop further administration once the thoracic duct is visualized or if an obstruction preventing further propagation is seen.…”

“…41,42,46 Possible complications occur in <5% and can arise from the injection of blue dye (eg, allergic reactions, permanent discoloration, necrosis of the skin, formation of methemoglobin) or the ethiodized oil itself (eg, allergic reactions, systemic or pulmonary embolization). 47 It is normal and unavoidable that a part of the injected ethiodized oil reaches the pulmonary circulation after draining into the venous system. This may result in pulmonary infarction or pneumonitis in rare cases.…”

Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part II. Classification and Treatment of the Lymphatic Disorders

“…More rarely, there have been reports of oil embolization in the liver and kidney, which are postulated to occur only in the presence of abnormal pathologies such as tumors that allow Lipiodol to shunt into these systems [ 84 ]. The examiner should always be aware of possible lymphovenous shunts through which large amounts of Lipiodol may preferentially flow into the systemic vein before filling the lymphatic system.…”