Lymphangiogram

A lymphangiogram is an uncommon procedure that can be performed by interventional radiologists, typically to identify and potentially treat the source of a chylous leak.

Pre Procedure

• Indications: Thoracic duct injury, usually from surgery, causing chylous effusion / chylothorax, or recurrent chylous ascites
• Surgical management (direct fix of the leak intraoperatively if visualized) and medical management should be optimized first. 
• Specifically, the patient should be on a low fat / medium chain triglyceride diet. Long chain triglycerides are absorbed by the lymphatics, which leads to extra lymph production. Medium chain triglycerides however are absorbed by the portal veins, reducing the production of lymph.  

Procedure

• Transpedal approach: prep the feet
• Inject 50/50 mix of isosulfan blue and lidocaine into the webbing between toes and wait 10-15 minutes for dye to be picked up by lymphatics
• Make incision parallel to lymphatic
• Strip away fat/tissue parallel to lymphatic
• Insert backing (cardboard/plastic) underneath lymphatic
• Insert 30 gauge needle into lymphatic and inject 100% lidocaine
• Bubble test: watch to see if air goes into lymphatics, or if it fizzes
• Take serial x-rays of lower extremities and abdomen to see lymphatics and eventually cysterna chyli fill
• Once filled, can insert 21 gauge needle directly into cisterna chyli and perform embolization, usually with coils and/or N-butyl cyanoacrylate glue

Post Procedure

• Evaluate for recurrent leak

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