Yeungnam Univ J Med.  2021 Jan;38(1):74-77. 10.12701/yujm.2020.00297.

Transpedal lymphatic embolization for lymphorrhea at the graft harvest site after coronary artery bypass grafting

• Cha JG
• Lee SY
• Hong J
• Ryeom HK
• Kim GC
• Do YW

• KMID: 2512071
• DOI: http://doi.org/10.12701/yujm.2020.00297

Abstract

Lymphorrhea is a rare but potentially severe complication that occurs after various surgical procedures. Untreated lymphorrhea may lead to wound dehiscence, infection, and prolonged hospital stay. Currently, there is no standard effective treatment. Early management usually includes leg elevation, drainage, and pressure dressing. However, these methods are associated with prolonged recovery and high recurrence rates. We report a case of lymphorrhea from a calf wound after endoscopic great saphenous vein (GSV) harvesting for coronary artery bypass grafting (CABG). The patient presented with intractable oozing from the postoperative wound on the right calf. Lymphorrhea perGsisted for 6 weeks despite negative-pressure wound therapy with a long-acting somatostatin. We performed unilateral pedal lymphangiography that confirmed wound lymphorrhea, followed by glue embolization. No recurrence was observed after 8 months of follow-up. This case report demonstrates the successful use of lymphangiography with glue embolization in the control of lymphorrhea after GSV harvesting for CABG.

Keyword

Embolization; Lymphangiography; Lymphatic system; Therapeutics

Figure

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  Fig. 1. Photographs of pedal lymphangiography. (A) Photograph of the foot during the subcutaneous injection of methylene blue into the web space. (B) Photograph of the medial calf shows injected methylene blue seeping through the wound (arrows), confirming lymphorrhea.

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  Fig. 2. Percutaneous lymphatic vessel embolization. (A) Photograph of the lymphatic vessel puncture site and transverse incision on the right foot dorsum. (B) Spot radiograph of the calf shows puncture needle (white arrow), normal ascending lymphatic vessel (black arrow), and lipiodol leakage into the calf wound (dashed arrow). (C) Spot radiograph reveals embolized culprit lymphatic vessel using N-butyl cyanoacrylate and lipiodol mixture (mixture ratio, 1:4). Note that additional lymphatic vessel is accessed with needle (white arrow), and additional lymphatic embolization is performed to prevent recurrence. (D) Photograph of the calf wound reveals polymerized glue cast released through the wound.

Reference

References

1. Unno N, Yamamoto N, Suzuki M, Tanaka H, Mano Y, Sano M, et al. Intraoperative lymph mapping with preoperative vein mapping to prevent postoperative lymphorrhea following paramalleolar bypass surgery in patients with critical limb ischemia. Surg Today. 2014; 44:436–42.

2. Heitink MV, Schurink GWH, de Pont CDJM, van Kroonenburgh MJPG, Veraart JCJM. Lymphedema after greater saphenous vein surgery. Eur J Vasc Endovasc Surg. 2009; 38:656.

3. Kos S, Haueisen H, Lachmund U, Roeren T. Lymphangiography: forgotten tool or rising star in the diagnosis and therapy of postoperative lymphatic vessel leakage. Cardiovasc Intervent Radiol. 2007; 30:968–73.

4. Rajebi MR, Chaudry G, Padua HM, Dillon B, Yilmaz S, Arnold RW, et al. Intranodal lymphangiography: feasibility and preliminary experience in children. J Vasc Interv Radiol. 2011; 22:1300–5.

5. Nadolski GJ, Itkin M. Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization. J Vasc Interv Radiol. 2012; 23:613–6.

6. Shinaoka A, Koshimune S, Suami H, Yamada K, Kumagishi K, Boyages J, et al. Lower-limb lymphatic drainage pathways and lymph nodes: a CT lymphangiography cadaver study. Radiology. 2020; 294:223–9.