Cerebral Embolization of Ethiodized Oil following Intranodal Lymphangiography

Abstract

Intranodal lymphangiography (IL) has supplanted pedal lymphangiography (PL) as an easier and more practical approach to opacifying lymphatic vessels for interventional radiologists treating refractory chyle leaks. As more interventional radiologists-many of who are not trained in or have not performed PL-incorporate IL into their practice, it is imperative that they be familiar with the risks of lymphangiography, including pulmonary and systemic embolization of oily contrast material. Herein, the authors report a devastating case of cerebral embolization of ethiodized oil following IL and review the literature regarding systemic embolization following lymphangiography.

Percutaneous Lymphatic Embolization of Abnormal Pulmonary Lymphatic Flow as Treatment of Plastic Bronchitis in Patients With Congenital Heart Disease

“…To mitigate this risk, we performed systemic-to-pulmonary venous collateral embolization and temporary fenestration occlusion in these patients. Sheybani et al 29 described cerebral embolization in patients without right-to-left shunt resulting in neurological deficit. The mechanism by which systemic embolization occurred in the 1 patient in this study is not completely understood because the patient already had complete occlusion of the TD and he did not have any known right-to-left shunts.…”

Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review

“…These 28 articles included 5 large original case series with > 10 patients (Category I data) and 3 small original case series with 3-9 patients (Category II data) [15,[19][20][21][22][23][24][25]. The other 20 articles included were case reports and other short reports such as letters to the editor and technical notes with < 3 patients (Category III data) [14,17,[26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43]. None of these articles included a prospective study or a randomized controlled trial.…”

“…for 8/20 articles) [28, 32, 33, 36-40, 42, 43]. In 2 articles, however, significant complications, morbidity and/or mortality are described [29,41]. In the article of Taki et al, acute respiratory distress syndrome was reported as a CL-related major complication after transpedal CL, and the patient developed pulmonary fibrosis necessitating domiciliary oxygen therapy due to permanent hypoxemia [41].…”

“…In the article of Taki et al, acute respiratory distress syndrome was reported as a CL-related major complication after transpedal CL, and the patient developed pulmonary fibrosis necessitating domiciliary oxygen therapy due to permanent hypoxemia [41]. In the article of Sheybani et al, Lipiodol embolization to the brain and to the lung was reported as a CL-related major complication after intranodal CL, and the patient died 69 days after CL (because all supportive care was withdrawn due to a very low probability of meaningful recovery after a complicated clinical course including deteriorating mental status and pneumonia) [29]. Somatostatin is secreted from the pancreas, stomach, and duodenum, and it exerts inhibitory actions on stomach acid and bile secretion, and thus reduces chyle flow by suppressing the absorption of fat, which is the raw material for chyle [47].…”

Therapeutic Intranodal Lymphangiography for Refractory Chylous Ascites Complicating Acute Necrotic Pancreatitis

“…If conservative management fails, bipedal [13] or intranodal [2] lymphangiography should be attempted. Potential complications related to the intralymphatic injection of ethiodized oil are rare and include paradoxical cerebral embolization and lung emboli [14]. Other treatment options are somatostatin analogues, repeat paracentesis or insertion of a tunneled peritoneal drainage catheter [15].…”