Cerebral Lipiodol Embolism after Lymphatic Embolization for Plastic Bronchitis

Kirschen, Matthew; Dori, Yoav; Itkin, Maxim; Licht, Daniel J.; Ichord, Rebecca; Vossough, Arastoo

doi:10.1016/j.jpeds.2016.05.036

Cited by 33 publications

(22 citation statements)

References 12 publications

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“…30,31 Other potential complications of this technique include thrombus formation, embolization to systemic vessels, creation of fistulae, local bleeding, and pain. 24,32 We also used the same technique during this period to treat PLE in a 53-year old with severe right heart failure with the same satisfying results. Previous reports have documented success in other conditions in adults such as ascites and hepatic lymphorrhea.…”

Section: Discussionmentioning

confidence: 97%

Percutaneous embolization of lymphatic fistulae as treatment for protein‐losing enteropathy and plastic bronchitis in patients with failing Fontan circulation

Maleux

Storme

Cools

et al. 2019

Cathet Cardio Intervent

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Background To determine the feasibility and clinical result of selective embolization of hepatoduodenal or paratracheal lymphatics in Fontan patients with protein‐losing enteropathy (PLE) or plastic bronchitis (PB). Methods Dilated lymph vessels in periportal (PLE) or paratracheal (PB) position were percutaneously punctured with a 22G Chiba needle. Intralymphatic position was confirmed by water soluble contrast injection with drainage to hepatoduodenal or tracheal fistulae. After flushing with 10% glucose solution, occlusion of hepatoduodenal or paratreacheal lymphatics was effected by injection of 1–4 cc mixture 4/1 of Lipiodol/n‐butyl cyanoacrylate (n‐BCA; Histoacryl). Results Seven patients with proven PLE were treated with periportal lymphatic embolization 10.7 (range: 6.6–13.5) years after the Fontan operation. The Fontan operation was performed at a median age of 3.7 (range: 2.9–5.7) years and PLE started a median of 3.1 (range: 0.9–4.7) years later. Five patients required a second procedure 2–8 months later. Complications were limited (spillage of glue in portal branch, transient cholangitis, and caustic duodenal bleeding). Six of seven patients reported significant improvement in quality of life and normalization of albumin levels after limited follow‐up (p < .01). One patient (Fontan at 2.9 years; age 16.4 years) had PB for 2 years. Selective transthoracic cone‐beam‐directed puncture of left and right paratracheal lymphatics with n‐BCA embolization of distal lymphatic fistulae resulted in lasting absence of tracheal casts (11 months). Conclusions Embolization of periportal/peritracheal lymphatics is a promising technique in Fontan patients with PLE/PB. Larger series are required to determine incidence and reasons of success/failure, with long‐term results and effects on liver function.

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Section: Discussionmentioning

confidence: 97%

Percutaneous embolization of lymphatic fistulae as treatment for protein‐losing enteropathy and plastic bronchitis in patients with failing Fontan circulation

Maleux

Storme

Cools

et al. 2019

Cathet Cardio Intervent

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“…This is a consideration in all patients with single ventricle physiology. Reducing the risks of systemic embolization requires concurrent cardiac catheterization for collateral vessel occlusion, or balloon occlusion of a fenestration in patients with Fontan physiology prior to lymphatic procedure . Careful neurological monitoring in these patients is needed during and after the procedures.…”

Section: Discussionmentioning

confidence: 99%

Lymphatic imaging and intervention in a pediatric population: Anesthetic considerations

Jobes

Brown

Dori

et al. 2018

Pediatric Anesthesia

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The recent adoption of an improved lymphatic access technique coupled with Dynamic Contrast-enhanced Magnetic Resonance Lymphangiography has introduced the ability to diagnose and treat severe lymphatic disorders unresponsive to other therapies. All pediatric patients presenting for lymphatic procedures require general anesthesia presenting challenges in managing highly morbid and comorbid conditions both from logistical as well as medical aspects. General anesthesia is used because of the procedural requirement for immobility to accurately place needles and catheters, treat pain secondary to contrast and glue injections, and to accommodate additional procedures. We reviewed a one-year cohort of all pediatric patients in a newly created Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for lymphatic procedures. The patients ranged in age from 4 days to 17 years and weighed from 2.5 to 92 kg. There were 106 anesthetics for 68 patients. Patients were functionally impaired (98% ASA 3 or 4) and included significant comorbidities (79.4%). Concurrent with lymphatic imaging and intervention additional procedures were frequently performed (76%). They included cardiac catheterization, bronchoscopy, endoscopy, and drain placement (thoracic or abdominal). Paralysis and controlled ventilation was used for all interventions. Reversal of paralysis and tracheal extubation occurred in all patients not previously managed by invasive respiratory support. All patients having an intervention were admitted to intensive care for observation where escalation of care or complications (fever, hypotension, bleeding, or stroke) occurred in 25% in the first 24 hours.

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“…Proposed mechanisms include right-to-left shunts (though many patients have had patent foramen ovale and pulmonary arteriovenous shunts excluded after the fact), loss of the filtering capability of the pulmonary capillaries due to overload of ethiodized oil, and lymphovenous shunts to the pulmonary veins. [26][27][28][29][30][31] Cerebral oil embolization has similarly been documented with transarterial chemoembolization and hysterosalpingography using ethiodized oil. [32][33][34][35] Ethiodized oil may lead to neurotoxicity due to vascular occlusion, blood-brain barrier disruption, or direct toxicity.…”

Section: Complications Of Lymphangiographymentioning

confidence: 98%

“…Cerebral oil embolization usually presents with seizure, confusion, lethargy, or other mental status change within minutes to hours after completion of lymphangiography. [26][27][28][29][30][31] Notably, the migration of ethiodized oil to the cerebral circulation has not been documented radiographically during lymphangiography, but rather noted only on CT or MRI studies performed after clinical symptoms became apparent. Proposed mechanisms include right-to-left shunts (though many patients have had patent foramen ovale and pulmonary arteriovenous shunts excluded after the fact), loss of the filtering capability of the pulmonary capillaries due to overload of ethiodized oil, and lymphovenous shunts to the pulmonary veins.…”

Section: Complications Of Lymphangiographymentioning

confidence: 99%

Complications during Lymphangiography and Lymphatic Interventions

Majdalany

Sanogo

Pabon‐Ramos

et al. 2020

Semin intervent Radiol

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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.

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Cerebral Lipiodol Embolism after Lymphatic Embolization for Plastic Bronchitis

Cited by 33 publications

References 12 publications

Percutaneous embolization of lymphatic fistulae as treatment for protein‐losing enteropathy and plastic bronchitis in patients with failing Fontan circulation

Percutaneous embolization of lymphatic fistulae as treatment for protein‐losing enteropathy and plastic bronchitis in patients with failing Fontan circulation

Lymphatic imaging and intervention in a pediatric population: Anesthetic considerations

Complications during Lymphangiography and Lymphatic Interventions

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