Clinical Nuclear Medicine:
Lymphoscintigraphy in the Diagnosis of Lymphatic Leak After Surgical Repair of Femoral Artery Injury
JONES, TIMOTHY R. M.D.*; CARLISLE, MARIE R. M.D., Ph.D.†; HOFMANN, LAWRENCE V. M.D.*; STRAUSS, H. WILLIAM M.D.†; OLCOTT, CORNELIUS IV M.D.‡
From the Department of Radiology,* Division of Nuclear Medicine,† Stanford Health Services, and the Department of Surgery,‡ Stanford Health Services, Stanford, California
Received for publication April 3, 2000.
Revision accepted July 23, 2000.
Reprint requests: Marie Reed Carlisle, M.D., Ph.D., Division of Nuclear Medicine, Room H-0250, Stanford Health Services, 300 Pasteur Drive, Stanford, California 94305-5281. E-mail: email@example.com
Purpose: Technetium-99m–labeled sulfur colloid lymphoscintigraphy is useful to evaluate lower extremity lymphatic circulation in cases of possible lymphedema and to reveal abnormal lymphatic collections. Groin lymphatic fistulas and lymphoceles are known complications of peripheral vascular surgical procedures. The authors describe a patient with ascites that developed into right lower extremity swelling after surgical repair of a femoral artery injury. Even after surgical ligation of multiple lymphatic channels, the patient continued to have lymphorrhea. It was unclear whether this was attributable to a persistent lymphatic leak or an ascitic leak from a postsurgical defect resulting in an abnormal connection with the peritoneal cavity.
Methods: Lymphoscintigraphy of the lower extremities was performed using Tc-99m sulfur colloid. Images were obtained at several intervals after injection of the radiotracer. Images were also acquired after the wound packing was removed.
Results: The images revealed an accumulation of radiotracer in the right groin, confirming the lower extremity lymphatic origin of the collection.
Conclusions: Lymphoscintigraphy is useful to evaluate the origin of serous collections in the groin, a region in which lymphatic complications of vascular surgery are not uncommon.
Technetium-99m–labeled sulfur colloid lymphoscintigraphy is a commonly performed, noninvasive test to evaluate the lower extremity lymphatic circulation. Although used most often in cases of possible lymphedema, this study is also valuable for revealing abnormal lymphatic collections (1,2). Lymphoceles and lymphatic fistulas can result from traumatic or surgical transection of lymph channels. Because of the number, orientation, and location of lymphatic vessels in the groin, vascular surgery in this region can result in lymphatic disruption (3,4). Lymphatic complications are often diagnosed clinically, but sometimes an imaging study is required. We describe a patient with a possible lymphatic leak after surgical repair of a femoral artery injury in which lymphoscintigraphy was used to confirm the diagnosis.
Materials and Methods
A 47-year-old man with cirrhosing ascites and hepatitis B underwent a hepatic angiogram for evaluation of a liver mass. After the angiogram, a percutaneous arteriotomy closure device was deployed and injured the right common femoral artery, requiring emergent surgery. One week after surgery, the patient returned with a presumed wound infection that was treated with a course of intravenous antibiotics. Surgical exploration revealed a focal serous fluid collection in the region of the previous surgical bed, with compression of the femoral vein. The collection was drained and the lymphatic channels were ligated. The wound was left open and continued to drain copious amounts (2 l/day) of serous fluid. At this time it was unclear whether the serous fluid was attributable to a lymphatic leak from the right leg or to an ascitic leak from a postsurgical defect involving the inguinal ligament, resulting in an abnormal connection with the peritoneal cavity.
Two 0.1-ml aliquots of Tc-99m sulfur colloid (0.250 μCi per injection) were injected subdermally in each foot, one on either side of the second toe. Anterior and posterior whole-body views were obtained at three different intervals: immediately after injection, 1 hour after injection, and 2 hours after injection. After 4.5 hours had elapsed, the dressing in the right inguinal region was changed. Another set of anterior and posterior whole-body images was acquired. The dressing was analyzed separately for the presence of radioactivity. A transmission scan was also acquired using a Co-60 flood after 4.5 hours. Images were acquired using a Siemens ECAM (Hoffman Estates, IL) gamma camera.
Normal lymphatic drainage in the lower extremities is visualized on the images obtained several minutes after injection of the radiotracer (Fig. 1). Two hours after injection (Fig. 2), normal inguinal lymph nodes are seen on the left but abnormal pooling of the radiotracer is noted in right inguinal region. After the dressing was removed, anterior and posterior whole-body scans were acquired (Fig. 3) that showed decreased activity in the region of the wound compared with the previous images. A whole-body transmission scan provided anatomic landmarks (Fig. 4). Finally, the original dressing was indeed radioactive. Lymphoscintigraphy revealed an accumulation of radiotracer in the right groin, confirming the lymphatic origin of the collection. The patient was returned to the operating room and multiple lymphatic vessels were again ligated. The wound was closed in multiple layers. Recovery was uneventful, with no evidence of fluid reaccumulation or infection at 4 months.
Groin lymphatic fistulas and lymphoceles are complications of peripheral vascular surgical procedures. Many afferent lymph channels converge in the inguinal region, making it nearly impossible to avoid transection of some vessels. In most cases, damaged channels seal spontaneously and no clinical complication occurs (3). With increasing size and number of disrupted vessels, however, the likelihood of lymphatic complication increases (3). The reported incidence of groin lymphocele or lymphatic fistula in femoral revascularization procedures is 1.5% to 4% (3,4). These complications are often diagnosed clinically by recognition of an enlarging mass or serous drainage in the region of the surgical wound (3,4). Sometimes, however, the diagnosis is unclear. In the patient we described, the lymphatic channels had been ligated, suggesting that the fluid was ascites leaking from the peritoneal cavity to the groin through a postsurgical defect in the inguinal ligament. Lymphoscintigraphy confirmed the lower extremity lymphatic origin of the fluid.
The use of lymphoscintigraphy to identify lymphatic collections in various anatomic locations has been described in the literature (1,2,5–8). Our case report shows how this study also can be used in the groin, a region where lymphatic complications of vascular surgery are not uncommon.
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Lymphoscintigraphy; Serous Collections; Tc-99m Sulfur Colloid.
© 2001 Lippincott Williams & Wilkins, Inc.
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