Lymphography By Dr/ Dina Metwaly

 lymphatic system  it is part of the circulatory system, comprising a network of lymphatic vessels that carry a clear fluid called lymph directionally towards the heart.  The lymphatic system consists of lymphatic organs, a conducting network of lymphatic vessels, and the circulating lymph.

The Lymphatic System functions Transport clean fluids back to the blood Drains excess fluids from tissues Removes “debris” from cells of body Transports fats from digestive system Slide 12.1

Lymphatic System Thymus Gland Lymph Vessels Lymph Nodes Spleen Tonsils

Lymphatic Capillaries Fluid leaks through mini-valves into lymph capillaries Higher pressure on the inside closes mini-valves

Lymphatic Vessels Collects lymph from lymph capillaries Delivers lymph to lymph nodes Returns fluid to circulatory veins near the heart Right lymphatic duct Thoracic duct

Lymphatic System Structures

Lymph Nodes Filter lymph before it is returned to the blood Defense cells in nodes: Medulla houses macrophages which engulf and destroy foreign substances Cortex nurtures lymphocytes which provide immune response to antigens (cortex)

Lymphoid Organs Several other organs contribute to lymphatic function Spleen Thymus Tonsils Peyer’s patches Figure 12.5

The Spleen Filters blood Destroys worn out blood cells Forms blood cells in the fetus Acts as a blood reservoir

The Thymus Functions at peak levels only during childhood Produces hormones (like thymosin) to program lymphocytes

Tonsils Small masses of lymphoid tissue around the pharynx Trap and remove bacteria and other foreign materials Tonsillitis is caused by congestion with bacteria

Peyer’s Patches “Tonsils of the intestine” Found in the wall of the small intestine Capture and destroy bacteria in the intestine

Lymphography General term applied to the radiologic examination of: Lymph nodes (lymphadenography) : radiographic visualization of the lymph nodes . Lymph Vessels: endovascular injection of radiopaque material into a lymphatic vessel

Injected in hand Checks drainage of lymph nodes Usually done to demonstrate pelvis and abdomen Injected in foot For axillary, clavicular area and upper limbs Injected in hand Checks drainage of lymph nodes

Indications Edema in limbs by Visualization of vessel obstruction Infections Rule out cancer Lymphoma staging & Check for metastasis Size, shape, location of enlarged nodes Fluoroscopy guided biopsy

Contraindications Pregnancy People with allergies to iodine-based contrast dyes. people with severe chronic lung, heart, kidney, or liver disease.

Pre Procedure Obtain PT history Obtain PT consent Make sure to have all supplies Make sure the absence of contraindications, which are cardiovascular or pulmonary disease Positioning aides and comfort supplies

Contrast Water based (less commonly used as it diffuse in nearby tissues). Oil based More commonly used Ethiodal Lipodal Dose: The total amount of oily contrast medium injected on each side should never exceed 10 mL

Procedure of lower limb lymphography ( pedal lymphangiography) Injection of mixture of local anesthesia + methylene blue violet on the dorsal aspect of the foot between the toes. longitudinal incision ---> isolation of lymphatic vessel from the surrounding fatty tissue https://www.google.com.sa/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http%3A%2F%2Fralphcarag.deviantart.com%2Fart%2FLymphangiography-Animation-258271111&ei=8ZEKVarcBoT2PKTDgfgL&psig=AFQjCNFsTaQCJyt6F9aHK9R66hggEIfozg&ust=1426842178372970

visualization of superficial collectors after subcutaneous injection of contrast material into the first and second inter-metatarsal spaces of the dorsal foot (for superficial circulation) or or lateral retro-malleolar space (for deep circulation) Nodes in pelvis and abdomen are demonstrated with foot injection

A needle or catheter is inserted into a lymphatic channel in either the foot or arm, and a contrast medium is injected into the body at a very slow rate (approximately 60 to 90 minutes for all the contrast medium to be injected). A fluoroscope is used to follow the dye as it spreads through the lymphatic system through the legs, into the groin, and along the back of the abdominal cavity. Once the contrast medium is injected, the catheter is removed, and the incisions are stitched and bandaged.

Filming X-rays are usually taken 1 HR after pressure injection that takes about 45 minutes After 1 hour 24 hrs 48 hrs (if needed) 72hrs (if needed) First hour= Contrast in lymph ducts 24 hours = If lymph nodes

After 1 hour= Lymphangiograms the first films are taken usually of the lymph vessels the upper body or any area of interest. These first flims are called “Lymphangiograms”!

Lymphadenograms 24 hours after the Lymphangiograms are taken the patient has to come back to have the films taken of the lymph nodes called “lymphadenograms!”

upper limb lymphography injection of contrast agent in a collector of dorsal radio-carpal surface (for superficial circulation) or ulnar retro-styloid location (for deep circulation) radiography of the lymphatic channels from forearm to axillary lymph nodes

Upper Limb Lymphography

Normal appearances and variations Normal appearance of lymph nodes. Lymphogram (filling phase): shows a homogeneous appearance of the lymph nodes. Lymphogram (nodal phase): shows a smooth peripheral indentation (arrowheads), which corresponds to the hilar area.  A a) filling b) Nodal

Para-aortic nodes have proved to be the most reliable group for showing features of high diagnostic accuracy The cisterna chyli is usually a saccular structure less than 5 cm in length usually lies at the midline of the body of L1 but may also be situated on either side of the midline. Lymphogram shows normal cisterna chyli and the abdominal segment of the thoracic duct.

The thoracic duct sharply merges into the junction of the left subclavian vein and left internal jugular vein Some rarely seen nodes are situated extrinsically to the usual lymphographic regions, such as the popliteal, posterior intercostal, mediastinal, bilateral hilar, paratracheal, and supraclavicular nodes Figure: Lymphogram shows Normal appearance of the thoracic duct. the termination of the thoracic duct at the left subclavian-jugular venous anastomosis at the base of the neck

Iliopelvic-aortic Lymphatic System

Iliopelvic Abdominoaortic Lymph Nodes

Inguinal Region

Lymphography Lipiodol lymphography: Left image: After the injection of contrast material (lymphangiographic phase) the normal lymphatic vessels of the minor pelvis are visualized. Right image: 24 hours after the injection normal inguinal, pelvic and paralumbar lymph nodes are demonstrated (nodal phase).

complications The major complications of lymphography are caused by the vital dye and contrast materials rather than the technique Major frequent complication: pulmonary oil embolization Pulmonary infarction hypersensitivity to methylene blue dye and ethiodized oil Rare complication: intraalveolar hemorrhage hypothyroidism systemic arterial embolization to the brain or kidney

Post Procedure Watch for signs of infection Swelling red and warm to touch Accompanied by a fever Contact DR right away Drink lots of water Major swelling in one limb Especially limb injected

Conclusion This procedure has largely been replaced by non-invasive MRI or CT procedures. However, lymphography has the unique capability of demonstrating internal architectural derangements within normal-sized lymph nodes. This highly valuable advantage makes lymphography diagnostically more accurate than CT (which demonstrates size rather than architecture) Lymphography still has a cornerstone role in diagnosis and management of lymphatic circulatory disorders. 

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