1. Lymphography By
Dr/ Dina Metwaly

2.  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.

3. 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

4. Lymphatic System
Thymus Gland
Lymph Vessels
Lymph Nodes
Spleen
Tonsils

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

7. 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

8. Lymphatic System Structures

9. 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)

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

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

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

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

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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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

25. 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”!

26. 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!”

27. 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

28. Upper Limb Lymphography

29. 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

30. 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.

31. 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

32. Iliopelvic-aortic Lymphatic System

33. Iliopelvic Abdominoaortic Lymph Nodes

34. Inguinal Region

35. 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).

36. 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

37. 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

38. 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. 

39. Q & A?