Technological improvements in alternative diagnostic modalities led to an abandonment of this technique for oncologic purposes because it was technically challenging and time intensive, provided less information, and was more invasive. Although proficiency and training in the performance of lymphangiograms decreased, the utility of lymphangiography to demonstrate lymphatic leak became an established indication [8,9,14,22,23]. Traditionally, lymphangiography is performed from a pedal approach with the patient in a supine position. In this technique, a dye such as methylene blue that stains the lymphatics is injected into the web spaces between the toes. After the lymphatic vessel fills with the dye, the tissue overlying the lymphatic vessel is incised vertically, the lymphatic vessel is carefully skeletonized, and a 30-gauge lymphangiography needle is used to access the vessel. After securing the lymphatic access, 6 to 8 mL of ethiodized oil is instilled at a rate of 4 to 10 mL/h. Serial spot radiographs from the foot to the chest are acquired approximately every 10 to 15 minutes to follow the progression of the ethiodized oil as it ascends [22,24-27]. More recently, an interest in nodal lymphangiography has developed [21,28]. In this alternative approach, an inguinal lymph node is targeted with a 25- to 26-gauge spinal needle under US guidance. The needle is positioned between the hilum and cortex of a lymph node. Hand injection of ethiodized oil at a rate of 1 mL per 5 to 7 minutes is then initiated for a total volume of 6 to 10 mL. Serial spot radiographs of the pelvis, abdomen, and thorax are then acquired to follow the progression of ethiodized oil [21,25,28-30]. Intranodal lymphangiography appears to decrease procedure time, is less technically challenging, and decreases the risk of wound infection when compared to pedal lymphangiography [21,28].
Chylothorax Treatment Planning. Technological improvements in alternative diagnostic modalities led to an abandonment of this technique for oncologic purposes because it was technically challenging and time intensive, provided less information, and was more invasive. Although proficiency and training in the performance of lymphangiograms decreased, the utility of lymphangiography to demonstrate lymphatic leak became an established indication [8,9,14,22,23]. Traditionally, lymphangiography is performed from a pedal approach with the patient in a supine position. In this technique, a dye such as methylene blue that stains the lymphatics is injected into the web spaces between the toes. After the lymphatic vessel fills with the dye, the tissue overlying the lymphatic vessel is incised vertically, the lymphatic vessel is carefully skeletonized, and a 30-gauge lymphangiography needle is used to access the vessel. After securing the lymphatic access, 6 to 8 mL of ethiodized oil is instilled at a rate of 4 to 10 mL/h. Serial spot radiographs from the foot to the chest are acquired approximately every 10 to 15 minutes to follow the progression of the ethiodized oil as it ascends [22,24-27]. More recently, an interest in nodal lymphangiography has developed [21,28]. In this alternative approach, an inguinal lymph node is targeted with a 25- to 26-gauge spinal needle under US guidance. The needle is positioned between the hilum and cortex of a lymph node. Hand injection of ethiodized oil at a rate of 1 mL per 5 to 7 minutes is then initiated for a total volume of 6 to 10 mL. Serial spot radiographs of the pelvis, abdomen, and thorax are then acquired to follow the progression of ethiodized oil [21,25,28-30]. Intranodal lymphangiography appears to decrease procedure time, is less technically challenging, and decreases the risk of wound infection when compared to pedal lymphangiography [21,28].