Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part I. History, Anatomy, Physiology, and Diagnostic Imaging of the Lymphatic System

Hur Saebeom,Kim Jinoo,Ratnam Lakshmi,Itkin Maxim 대한영상의학회 2023 Korean Journal of Radiology Vol.24 No.2

Recent advances in lymphatic imaging have provided novel insights into the lymphatic system. Interventional radiology has played a significant role in the development of lymphatic imaging techniques and modalities. Radiologists should be familiar with the basic physiology and anatomy of the lymphatic system to understand the imaging features of lymphatic disorders, which reflect their pathophysiology. This study comprehensively reviews the physiological and anatomical aspects of the human lymphatic system as well as the latest lymphatic imaging techniques.

Hepatocellular Carcinomas Smaller Than 4 cm Supplied by the Intercostal Artery: Can We Predict Which Intercostal Artery Supplies the Tumor?

Hur, Saebeom,Kim, Hyo-Cheol,Chung, Jin Wook,Kim, Min-Uk,Kim, Ji Dae,Kim, Gyoung Min,Lee, In Joon,Kim, Young Il,Jae, Hwan Jun,Park, Jae Hyung The Korean Society of Radiology 2011 KOREAN JOURNAL OF RADIOLOGY Vol.12 No.6

<P><B>Objective</B></P><P>To predict which intercostal artery supplies a tumor by examining the spatial relationship between hepatocellular carcinoma (HCC) and the intercostal artery feeding the tumor on transverse computed tomography (CT) images.</P><P><B>Materials and Methods</B></P><P>Between January 2000 and September 2009, 46 intercostal arteries supplying HCCs smaller than 4 cm were noted in 44 patients, and CT scans and angiograms of these patients were retrospectively reviewed. The intercostal artery feeding the tumor was marked on the CT scan showing the center of the tumor. In addition, its spatial relationship with the tumor center was examined. The angle of the tumor location was measured on the transverse CT scan in the clockwise direction from the sagittal line on the virtual circle centered in the right hemithorax. Correlations between the angle of the tumor location and the level of the tumor-feeding intercostal artery were assessed with the Spearman rank coefficient.</P><P><B>Results</B></P><P>Of 46 intercostal arteries feeding HCC, 39 (85%) were the first ones observed from the tumor center in a counterclockwise direction on the transverse CT image containing the tumor center. The level of the tumor-feeding intercostal artery was significantly correlated with the angle of the tumor, as the posteriorly located tumor tends to be supplied by lower intercostal arteries, while the laterally located tumor by upper intercostal arteries (Spearman coefficient = -0.537; <I>p</I> < 0.001).</P><P><B>Conclusion</B></P><P>We can predict the tumor feeder with an accuracy of 85% as the first intercostal artery encountered from the tumor center in a counterclockwise direction on a transverse CT image.</P>

80-kVp CT Using Iterative Reconstruction in Image Space Algorithm for the Detection of Hypervascular Hepatocellular Carcinoma: Phantom and Initial Clinical Experience

Hur, Saebeom,Lee, Jeong Min,Kim, Soo Jin,Park, Ji Hoon,Han, Joon Koo,Choi, Byung Ihn The Korean Society of Radiology 2012 KOREAN JOURNAL OF RADIOLOGY Vol.13 No.2

<P><B>Objective</B></P><P>To investigate whether the low-tube-voltage (80-kVp), intermediate-tube-current (340-mAs) MDCT using the Iterative Reconstruction in Image Space (IRIS) algorithm improves lesion-to-liver contrast at reduced radiation dosage while maintaining acceptable image noise in the detection of hepatocellular carcinomas (HCC) in thin (mean body mass index, 24 ± 0.4 kg/m<SUP>2</SUP>) adults.</P><P><B>Subjects and Methods</B></P><P>A phantom simulating the liver with HCC was scanned at 50-400 mAs for 80, 100, 120 and 140-kVp. In addition, fifty patients with HCC who underwent multiphasic liver CT using dual-energy (80-kVp and 140-kVp) arterial scans were enrolled. Virtual 120-kVP scans (protocol A) and 80-kVp scans (protocol B) of the late arterial phase were reconstructed with filtered back-projection (FBP), while corresponding 80-kVp scans were reconstructed with IRIS (protocol C). Contrast-to-noise ratio (CNR) of HCCs and abdominal organs were assessed quantitatively, whereas lesion conspicuity, image noise, and overall image quality were assessed qualitatively.</P><P><B>Results</B></P><P>IRIS effectively reduced image noise, and yielded 29% higher CNR than the FBP at equivalent tube voltage and current in the phantom study. In the quantitative patient study, protocol C helped improve CNR by 51% and 172% than protocols A and B (<I>p</I> < 0.001), respectively, at equivalent radiation dosage. In the qualitative study, protocol C acquired the highest score for lesion conspicuity albeit with an inferior score to protocol A for overall image quality (<I>p</I> < 0.001). Mean effective dose was 2.63-mSv with protocol A and 1.12-mSv with protocols B and C.</P><P><B>Conclusion</B></P><P>CT using the low-tube-voltage, intermediate-tube-current and IRIS help improve lesion-to-liver CNR of HCC in thin adults during the arterial phase at a lower radiation dose when compared with the standard technique using 120-kVp and FBP.</P>

Quantitative Assessment of Foot Blood Flow by Using Dynamic Volume Perfusion CT Technique: A Feasibility Study.

Hur, Saebeom,Jae, Hwan Jun,Jang, Yeonggul,Min, Seung-Kee,Min, Sang-Il,Lee, Dong Yeon,Seo, Sang Gyo,Kim, Hyo-Cheol,Chung, Jin Wook,Kim, Kwang Gi,Park, Eun-Ah,Lee, Whal Radiological Society of North America 2015 Radiology Vol. No.

<P>Purpose: To demonstrate the feasibility of foot blood flow measurement by using dynamic volume perfusion computed tomographic (CT) technique with the upslope method in an animal experiment and a human study. Materials and Methods: The human study was approved by the institutional review board, and written informed consent was obtained from all patients. The animal study was approved by the research animal care and use committee. A perfusion CT experiment was first performed by using rabbits. A color-coded perfusion map was reconstructed by using in-house perfusion analysis software based on the upslope method, and the measured blood flow on the map was compared with the reference standard microsphere method by using correlation analysis. A total of 17 perfusion CT sessions were then performed (a) once in five human patients and (b) twice (before and after endovascular revascularization) in six human patients. Perfusion maps of blood flow were reconstructed and analyzed. The Wilcoxon signed rank test was used to prove significant differences in blood flow before and after treatment. Results: The animal experiment demonstrated a strong correlation (R2 = 0.965) in blood flow between perfusion CT and the microsphere method. Perfusion maps were obtained successfully in 16 human clinical sessions (94%) with the use of 32 mL of contrast medium and an effective radiation dose of 0.31 mSv (k factor for the ankle, 0.0002). The plantar dermis showed the highest blood flow among all anatomic structures of the foot, including muscle, subcutaneous tissue, tendon, and bone. After a successful revascularization procedure, the blood flow of the plantar dermis increased by 153% (P = .031). The interpretations of the color-coded perfusion map correlated well with the clinical and angiographic findings. Conclusion: Perfusion CT could be used to measure foot blood flow in both animals and humans. It can be a useful modality for the diagnosis of peripheral arterial disease by providing quantitative information on foot perfusion status. (C) RSNA, 2015</P>

Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part II. Classification and Treatment of the Lymphatic Disorders

Hur Saebeom,Kim Jinoo,Ratnam Lakshmi,Itkin Maxim 대한영상의학회 2023 Korean Journal of Radiology Vol.24 No.2

Lymphatic disorders encompass a broad spectrum of diseases involving the lymphatic system, ranging from traumatic lymphatic leaks to lymphatic malformations. Lymphatic disorders can be categorized into traumatic and non-traumatic disorders according to their etiology. These two categories may be further divided into subgroups depending on the anatomical location of the lymphatic pathology and their association with clinical syndromes. Thoracic duct embolization was a milestone in the field of lymphatic intervention that encouraged the application of percutaneous embolization techniques to treat leaks and reflux disorders in the lymphatic system. Additional access routes for embolization, including retrograde thoracic duct and transhepatic lymphatic access, have also been developed. This article comprehensively reviews a variety of options for the treatment of lymphatic disorders, from conservative management to the most recent embolization techniques.

Inadvertent Stenting and Percutaneous Aspiration for Treatment of Adventitial Cystic Disease in the Popliteal Artery: A Case Report

Hye Young Woo,Saebeom Hur,Hwan Jun Jae,Seung-Kee Min 대한혈관외과학회 2022 Vascular Specialist International Vol.38 No.2

Adventitial cystic disease (ACD) is a rare, non-atherosclerotic disease that mainly affects the popliteal artery. Treatment is primarily surgical as endovascular approaches are affected by high recurrence rates. However, some studies have reported successful endovascular treatments of popliteal ACD cases. A 55-year-old female presented with right calf claudication. Computed tomography angiography revealed segmental occlusion of the right distal superficial femoral artery. Subsequently, a drug-eluting stent was successfully deployed. However, an unusual adventitial cystic lesion occluding the lumen that was characteristic of ACD was detected during a postoperative imaging review. It was aspirated using an ultrasound- guided percutaneous needle and drained using a pigtail catheter for 24 hours. Follow-up images after 39 months showed a patent artery with no recurrence of any cystic lesions, highlighting successful ACD treatment via stenting, ultrasound-guided aspiration, and cyst drainage. Stenting and cyst aspiration can be an alternative option for selected patients with ACD.

Glue Embolization of Lymphopseudoaneurysm for Chylous Ascites after Retroperitoneal Surgery

Kwon Lyo Min,Hur Saebeom,Jeong Chang Wook,Jae Hwan Jun,Chung Jin Wook 대한영상의학회 2021 Korean Journal of Radiology Vol.22 No.3

Objective: To assess the safety and efficacy of lymphopseudoaneurysm (LPA) glue (n-butyl cyanoacrylate [NBCA]) embolization in the management of chylous ascites after retroperitoneal surgery. Materials and Methods: A retrospective analysis from January 2014 to October 2018 was performed in six patients (4 females and 2 males; mean age, 45.3 ± 14.2 years; range, 26–61 years) who underwent LPA embolization for chylous ascites developing after retroperitoneal surgery involving the perirenal space (four donor nephrectomies, one partial nephrectomy, and one retroperitoneal lymphadenectomy). After placing a percutaneous drainage catheter into the LPA or adjacent lymphocele, embolization was performed by filling the LPA itself with a mixture of glue and Lipiodol (Guerbet). Results: Daily drainage from percutaneously placed drains exceeded 300 mL/day despite medical and surgical treatment (volume: mean, 1173 ± 1098 mL; range, 305–2800 mL). Intranodal lymphangiography was performed in four of the six patients and revealed leakage in 2 patients. Percutaneous embolization of the LPA was successful in all patients using an NBCA and Lipiodol mixture in a ratio of 1:1–1:2 (volume: mean, 4.3 ± 1.1 mL; range, 3–6 mL). Chylous ascites was resolved and the drainage catheter was removed in all patients within 4 days after the procedure (mean, 2.0 ± 1.8 days; range, 0–4 days). No procedure-related complications or recurrence of chylous ascites occurred during a mean follow-up period of 37.3 months (range, 21.1–48.4 months). Conclusion: Glue embolization of LPA has the potential to be a feasible and effective treatment method for the management of chylous ascites after retroperitoneal surgery.

The Efficacy of Lymph Node Embolization Using <i>N</i>-Butyl Cyanoacrylate Compared to Ethanol Sclerotherapy in the Management of Symptomatic Lymphorrhea after Pelvic Surgery

Kim, Se Woo,Hur, Saebeom,Kim, Sang Youn,Cho, Jeong Yeon,Kwak, Cheol,Kim, Hee Seung,Ha, Jongwon,Min, Seung-Kee,Lee, Myungsu,Kim, Hyo-Cheol,Jae, Hwan Jun,Chung, Jin Wook Elsevier 2019 Journal of vascular and interventional radiology Vol.30 No.2

<P><B>Abstract</B></P> <P><B>Purpose</B></P> <P>To compare the efficacy of lymph node (LN) embolization using <I>N</I>-butyl cyanoacrylate versus ethanol sclerotherapy in the management of symptomatic postoperative pelvic lymphorrhea.</P> <P><B>Materials and Methods</B></P> <P>Thirty-three patients with 40 instances of symptomatic postoperative lymphorrhea were treated with either LN embolization or sclerotherapy at Seoul National University Hospital from January 2009 to July 2017 and were retrospectively included (LN embolization group: 24 lymphoceles of 19 patients, mean age of 59.29 years; sclerotherapy group: 16 lymphoceles of 14 patients, mean age of 60.95 years). The types of operations were hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9), radical prostatectomy (n = 3), and renal transplantation (n = 2) for the sclerotherapy group and radical prostatectomy (n = 10) and hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9) for the LN embolization group. The 3 most common indications of treatment were lower extremity edema (n = 11), pain (n = 11), and fever (n = 8). The amount of leak before treatment (initial daily drainage) and clinical outcomes, including the clinical success rate in 3 weeks, treatment period, and complication rate were compared between both groups.</P> <P><B>Results</B></P> <P>LN embolization showed a higher 3-week clinical success rate than sclerotherapy in a univariate analysis (83.3% and 43.8%, <I>P</I> = .026). There was no statistically significant difference in the treatment period and the complication rate (7.1 days and 12.3 days, <I>P</I> = .098; 8.3% and 25.0%, <I>P</I> = .184).</P> <P><B>Conclusions</B></P> <P>LN embolization is more effective for treating postoperative pelvic lymphorrhea than sclerotherapy with similar safety.</P>

Treatment of uncontrolled chyloascites by using intraoperative lipiodol lymphangiography and lymphovenous shunt guided by fluorescence laparoscopy

( Hyunji Lim ),( Soo Jin Park ),( Saebeom Hur ),( Ung Sik Jin ),( Hee Seung Kim ) 대한산부인과학회 2020 대한산부인과학회 학술대회 Vol.106 No.-

Objective: To suggest the effect of intraoperative mesenteric lipiodol lymphangiography and lymphovenous shunt guided by fluorescence laparoscopy for treating refractory chylous ascites. Methods: A 22-year-old woman visited due to refractory chylous ascites. Chylous ascites developed after laparoscopic left adenexectomy for dermoid cyst three years ago, and it could not be controlled by repetitive treatment such as total parenteral nutrition, multiple lymphatic embolization and several times of multiple lymphatic ligations. For relieving abdominal distention, ascites had been discharged 3 L/day through the pigtail catheter, and her weight was reduced 58 kg to 38kg. Results: On CT or MRI lymphangiography, we found lymphatic reflux through the left ovarian vein with enhanced lymphatic structure with at the presacral area. Thus, we ligated the left ovarian vein and intestinal branches of cisterna chyli guided by intraoperative mesenteric lipiodol lymphangiography. For reducing lymphatic pressure, we performed lymphovenous shunt between the inferior mesenteric vein and left para-aortic enlarged lymphatics. However, chylous ascites developed again seven days after the first surgery. Thus, we performed intraoperative lipiodol lymphangiography for the pelvic lymphatics, and found leakage point of lymphatic fluid in the aortocaval area guided by fluorescence laparoscopy. We conducted lymphovenous shunt between the right ovarian vein and the enlarged lymphatics in the aortocaval area, and repaired multiple and small lymphatic leakage around the shunt. She has shown no recurrence up to now, and germline CELSR1 variants of uncertain significance related with hereditary lymphedema has been detected. Conclusion: Detection of leakage point and decompression by lymphovenous shunt by intraoperative lipiodol lymphangiography and fluorescence laparoscopy can control refractory chylous ascites.

Recanalization of an Occluded Vena Cava Filter and Iliac Veins with Kissing Stents to Treat Postthrombotic Syndrome with a Venous Stasis Ulcer

고현민,Sanghyun Ahn,Sang Il Min,Saebeom Hur,Hwan Jun Jae,민승기 대한혈관외과학회 2020 Vascular Specialist International Vol.36 No.2

Inferior vena cava filters (IVCFs) are effective in preventing pulmonary embolism and their usage has rapidly increased over the past decades. However, complications have also significantly increased, as IVCF occlusion causes serious chronic venous insufficiency. Herein, we report a case of infrarenal IVCF occlusion that was successfully treated with the introduction of kissing stents through the IVCF into both iliac veins. A 54-year-old male presented with non-healing ulcers on his left leg. He had undergone IVCF implantation and warfarin medication due to deep vein thrombosis 4 years earlier in another hospital. Computed tomography (CT) revealed the filter-bearing IVC occlusion. Endovascular IVCF removal was attempted but failed. Kissing stents were deployed across the IVCF and extended into both iliac veins. Cone beam CT showed well-deployed stents just behind the occluded IVCF. Venous flow was restored without complications, and the recurrent ulcer healed immediately.