What we treat
Lymphatic interventions cover a focused set of conditions that share one feature: the lymphatic system isn’t doing its job. The most common reasons for referral are:
Chylothorax and chylous ascites
The thoracic duct runs from the abdomen up through the chest and empties fat-rich lymph into the bloodstream near the left collarbone. When it’s injured — most often during esophagectomy, lung resection with mediastinal lymph node dissection, congenital heart surgery, or thoracic aortic surgery — chyle leaks into the chest (chylothorax) or abdomen (chylous ascites). Conservative management is tried first: a low-fat or medium-chain triglyceride diet, octreotide, and chest tube drainage. When the leak doesn’t resolve in 1–2 weeks, thoracic duct embolization (TDE) is the next step. After a lymphangiogram opacifies the lymphatic system, the cisterna chyli is punctured through the abdomen with a thin needle, a microcatheter is advanced into the thoracic duct, and microcoils plus a permanent tissue glue (n-butyl cyanoacrylate) seal the leak. Most patients are discharged the day after the procedure.
Postsurgical lymphoceles
A lymphocele is a collection of lymphatic fluid that forms after pelvic, retroperitoneal, or transplant surgery — anywhere lymph nodes have been dissected. The most common scenarios:
- After radical prostatectomy with pelvic lymph node dissection (PLND) — symptomatic lymphoceles develop in a meaningful minority of robotic prostatectomy patients
- After kidney transplantation — lymphoceles can compress the transplanted ureter or vessels
- After gynecologic oncology surgery — radical hysterectomy or staging lymphadenectomy for endometrial, ovarian, or cervical cancer
- After vascular surgery — particularly groin incisions for bypass or aortic procedures
Most lymphoceles resolve with simple percutaneous drain placement. When the lymphocele persists or recurs, sclerotherapy — instilling ethanol, doxycycline, or povidone-iodine through the catheter — obliterates the cavity and avoids a return to the operating room.
Lymphatic malformations and complex lymphatic anomalies
Some patients are born with abnormal lymphatic channels that cause lifelong problems. These include macrocystic and microcystic lymphatic malformations (sometimes still called cystic hygromas), central conducting lymphatic anomaly (CCLA), generalized lymphatic anomaly (GLA), kaposiform lymphangiomatosis (KLA), and Gorham-Stout disease. Sclerotherapy and embolization play a central role in management of these complex cases, often alongside medical therapy with sirolimus or PI3K-pathway inhibitors. Plastic bronchitis and protein-losing enteropathy after Fontan palliation in single-ventricle congenital heart disease have also become treatable with lymphatic embolization in pediatric IR.
Lymphangiography — diagnosis and therapy in one
Lymphangiography is both the diagnostic test that maps the lymphatic system and, in some cases, a treatment in itself. Under ultrasound guidance, ethiodized oil (Lipiodol) is injected directly into a groin lymph node (intranodal lymphangiography) or into a small lymphatic vessel on the foot (pedal lymphangiography). The contrast travels through the lymphatic system under live X-ray imaging, identifying the source of any leak. For low-output postsurgical chyle leaks, the inflammatory response to the contrast itself can be enough to seal the leak — meaning some patients are cured by lymphangiography alone, without needing embolization.
Who is a good candidate?
Most lymphatic interventions are referred from the surgical or specialty team managing the patient: thoracic surgery, cardiothoracic surgery, vascular surgery, urology, gynecologic oncology, transplant surgery, surgical oncology, head and neck surgery, or pediatric specialty teams. The most common patient profiles are someone with a postsurgical chylothorax that won’t resolve, a recurrent lymphocele after pelvic or transplant surgery, or a child or adult with a complex lymphatic anomaly. Workup typically includes a CT, an MR lymphangiogram (DCMRL) when available, and analysis of the leaking fluid (triglycerides above 110 mg/dL or chylomicron presence confirms chyle).
References
- Cope C. Diagnosis and treatment of postoperative chyle leakage via percutaneous transabdominal catheterization of the cisterna chyli: a preliminary study. J Vasc Interv Radiol. 1998;9(5):727–734.
- Itkin M, Kucharczuk JC, Kwak A, Trerotola SO, Kaiser LR. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg. 2010;139(3):584–589.
- Kim YH, Kim DH, Lim YS, et al. Percutaneous catheter drainage with sclerotherapy for symptomatic lymphocele after pelvic surgery. J Vasc Interv Radiol. 2019;30(7):1056–1064.
- Dori Y, Keller MS, Rome JJ, et al. Percutaneous lymphatic embolization of abnormal pulmonary lymphatic flow as treatment of plastic bronchitis in patients with congenital heart disease. Circulation. 2016;133(12):1160–1170.
Frequently asked questions
What are lymphatic interventions?
Lymphatic interventions are image-guided, minimally invasive procedures used to diagnose and treat problems of the lymphatic system. The most common are intranodal or pedal lymphangiography (a diagnostic test that maps the lymphatic system), thoracic duct embolization (closing off a leaking thoracic duct after surgery), percutaneous lymphocele drainage and sclerotherapy (treating fluid collections after pelvic or transplant surgery), and embolization or sclerotherapy of lymphatic malformations and complex lymphatic anomalies.
What is a chylothorax and why does it need an intervention?
Chylothorax is a milky fluid (chyle) that collects in the chest cavity when the thoracic duct is injured, most often during esophagus, lung, or heart surgery. When chylothorax doesn’t resolve with conservative care (special diet, octreotide, chest tube drainage), thoracic duct embolization can usually seal the leak through a small puncture in the abdomen, avoiding the need for a thoracotomy.
I had a robotic prostatectomy and have a lymphocele. Can it be treated without surgery?
Yes. Lymphoceles after radical prostatectomy with pelvic lymph node dissection are very common and most resolve with simple percutaneous drainage. When a lymphocele persists or recurs, sclerotherapy — instilling a sclerosing agent such as ethanol, doxycycline, or povidone-iodine through the drainage catheter — can obliterate the cavity and avoid a return to the operating room. Similar approaches are used for lymphoceles after kidney transplantation, gynecologic oncology surgery, and vascular surgery.
What is thoracic duct embolization?
Thoracic duct embolization (TDE) is a minimally invasive procedure to seal a leaking thoracic duct. After a lymphangiogram opacifies the lymphatic system, the cisterna chyli is punctured through the abdomen with a thin needle, and a microcatheter is advanced into the duct. Microcoils and a permanent tissue glue (n-butyl cyanoacrylate) are then deposited to close the leak. Most patients are discharged the day after the procedure.
Can lymphatic interventions help children with congenital lymphatic problems?
Yes. Pediatric lymphatic interventions are an important part of the field, including treatment of congenital chylothorax, plastic bronchitis and protein-losing enteropathy after Fontan palliation in single-ventricle congenital heart disease, central conducting lymphatic anomaly, generalized lymphatic anomaly, kaposiform lymphangiomatosis, and Gorham-Stout disease. These cases are managed in close collaboration with pediatric cardiology, pediatric surgery, and vascular anomaly teams.
Do lymphatic interventions treat lymphedema?
Lymphedema — chronic limb swelling, often after lymph node dissection or radiation for cancer — is primarily managed by certified lymphedema therapists with complete decongestive therapy and, in selected patients, lymphatic surgery (lymphovenous anastomosis or vascularized lymph node transfer) by specialty surgeons. Lymphatic interventional radiology can play a diagnostic role using MR lymphangiography and a procedural role for specific complications, but day-to-day lymphedema care belongs to the lymphedema team.
Who performs lymphatic interventions?
Lymphatic interventions are performed by interventional radiologists. The procedures are highly imaging-dependent and are coordinated closely with the referring cardiothoracic surgery, vascular surgery, urology, gynecologic oncology, transplant surgery, and pediatric specialty teams that manage the underlying problem.
