Percutaneous sclerotherapy of massive post-surgical inguinal lymphocele

Case contributed by Dr Umberto Pisano

Presentation

2-month history of massive oval swelling in left inguinal region. Background of peripheral vascular disease and critical ischemia of left foot, requiring recent exposure of profunda femoris artery on left side for right-to-left femoro-femoral cross-over graft. After fluid analysis and lymphoscintigraphy (not shown) to confirm the diagnosis of post-surgical lymphocele, this was aspirated on repeated occasions, with immediate reaccumulation. Surgical capsule excision and empirical ligation of the perivenous tissue around the greater saphenous vein in the upper thigh also resulted in complete reaccumulation of fluid. The interventional radiology service was then consulted for possible further options.

Patient Data

Age: 70 years
Gender: Male

3D reconstruction and axial CT

CT

Massive superficial homogenous hypoattenuating collection lying anterior to right-to-left common femoral to profunda cross-over graft, with features of prior left common femoral artery endarterectomy. Completely calcified native left superficial femoral artery.

Extensive atherosclerotic features in splanchnic vasculature and right lower limb.

First session of Bleomycin sclerotherapy

Fluoroscopy

A conventional lymphangiography via incision over first web space of the left foot, after subcutaneous injection of methylene blue, was abandoned due to lack of suitable targets.

Over 1500 mL of liquid were aspirated from the lymphocele. No feeding vessel seen on fluoroscopy. 60 000 units of bleomycin were injected in the collection for 2 hours, then removed via a 12 Fr locking pigtail drain. The fluid reaccumulated completely in less than a week.

Second alcohol-based sclerotherapy session

Fluoroscopy

A second procedure consisting of re-do drainage, fluoroscopic assessment and alcohol sclerotherapy. A 9 Fr sheath was inserted and a variety of catheters were used in the attempt to demonstrate possible feeding vessels, unsuccessfully. 100 mL of 100% ethyl alcohol was administered via a 12 Fr pigtail drain: the agent was left within the cavity for 6 hours before aspiration; the drain was then left uncapped in situ to assess for recurrence.

Third alcohol-based sclerotherapy session

Fluoroscopy

A few weeks later, the patient referred reduction in size of the collection and some thickening of the overlying skin.

A third session was undertaken with similar modalities to previous: this time, it only took 100 mL of mixed saline and contrast to fill the lymphocele. A feeding lymphatic became evident in the medial aspect of the thigh. After 22Ga needle stereotactic localization, this was ligated successfully by the vascular colleagues: a patch of contrast is seen on the third image representing its disruption. Another 100 mL of 100% ethylic alcohol was administered into the lymphocele. This time, the ethanol was left overnight, and completely aspirated the following morning.

Case Discussion

The sclerotherapy sessions were uneventful. Specifically, no skin or systemic reaction was seen after the use of bleomycin. Both alcohol-based sessions resulted in moderate obtundation after the expected absorption of the agent into the bloodstream. 

Following the third intervention, the patient is currently well and reports essentially complete resolution of the inguinal collection; some occasional discharge from the drain site and skin induration are present. More conspicuous lymphedema has developed but is being managed effectively with dedicated stockings.

This was a very challenging case where a multidisciplinary approach proved to be beneficial. There is no established practice regarding the use of sclerosing agents in post-surgical lymphocele: good effects have been documented with n-butyl cyanoacrylate 1, as well as bleomycin 2 and alcohol 3. It is very common for large collections to require multiple sessions to achieve meaningful improvement.

Case presented with Vascular Consultant D Byrne and fellow IR Consultant M Philippou.

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