Abstract
Most protocols for lymphatic imaging of the lower limb conventionally inject tracer materials only into the interdigital space; however, recent studies indicate that there are four independent lymphatic vessel groups (anteromedial, anterolateral, posteromedial, and posterolateral) in the lower limb. Thus, three additional injection sites are needed for lymphatic imaging of the entire lower limb. We aimed to validate a multiple injection designed protocol and demonstrate its clinical benefits. Overall, 206 lower limbs undergoing indocyanine green fluorescent lymphography with the new injection protocol were registered retrospectively. To assess the influence of predictor variables on the degree of severity, multivariable logistic regression models were used with individual known risk factors. Using a generalized linear model, the area under the curve (AUC) of the conventional clinical model, comprising known severity risk factors, was compared with that of the modified model that included defects in the posterolateral and posteromedial groups. Multivariable logistic regression models showed a significant difference for the posteromedial and posterolateral groups. The AUC of the modified model was significantly improved compared to that of the conventional clinical model. Finding defects in the posteromedial and posterolateral groups is a significant criterion for judging lymphedema severity and introducing a new lymphedema severity classification.
Highlights
Most protocols for lymphatic imaging of the lower limb conventionally inject tracer materials only into the interdigital space; recent studies indicate that there are four independent lymphatic vessel groups in the lower limb
We checked for the existence of DB and colored the entire courses of the four lymphatic vessel groups from the injection sites to the lymph nodes according to the anatomical classification in the indocyanine green (ICG) fluorescent lymphography images (Fig. 2)
When compared with our previous cadaveric data, the relationship between the injection sites and lymphatic groups was similar in the control group, but the rate of visualization for each of the injection sites was higher than that obtained in the cadaveric study
Summary
Most protocols for lymphatic imaging of the lower limb conventionally inject tracer materials only into the interdigital space; recent studies indicate that there are four independent lymphatic vessel groups (anteromedial, anterolateral, posteromedial, and posterolateral) in the lower limb. Three additional injection sites are needed for lymphatic imaging of the entire lower limb. 206 lower limbs undergoing indocyanine green fluorescent lymphography with the new injection protocol were registered retrospectively. Using a generalized linear model, the area under the curve (AUC) of the conventional clinical model, comprising known severity risk factors, was compared with that of the modified model that included defects in the posterolateral and posteromedial groups. Multivariable logistic regression models showed a significant difference for the posteromedial and posterolateral groups. New indirect imaging techniques, such as infrared fluorescent lymphography[17], interstitial computed tomography-lymphography[18], magnetic resonance imaging lymphography[19,20], Single
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