Indocyanine Green Lymphography Findings Research Articles

Indocyanine green lymphography in the congenital chylothorax and chylous ascites.

The prognosis of congenital chylothorax and ascites ranges from spontaneous resolution to death, but no established examination exists to predict the prognosis. We aimed to develop a clinically useful method to evaluate lymphatic abnormalities using indocyanine green (ICG) lymphography in infants with congenital chylothorax and ascites. We retrospectively evaluated infants with congenital chylothorax and chylous ascites who underwent ICG lymphography in our hospital between 2012 and 2022. The ICG lymphography findings was evaluated. We defined the dermal backflow in the trunk as the lymphatic flow from the end of the limb back through the lymphatic vessels on the surface of the trunk. The association between the dermal backflow in the trunk and clinical outcomes, as follows, are investigated: the duration of the drainage period, the duration of endotracheal intubation, and the length of hospital stay. Twenty infants had a dermal backflow in the trunk, and ten did not. Clinical outcomes in infants with and without dermal backflow in the trunk were as follows (median): the duration of the drainage period (20 vs. 0 days, p = 0.001), the duration of endotracheal intubation (12 vs. 2 days, p = 0.04), and the length of hospital stay (62 vs. 41 days, p = 0.04), respectively. In multivariate linear regression analysis adjusted for gestational age, the duration of the drainage period was correlated with the dermal backflow in the trunk [exp(B) = 2.62; p = 0.003]. The dermal backflow in the trunk in ICG lymphography was useful in predicting the clinical course of congenital chylothorax and ascites.

Three-dimensional non-contrast magnetic resonance lymphography severity stage for upper extremity lymphedema

PurposesNon-contrast magnetic resonance lymphography (NMRL) has recently shown the capability of evaluating anatomical fluid distribution in upper extremity lymphedema (UEL). However, there is still a lack of knowledge about the correlation between the characteristic three-dimensional (3D) NMRL findings and the indocyanine green lymphography (ICG-L) findings. Our goal was to clarify the relationship between the 3D NMRL findings and the ICG-L findings. MethodsMedical charts of patients with secondary UEL who underwent NMRL and ICG-L between January 2018 to October 2021 were reviewed. The upper extremities were divided into 6 regions; the hand, elbow, and the radial and ulnar aspects of the forearm and the upper arm. We investigated the prevalence of characteristic 3D NMRL patterns (Mist/Spray/Inky) in each region based on the ICG-L stage. We also examined the association between the 3D NMRL stage which we proposed and the ICG-L stage, and other clinical factors. ResultsA total of 150 regions of 25 patients with upper extremities lymphedema were enrolled in the study. All of the characteristic patterns increased significantly as the ICG-L stage advanced (p < 0.001, < 0.001, and < 0.001, respectively). The predominant NMRL patterns changed significantly from the Early pattern (Mist pattern) to the Advanced pattern (Inky/Spray pattern) as the ICG-L stage progressed (p < 0.001). The higher Stage of 3D NMRL was significantly associated with the progression of the ICG-L stage (rs = 0.80, p < 0.001). ConclusionsCharacteristic 3D NMRL patterns and the 3D NMRL Stage had a significant relationship with the ICG-L stage and other clinical parameters. This information may be an efficient tool for a more precise and objective evaluation of various treatments for UEL patients.

Lymphatic Pathways on Indocyanine Green Lymphography in Patients with Labia Minora Hypertrophy.

Labia minora hypertrophy (LH) is a growing aesthetic concern, yet its etiology and local lymphatic anatomy remain unclear. This study aimed to use indocyanine green (ICG) lymphography to investigate evidence of lymphedema in LH and clarify the anatomy of lymph vessels from labia minora. Thirty-five patients with LH underwent preoperative ICG lymphography of their bilateral labia minora. The study reviewed demographic, ICG imaging, and measurement data to identify the characteristics of the superficial lymphatic anatomy in labia minora. The ICG lymphography findings revealed that 97.1% of the observed patterns were linear, and 2.9% were dermal backflow patterns. Further analysis of the linear patterns revealed the presence of three main superficial pathways originating from the labia minora and connecting to the labia majora and clitoral hood. These pathways were identified as the superior, median, and inferior channels. Based on the observed lymphatic mapping in the labia minora, three types were classified: type 1 (Superior + Inferior channels) accounted for 75.0% (51 sides), type 2 (Median + Inferior channels) accounted for 8.8% (6 sides), and type 3 (Superior + Median + Inferior channels) accounted for 16.2% (11 sides). The study demonstrates that ICG lymphography enables clear visualization of superficial lymph flow from labia minora. It also suggests that lymphedema is not a common pathologic feature of LH. Understanding the lymphatic anatomy of the labia minora can provide valuable guidance for surgical interventions involving the female external genitalia.

Differentiation of lipoedema from bilateral lower limb lymphoedema by imaging assessment of indocyanine green lymphography.

Lipoedema is characterized by disproportionate painful fat accumulation mostly in the lower limbs. The presence of lymphoedema in lipoedema remains controversial. This study aimed to assess the presence or absence of lymphoedema in the lower limbs of women with lipoedema using indocyanine green (ICG) lymphography. A cross-sectional retrospective study was undertaken in women with a clinical diagnosis of lipoedema whose lower limbs were examined with ICG lymphography. MD Anderson Cancer Center (MDACC) ICG staging was used to determine lymphoedema presence and severity. Patient characteristics, ICG lymphography findings, Stemmer sign, body mass index, waist-to-hip ratio, limb volume and bioimpedance spectroscopy measures were recorded. Forty women with lipoedema underwent ICG lymphography for the lower limbs from January 2018 to July 2022. Thirty-four women (85.0%) were determined by ICG lymphography as MDACC ICG Stage 0 representing normal lymphatics. Of the six women who demonstrated dermal backflow on ICG lymphography, all were determined as ICG Stage 1, four had localized traumatic dermal backflow area at their ankles, one had previously diagnosed with primary lymphoedema and one was classified as lipoedema stage 4. ICG lymphography findings suggested the absence of lymphoedema in a clear majority of women with lower limb lipoedema.

Anatomical Location of Lymphatic Pathways in the Posterior Thigh.

It is necessary for treating lower extremity lymphedema to understand the lymphatic pathways in the extremities. This study aimed to clarify the anatomical locations of lymph vessels in the posterior thigh using indocyanine green (ICG) lymphography. Medical records of cancer survivors who underwent ICG lymphography for secondary lymphedema screening from February 2019 to November 2020 were reviewed. Nonlymphedematous limbs without dermal backflow pattern on ICG lymphography (ICG stage 0) were included. Indocyanine green (0.1 mL) was injected intradermally at 2 points in the midlateral thigh, at the levels of one third and two thirds from the popliteal fossa to the gluteal fold in a prone position. Locations of the posterior thigh collecting lymph vessels visualized by ICG lymphography were marked on the skin surface with a pen, and distances from the popliteal fossa to the collecting lymph vessels were measured at the posterior midline in percentage, with the popliteal fossa set as 0% and the gluteal fold as 100%. Based on ICG lymphography findings, the number of the collecting lymph vessels shown as linear pattern and anatomical locations at the posterior thigh midline were investigated. Twenty limbs of 20 cancer survivors were included. Linear pattern was identified in all lower extremities; average number was 2.3 ± 0.7 (range, 1-3). Most collecting lymph vessels shown on ICG lymphography, 26.7% (12 of 45) lymph vessels, were located within 40% to 50% of the region, and 24.4% (11 of 45) lymph vessels within 30% to 40% of the region. There are 1 or more collecting lymph vessels in the posterior thigh by midlateral thigh ICG injection, which can be addressed for posterior thigh lymphedema.

Indocyanine green lymphography findings in older patients with lower limb lymphedema

ObjectiveLymphedema is classified as primary or secondary according to the underlying cause. Primary lymphedema is hereditary and is considered a consequence of an inherited abnormality of the lymphatic system. Secondary lymphedema, however, is a consequence of lymphatic failure resulting from trauma, parasitic infection, or iatrogenic obstruction. Primary lymphedema is divided into three broad groups, namely, lymphedema congenita, lymphedema praecox, and lymphedema tarda. With the exception of lymphedema tarda, it is thought that age-related deterioration in lymphatic pump function is caused by oxidative stress. The aim of this study was to evaluate and to classify indocyanine green (ICG) lymphography findings in patients with lower limb lymphedema to ascertain whether there is a pattern to age-related deterioration. MethodsThere were 56 patients (104 edematous lower limbs) who had undergone ICG lymphography and for whom the lower extremity lymphedema (LEL) index had been calculated enrolled in this study. Specific inclusion criteria were used to exclude other causes of edema. ICG lymphography images were recorded in the plateau phase (12-18 hours after injection), when no further changes of images would be expected. The LEL index was calculated by summation of the squares of the circumference for five areas in each lower extremity divided by the body mass index. ResultsThe clinical lymphedema pattern was determined as bilateral in 48 patients and unilateral in 8 patients. Patients with bilateral lymphedema were significantly older than those with unilateral lymphedema (76.40 ± 8.03 years vs 53.13 ± 14.12 years; P < .01). The ICG lymphography pattern was categorized as linear, low enhancement (LE), distal dermal backflow (DB), or extended DB in bilateral lymphedema. ICG lymphography showed the DB pattern on both the thigh and lower leg regions in all eight legs with unilateral lymphedema. There were also significant between-group differences in the LEL index (linear vs distal DB, P < .05; linear vs extended DB, P < .01; linear vs unilateral, P < .01; LE vs extended DB, P < .01; LE vs unilateral, P < .01; distal DB vs extended DB, P < .05; and distal DB vs unilateral, P < .01). ConclusionsIn this study, unilateral lymphedema, with its younger age at onset, severity, and unilateral dominance, corresponded to lymphedema tarda. In contrast, bilateral lymphedema corresponded to senile lymphedema, which is distinct from primary lymphedema in general and lymphedema tarda in particular. Age-related deterioration in lymphatic pump function rather than iatrogenic obstruction or genetic abnormality is likely to account for the characteristic older age at onset of lymphedema and its progression from the distal region.

Factors Associated with Lymphosclerosis: An Analysis on 962 Lymphatic Vessels.

Lymphaticovenular anastomosis is a useful treatment option for compression-refractory lower extremity lymphedema, but its efficacy depends largely on the severity of lymphosclerosis. To maximize lymphaticovenular anastomosis efficacy, it is important to elucidate factors associated with severe lymphosclerosis. Medical charts of 134 lower extremity lymphedema patients who underwent preoperative indocyanine green lymphography and lymphaticovenular anastomosis were reviewed to obtain data of clinical demographics, indocyanine green lymphography findings, and intraoperative findings. Based on intraoperative findings of lymphatic vessels, severity of lymphosclerosis was classified into s0, s1, s2, and s3. Severe lymphosclerosis was defined as lymphatic vessels with s3 sclerosis. Logistic regression analysis was used to identify independent factors associated with severe lymphosclerosis. In total, 962 lymphatic vessels were analyzed, among which severe lymphosclerosis was observed in 97 (10.1 percent). Multivariate analysis revealed that independent factors associated with severe lymphosclerosis were higher body mass index (OR, 1.803; 95 percent CI, 1.041 to 3.123; p = 0.035), incision site in the thigh/foot compared with in the groin (OR, 2.355/4.471; 95 percent CI, 1.201 to 4.617/2.135 to 9.362; p = 0.013/p < 0.001), and S-region/D-region on indocyanine green lymphography compared with L-region (OR, 83.134/1441.126; 95 percent CI, 11.296 to 611.843/146.782 to 14149.195; p < 0.001/p < 0.001). Inverse associations were observed in positive history of radiation therapy (OR, 0.461; 95 percent CI, 0.269 to 0.788; p = 0.005). Independent factors associated with severe lymphosclerosis were clarified. Indocyanine green lymphography pattern had the strongest association with severe lymphosclerosis. D-region on indocyanine green lymphography should be avoided for lymphaticovenular anastomosis. Risk, III.

Contribution of Simultaneous Breast Reconstruction by Deep Inferior Epigastric Artery Perforator Flap to the Efficacy of Vascularized Lymph Node Transfer in Patients with Breast Cancer-Related Lymphedema.

Background The contribution of simultaneous breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap to the efficacy of vascularized groin lymph node transfer (LNT) for breast cancer-related lymphedema (BCRL) was investigated. Methods Patients were divided into two groups: the first group underwent groin LNT + DIEP flap surgery for simultaneous breast reconstruction (groin LNT + DIEP flap group) and the second group underwent groin LNT only (groin flap alone group). Patients with BCRL were evaluated based on indocyanine green lymphography findings. LNT was indicated only in advanced-stage BCRL cases, and groin nodes nourished by superficial circumflex iliac artery (SCIA) were used as donors. The side for the vascular pedicle(s) was decided based on our algorithm. In patients with pendulous breast, the flap was vertically transferred on the chest. Lymphatic function was assessed after LNT using imaging tests, and transferred lymph nodes were evaluated using ultrasonography. Results In this study, 27 patients with advanced-stage BCRL underwent LNT. Of them, 13 belonged to the groin LNT + DIEP flap group and 14 belonged to the groin flap alone group. Although reduction volume was not significantly different between the groups, the number of patients in whom lymphatic function was improved and the need for compression therapy could be reduced was significantly higher in the groin LNT + DIEP flap group than in the groin flap alone group. Conclusion When a patient with advanced-stage BCRL undergoes LNT based on SCIA, simultaneous breast reconstruction using DIEP flap may reduce the need for compression therapy.

Genital Lymphedema Score: Genital Lymphedema Severity Scoring System Based on Subjective Symptoms.

Genital lymphedema (GL) causes irritating symptoms such as urinary troubles due to genital edema and genital lymphorrhea, which deteriorate patients' quality of life. Indocyanine green genital lymphography has been reported to be useful for severity evaluation of GL but is not available in all medical settings. More convenient and simple severity evaluation methods are required in clinical practice. Thirty-two female secondary lower extremity lymphedema patients with GL were evaluated using the genital lymphedema score (GLS) based on patients' symptoms related to GL (score from 0 to 9; higher is worse) and the genital dermal backflow (GDB) stage based on indocyanine green lymphography findings. The GLS was compared according to GDB stage. The GLS ranged from 1 to 9 (mean, 3.0), and GDB stage ranged from I to IV (9 in GDB stage I, 13 in GDB stage II, 8 in GDB stage III, and 2 in GDB stage IV). There was a significant difference between GLS in GDB stage I, GDB stage II, GDB stage III, and GDB stage IV [1.2 (0.4), 2.4 (0.5), 4.8 (0.9), and 8.0 (1.4), respectively; P < 0.001). The GLS was well associated with pathophysiological GL severity staging system and increased with progression of GDB stage. Because GLS is more convenient and simple than GDB stage, GLS is useful for primary evaluation of GL.

Correlation between indocyanine green (ICG) patterns and real-time elastography images in lower extremity lymphedema patients

Indocyanine green (ICG) lymphography is becoming a popular modality, but unfortunately it is not available in all institutions. Elastography is a relatively new ultrasonographic technique to evaluate tissue elasticity, which visualizes fluid retention as a red region in lymphedema patients. The aim of this study was to evaluate the correlation between elastography and ICG lymphology. Thirty-six legs in 18 patients with secondary lower extremity lymphedema (LEL) and 20 legs in 10 healthy volunteers were examined using elastography. Thirty-six legs in 18 secondary LEL patients were examined using ICG lymphography. Elastography was performed on both legs at the following three sites: medial thigh (MT), medial leg (ML), and anterior ankle (AA). The area of the red region in the subcutaneous tissue demonstrated by elastography was calculated using Image software. ICG lymphography findings were classified into the following four patterns: linear (ICG1), splash (ICG2), stardust (ICG3), and diffuse (ICG4) patterns. As ICG pattern progressed, the red region area was likely to increase. There was a correlation between ICG patterns and red region area according to the severity at bilateral MT (rs = 0.665), ML (rs = 0.623), and AA (rs = 0.668). Significant difference was demonstrated among group means of the red region area by analysis of variance (healthy vs. ICG1 vs. ICG2 vs. ICG3 vs. ICG 4: 14.4 ± 5.7 vs. 15.1 ± 10.3 vs. 25.2 ± 6.2 vs. 30.8 ± 9.4 vs. 35.0 ± 2.8; P < 0.001). The area of the red region in the subcutaneous tissue shown using elastography, which represents fluid, increases with the aggravation of lymphedema demonstrated by ICG patterns. As elastography is performed by ultrasonography, which is available in most institutions, elastography could be a useful alternative evaluation for lymphedema severity when ICG lymphography is not available.

Indocyanine Green Lymphography Findings in Primary Leg Lymphedema

Indocyanine green (ICG) lymphography has been reported to be useful for the evaluation of secondary lymphedema, but no study has reported characteristic findings of ICG lymphography in primary lymphedema. This study aimed to classify characteristic ICG lymphography patterns in primary lymphedema. The study was a retrospective observational study. Thirty one primary lower extremity lymphedema (LEL) patients with a total of 62 legs were studied. ICG lymphography patterns were categorized according to the visibility of lymphatics and dermal backflow (DB) extension. Clinical demographics were compared with categorized ICG lymphography patterns. All symptomatic legs showed abnormal patterns, and all asymptomatic legs showed normal patterns on ICG lymphography. Abnormal lymphographic patterns could be classified into proximal DB (PDB), distal DB (DDB), less enhancement (LE), and no enhancement (NE) patterns. There were significant differences between PDB (16 patients), DDB (6 patients), LE (4 patients), and NE patterns (5 patients) in age (37.3 ± 18.3 vs. 61.8 ± 19.2 vs. 50.8 ± 27.7 vs. 29.2 ± 18.0 years, p = .035), onset of edema (23.9 ± 19.4 vs. 46.8 ± 27.0 vs. 43.0 ± 31.3 vs. 6.6 ± 14.2 years, p = .020), laterality (bilateral; 18.8% vs. 66.7% vs. 75.0% vs. 0%, p ¼ .016), cellulitis history(56.3% vs. 100% vs. 25.0% vs. 0%, p ¼ .007), and LEL index (292.2 ± 32.8 vs. 254.2 ± 28.6 vs. 243.3 ± 9.4 vs. 295.2 ± 44.8, p = .016). ICG lymphography findings in primary lymphedema could be classified into four patterns withdifferent patient characteristics.

Evaluation of Lymphatic Dysplasia in Patients with Congenital Pleural Effusion and Ascites Using Indocyanine Green Lymphography

To investigate the use of indocyanine green (ICG) lymphography in the diagnosis and assessment of the severity of lymphatic dysfunction in infants and neonates with congenital lymphatic pleural effusion and ascites. We performed ICG lymphography on 10 neonates and infants with congenital lymphatic pleural effusion and ascites. After the subcutaneous injection of ICG, circumferential fluorescent images of lymphatic drainage channels in the extremities and trunk were identified using an infrared camera system. The lymphographic findings were classifiable into 2 patterns-those showing a linear lymphatic pattern, suggesting normal lymphatic flow, and those showing lymphatic channels with retrograde lymphatic flow (dermal backflow pattern), suggesting an abnormal lymphatic flow. We analyzed the severity of the ICG lymphography findings and the clinical outcomes. Based on the ICG lymphography, the severity of lymphatic dysplasia were classified into 4 categories: mild dysplasia, moderate dysplasia, severe dysplasia, and lymphatic hypoplasia. All cases diagnosed with mild (n = 3) or moderate dysplasia (n = 2) survived, and 2 of the 4 cases diagnosed with severe dysplasia died. The duration of endotracheal intubation ranged from 1 to 17 days (median, 7) in the patients with mild or moderate dysplasia and from 25 to 110 days (median, 77) in those with severe dysplasia. The ICG lymphographic findings were consistent with the clinical conditions. This imaging technique may be important to the future clinical management of lymphatic dysplasia in neonates and infants.

Comparison of Indocyanine Green Lymphographic Findings with the Conditions of Collecting Lymphatic Vessels of Limbs in Patients with Lymphedema

The authors investigated the relationship between findings from indocyanine green lymphography and the condition of lymphatics according to the Normal, Ectasis, Contraction, Sclerosis Type classifications observed in each area during surgery. The authors examined 43 limbs of 25 patients who had undergone lymphaticovenous anastomosis from April to July of 2012 at the Department of Plastic and Reconstructive Surgery, University of Tokyo Hospital. After the injection of indocyanine green, linear, splash, stardust, and diffuse patterns were determined. Visual findings of the collecting lymph vessels during the anastomosis at each incision site were evaluated using the Normal, Ectasis, Contraction, Sclerosis Type classifications. Lymphaticovenous anastomosis was conducted on 164 collecting lymph vessels within 43 limbs of 25 people. Normal-type lymph vessels were observed in 36, ectasis type in 43, contraction type in 52, and sclerosis type in 33. Many normal vessels were found in the linear region, but the proportion of this type declined in the more severe stardust and diffuse regions. In contrast, no sclerosis-type vessels were found in the linear region, while the proportion of this type increased with lymphedema severity. Indocyanine green lymphography findings and the Normal, Ectasis, Contraction, Sclerosis Type classification of collecting lymph vessels seem to have a relationship. An increase in the severity of lymphedema according to the indocyanine green lymphography findings indicated an increase in the stage of lymphedema according to the Normal, Ectasis, Contraction, Sclerosis Type classification. Diagnostic, IV.

Indocyanine green lymphography for evaluation of genital lymphedema in secondary lower extremity lymphedema patients.

Treatment of genital lymphedema (GL) is challenging, and early diagnosis and intervention is important to prevent progression of GL. However, early treatment ofGL is difficult due to a lack of appropriate evaluation methods allowing early diagnosis. We sought to develop a novel pathophysiological evaluation method for early diagnosis of GL using indocyanine green (ICG) lymphography. This was a retrospective observational study set in a teaching hospital. Patient characteristics and ICG lymphography findings of 68 lower limb lymphedema patients secondary to gynecologic cancer treatments were reviewed. The clinical data and dermal backflow (DB) stages based on ICG lymphography findings were analyzed to compare between the left and right region with and without symptomatic GL. Twenty-two of 136 lateralities were symptomatic GL. Univariate analyses revealed statistically significant differences between lateralities with (n= 22) and without GL (n= 114) in the duration of leg edema (6.3± 1.1 vs 3.8± 0.5 years; P= .032), International Society of Lymphology stage (stage 0/1/2/3: 0/4/15/3 vs 40/32/32/10; P= .001), leg DB stage (stage 0/I/II/III/IV/V: 0/0/7/9/4/2 vs 6/35/23/29/18/3; P= .002), and genital DB stage (stage 0/I/II/III/IV: 0/0/0/20/2 vs 27/43/28/16/0; P< .001). ICG lymphography can clearly visualize abnormal lymph circulation in the lower abdominal and genital region. Genital DB stage based on ICG lymphography findings allows early diagnosis of GL before symptom manifestation. Further studies are needed to clarify that ICG lymphography is a key evaluation for prevention and early intervention of GL.

Indocyanine Green–Enhanced Lymphography for Upper Extremity Lymphedema

Management of arm lymphedema following breast cancer treatment is challenging, and emphasis should be put on early diagnosis and prevention of secondary lymphedema. Indocyanine green lymphography is becoming a method of choice for evaluation of lymphedema. Twenty patients with secondary arm lymphedema after breast cancer treatment underwent indocyanine green lymphography. Characteristic findings of indocyanine green lymphography were analyzed according to corresponding clinical stages and duration of edema. Based on changes in indocyanine green lymphography findings with progression of lymphedema, a new severity stage, arm dermal backflow stage, was developed and compared with clinical stages. The indocyanine green lymphographic findings were classified into two large groups: linear pattern and dermal backflow patterns. The dermal backflow pattern could be subdivided into splash, stardust, and diffuse patterns. The dermal backflow patterns were found more frequently than the linear pattern in the proximal upper extremity (p=0.001). The dermal backflow patterns also increased significantly in prevalence overall as the duration of lymphedema increased (p=0.032). The arm dermal backflow stage was linearly correlated with clinical stage as described by the line y=1.092x+0.083 (R=0.997; analysis of variance, p<0.001). Indocyanine green lymphography is a safe and convenient evaluation method for lymphedema that allows qualitative pathophysiologic assessment of lymphedema. The arm dermal backflow stage, based on indocyanine green lymphographic findings, is a simple severity staging system that demonstrates a significant correlation with clinical stage. Indocyanine green lymphography may come to play an important role in early diagnosis of secondary arm lymphedema. Diagnostic, V.