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BackTable / VI / Podcast / Transcript #477
Podcast Transcript: Building a Successful Lymphangiography Practice
with Dr. William Majdalany
What’s needed to build a successful lymphangiography practice? Dr. Bill Majdalany joins host Dr. Chris Beck to answer this question and to discuss advancements in lymphangiography over the past decade. Dr. Majdalany is the Chief and Vice Chair of Research of Interventional Radiology at University of Vermont. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Expanding the Scope of Lymphangiography
(2) Referral Patterns & Key Procedures in Lymphatic Interventions
(3) Building a Lymphangiography Practice
(4) Efficient Lymphangiography Procedures
(5) Lymphatic Embolization Techniques in Resource-Limited Settings
(6) Evolving Landscape of Lymphatic Intervention
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[Dr. Chris Beck]
Ladies and gentlemen, welcome to The Backtable Podcast. If you're a new listener, welcome. For all of our regular listeners, welcome back, and thank you for listening. You can find all previous episodes of the podcast on iTunes, Spotify, or our website, which is backtable.com. Now a quick word from our sponsor. Guerbet has become one of the leading experts in medical imaging worldwide. Collectively, Guerbet offers a full range of medical solutions and services in diagnostic and interventional imaging, including the first and only iodinated oil-based contrast agent in the United States. Visit www.guerbet-us.com to learn more about Guerbet's full range of products, unwavering commitment to education, and opportunities for collaboration and partnership.
Now back to the show. Welcome Backtable listeners. Our topic today is about building a successful lymphangiography practice and to help me with this discussion, we have Dr. Bill Majdalany. Bill has been on a previous episode with us, Episode 135, and that was three years ago. Bill, welcome back to the show.
[Dr. Bill Majdalany]
Thank you so much, Chris. It's a pleasure to be here.
[Dr. Chris Beck]
Let's get just some introductions out of the way for people who didn't go back and listen to 135, will you just tell us your background, training, and where you're at now because there are some changes?
[Dr. Bill Majdalany]
Absolutely. I did all my training at Brigham and Women's Hospital, both for residency as well as fellowship. After that, I've been through the academic churn. I started my career at Ohio State University. After a couple of years there, then I went to University of Michigan, spent about five years there, then almost four years at Emory University. Then came up here at the University of Vermont as the Chief of IR, as well as the Vice Chair of Research for the Department of Radiology.
[Dr. Chris Beck]
Congratulations. That's awesome. What's the practice like at University of Vermont Medical Center?
[Dr. Bill Majdalany]
It's a fully well-rounded IR practice. We always think about all these academic places that have people coming and going, a lot of turnover, et cetera. The funny thing is no one has ever left the practice here in decades.
[Dr. Chris Beck]
Get out of here.
[Dr. Bill Majdalany]
No joke. No joke at all. We actually just had our most senior partner retire at the end of June after 34 years here. He was the second IR at the University of Vermont, started in the late 1980s. He's trained the subsequent people who have either joined the practice. There's only been one external hire prior to myself who came from Northwestern.
[Dr. Chris Beck]
Wow, that's really neat. That must also be, there's probably a very unique way of doing things. I don't want to say unique way of, but when everyone is trained at the University of Vermont, there must be a very University of Vermont Medical Center way of doing things.
[Dr. Bill Majdalany]
For sure. The biggest thing I'd say is that they take great pride in the quality of the practice and the clinical care. They always have. I think when you look at a large majority of academic practices across the country, there's varying practice patterns of who may be doing the PEs, who may be doing the renal artery stenting, who may be doing the enteral and bentons, the IO, et cetera, et cetera. To large credit to my partners here who've been here for decades and put the time and the work in, all of these things are still done by our practice.
They take great pride in it. They do a great job with it. Do we have our own way to do it? I suppose so. It's a little bit more old school. It's been a solid 10, 15 years since I've done a TIPS with only moderate sedation, but that's how they've always done it here, and that's how we still do it now.
[Dr. Chris Beck]
Wow, that's something. Okay. All right. It's good to hear that there are other ways to do it.
[Dr. Bill Majdalany]
Exactly.
(1) Expanding the Scope of Lymphangiography
[Dr. Chris Beck]
I guess a good way to get started is, either at your former job or your current job, what does your lymphangiography practice look like? Which kind of patients are you taking care of? I get a lot of questions about it, but I'll just open it up. What does the practice look like for you right now?
[Dr. Bill Majdalany]
Absolutely. Everywhere I've been along my path, the lymphangiography practice has been there. I think that's really one of the salient points really makes that. I've never had to try hard to build a lymphangiography practice. It's there, and the patients need the help. Really the biggest thing is the visibility of, is there somebody there with the know-how, the willingness to take it on? I can't think of a single medical center, community hospital, academic hospital, private practice, et cetera. If you're servicing a hospital that even has 100 patients, 100 beds, for instance, you can't tell me that they don't do a lymphadenectomy or any type of prostate surgery, spine surgery, et cetera.
All of these things are where you can run into lymphatic things. How do they get managed? Can they be managed by you, or do they need to be sent elsewhere? The reality is almost all of these things can be managed by an interventionalist who is interested in doing it. I think anytime we can solve a problem for a colleague in our hospital, that's a natural way to build a practice.
[Dr. Chris Beck]
Sure. How did you yourself get interested in it, specifically? A lot of IRs-- At least one of the reasons we wanted to cover this topic is we feel like this can be a blind spot, not only in training, but just sometimes it's, your interventional radiologists sometimes are asked to do a lot of things, and sometimes it's an easy one to say, "Just not going to make this part of the practice," right?
[Dr. Bill Majdalany]
Sure. I think a great deal of it goes back to my own training. I did my residency at Brigham and Women's, which is one of the few places that was still doing pedal lymphangiography, along with the University of Pennsylvania was one of the places where thoracic duct embolization was done back in the early 2000s. It was largely because we had a population of patients with mesothelioma, and we were international center for mesothelioma patients who would come in. They'd have these large extrapleural pneumonectomies, et cetera, invariably that have great outcomes from a mesothelioma standpoint, or at least as good as you can imagine, but they would have complications with lymphatic injuries.
You want to get those patients back on chemotherapy, you want to maintain their nutrition, you need to do all this stuff, and a chylous leak or a thoracic duct injury isn't going to allow that to happen. You can imagine that the desire to go in and re-operate on somebody where you've just maybe put intrapleural, intracavitary chemotherapy, et cetera, is non-existent. I remember actually, it was my first rotation in IR. I was a first-year resident, and IR fellows all were shying away from this case because they knew back in the old pedal lymphangiography days, it's going to be four or five hours per case.
[Dr. Chris Beck]
Sure. It's a while.
[Dr. Bill Majdalany]
They all jumped into other cases, and like, "Oh, hey, this is a great first case for you to do."
[Dr. Chris Beck]
Yes. First-year resident. What else? Pedal lymphangiography.
[Dr. Bill Majdalany]
I go in. Of course, the attending does almost all of it. I'm doing my best to not screw things up. We end up doing this case. It was so transformative to have seen the patient before, who's A, not eating, B, has chest tubes in, is losing all this vital fluid, and a day later is functionally cured. Then seeing it again and again, whether it's for esophageal surgeries, or CABGs, or post spinal surgeries, et cetera, we did quite a few at Brigham and Women's. Along that time span, 2011 at Children's Boston, I also rotated there, they had moved from doing pedal lymphangiography because you really can't do it in these really tiny kids.
They had gone along with nodal lymphangiography, which is a blast from the past in the 1950s and '60s. They used that as a way to easily access the lymphatics and do your lymphangiography. We started doing it in adults, and it made things even so easy by the time I was a senior resident and a fellow. We were doing these very often in several-week mini-cases-
[Dr. Chris Beck]
Wow.
[Dr. Bill Majdalany]
-before things really caught on and started spreading. In a way, I got to see this lymphatic revolution where it went from a really challenging procedure that was only done at a couple of places to something that could be easily within the armamentarium of any IR, anywhere, and to great effect. What's really continued to change is we've moved beyond just thoracic duct embolization, into so many other types of lymphatic interventions. I think that's really where the excitement is, that you can start with just lymphangiography, but where you branch off and where it goes is tremendous.
[Dr. Chris Beck]
Out of curiosity, I've never seen or performed pedal lymphangiography. How long actually does it take?
[Dr. Bill Majdalany]
Hours.
[Dr. Chris Beck]
Okay.
[Dr. Bill Majdalany]
There's a skill to it for sure. Not just even injecting the dye between the toes to try to do it as painlessly as possible for patients. Then you're milking that blue dye into the dorsum of the foot and then cutting down on these little skinny vessels, and cannulating with a 30 or 32-gauge needle. It's something that is somewhat lost on us because, to a certain degree, we do these bigger actions with much bigger needles thoughtlessly. Historically, in the earlier days of lymphangiography, '60s, '70s, '80s, et cetera, a lot of the techs that we work with became so proficient that they would do a lot of the pedal lymphangiograms themselves.
I know even here, I remember them telling me that, "Oh, yes. Some of our senior techs used to do these and these, and they did them fairly quickly." I was like, "Wow," because that skill was lost right between the '80s, '90s, and 2000s. It went from lymphangiography being there as a diagnostic modality to stage cancer to differentiate infection from inflammation and malignancy, et cetera, to CTs and MRs around. Who wants to do a lymphangiogram, that isn't as sensitive or as good, never mind the time and the potential complications with an incision, et cetera? It passed away with time and now it's really been revived. Not from a pedal standpoint, but from a standpoint of, re-exploring how the lymphatics interact with the pathophysiology we may be treating.
(2) Referral Patterns & Key Procedures in Lymphatic Interventions
[Dr. Chris Beck]
Sure. My next question is about referral patterns and you can either use old hospitals, either past experiences or current experiences, and we touched on it a little bit, but what are some of the common referral patterns like physicians or hospital service lines that seek you out? Also, I'm interested to know about a little bit, inpatient versus outpatient mix.
[Dr. Bill Majdalany]
Sure. Really, the whole spectrum. Actually, I'll say I have never had a referral from psychiatry. I will say that.
[Dr. Chris Beck]
I don't think I've ever had a referral from psych.
[Dr. Bill Majdalany]
I'd say that the bread and butter ones who I hear from all the time, of course, thoracic surgery and pulmonology for all manner of traumatic and non-traumatic chylothorax, GI, surgeonc, gyneonc, urology for everything from chylous ascites and lymphoceles. Plastics, again, for lymphoceles, lymphedema, potentially mapping. Vascular surgery, depending on where they are, can have issues with chylous ascites and/or lymphoceles. Spine surgeries, ortho, et cetera. Particularly doing spine fusions can damage some of lymphatics potentially unknowingly as well.
I think a lot of it isn't so much the specialty, as much as it is what your medical center may or may not do. If you're at a place that's doing prostatectomies or lymphadenectomy, you're going to have lymphoceles. If you're at a place that's doing renal transplants, you're going to have lymphoceles. I probably see one a week here right now from a lymphocele standpoint. Thoracic ducts embolizations for chylothoraces, it's going to really depend on, is your place doing esophagectomies. Are they doing pneumonectomies? Are they doing CABGs? All of these things can run into chylous surgeries.
Then whether or not there's retrograde needle lymphadenectomies, places with liver disease, you can have non-traumatic chylous ascites or chylous ascites related to portal hypertension. You're going to see all of these things across the spectrum in an IR practice because you're probably going to be doing some degree of paracentesis, or arthrocentesis, or draining some type of post-op collection that can surprisingly end up being something that nobody expects it to be, whether it's a lymphocele or chylous in nature.
[Dr. Chris Beck]
I think this is good enough time to bring up, what do you consider the armamentarium that falls into someone with a solid lymphangiography program where you manage everything from the super simple straightforward case like lymphoceles to thoracic duct embos? Or maybe even something I'm not even thinking of. I was just thinking, what's the armamentarium of procedures that you think about?
[Dr. Bill Majdalany]
Sure. Some of the diagnostic lymphangiography alone can be therapeutic in many cases. I think from that spectrum would be the most basic thing to do. Then adding on other imaging modalities, whether it's CT or MR in combination with nodal lymphangiography is where things can start from a diagnostic perspective. As you get into more advanced diagnostic things, you can do mesenteric or hepatic lymphangiography. From the standpoint of intervention, with the intention of treating, you can go from something as typical as a thoracic duct embolization with coils and liquid embolic or glue to nodal glue embolization or using needles for direct embolization.
Or to more cutting edge things where we're stenting thoracic ducts, where we're recanalizing and opening blocked channels, and/or looking at thoracic duct obstructions that are retrograde causing other things in other parts of the body. I think it's a very interesting time because there's a lot of these things we are continuing to have an evolution in the understanding of what to do with the lymphatics.
[Dr. Chris Beck]
Out of curiosity, if you're planning a procedure, say it's a more advanced procedure, whether it's stenting, crossing obstruction or even a thoracic duct embolization, how often are you getting a diagnostic study, whether it be CT or MRI before, as a planning part of the procedure, or do you consider wrapping it all up together?
[Dr. Bill Majdalany]
When it's something that I have an idea what the etiology is and the time course, and all that makes sense, look, somebody had an esophagectomy, they have a chylothorax and it's on this side, and it all makes sense, we're just going to go to lymphangiography and access it, and embolize it.
[Dr. Chris Beck]
Got it.
[Dr. Bill Majdalany]
Somebody comes in and they say, "Hey, I have this swelling in my neck, and when I cough, this happens," and it doesn't make sense, we're going to probably dive into it a little bit more and do, either CT lymphangiography or MR lymphangiography ahead of time. Some of the non-traumatic ones are probably the more challenging leaks and/or disorders. I think in those situations, assuming that the patient isn't traveling from eight hours away or all these other things, we're going to try to figure it out and have a game plan before we go in on intervention day.
[Dr. Chris Beck]
Okay, fair enough. From a diagnostic perspective, do you ever participate in, like if you're doing the lymphangiography, but then they're later going to MR or CT, are you helping build those protocols or speaking with the body diagnostic radiologist to help build a protocol for that? Or do you do your section, and they're like, "All right, we'll take it from here," or is there like a conversation that you guys have about, "Every patient is unique and this is what I'm looking for."? I'm interested both on the how they interpret it, but also how the protocols get built for CT or MR lymphangiography.
[Dr. Bill Majdalany]
Yes, absolutely. The politics is always a little bit local.
[Dr. Chris Beck]
Okay, fair.
[Dr. Bill Majdalany]
Yes, I can tell you, for example, here at the University of Vermont, we read all of the CTAs and MRAs, so, all the vascular imaging studies. Here for the CT lymphangiograms, I actually do them in our procedural CT. I book it like any other procedure. The MRs are sometimes a little bit harder to get dedicated MR time. I think more of the people who are in the diagnostics side of radiology want to be more present at the workstation, cranking out along the list, rather than being at the scanner itself monitoring the exam. I think that's the most important thing when you do the CT lymphangiograms and MR lymphangiograms.
You have to actually be there, not just to access the lymph nodes and get the injection going, but to actually monitor the injection and potentially do some dynamic additional sequences. More often than not, unless you have somebody who is genuinely interested in-- For example, at the University of Michigan, I had a partner on the body imaging side, who would take a great lead on that after I would access them and would allow me to go do other things. My last, both at Emory University as well as here at the University of Vermont, a lot of it actually is something that I take ownership of, and I think it's great.
(3) Building a Lymphangiography Practice
[Dr. Chris Beck]
One of my questions about building a successful lymphangiography practice is people shy away from it. Is there any buy-in that has to happen from your partners? Is it a good idea for a junior-level academic person or someone who's starting out in a private practice, like, "Hey, let me try and build this."? Have there been any system roadblocks that you've had to overcome to build this type of practice? It does require some special, what I would call facility management, but it's a little bit nuanced in the terms of the resources that you need.
[Dr. Bill Majdalany]
I think you bring up a really good point. Historically, some of the roadblocks were having the particular pumps to do the injections and things like that. That really isn't a roadblock anymore. My typical kit is a 25-gauge, 9-centimeter needle, a three-way that holds up to the contrast media for lymphangiograms, some tubing, and some polycarbonate syringes. That's it.
[Dr. Chris Beck]
You don't hook them up to the balloon insufflators?
[Dr. Bill Majdalany]
No. I actually like doing the hand injection and controlling it. I like actually being in the room and watching because what I do is I take spot radiographs at different time points to really monitor it myself. Sometimes I like watching it with fluoroscopy just to see what the pattern of flow looks like. The reason is that particularly early, for example, like in a lymphocele, I want to see that lymph node that I'm injecting through how it communicates with the lymphocele, how close it is, how many branches are going to that. Where's the early flow versus the late flow?
If I vary how I inject, what's happening? I like to actually be there and doing it rather than just letting the insufflator do it. The actual inventory, compared to spyglass, for instance, some places will say, "Hey, this is really expensive. We need the tower, we need this, that, the other." You really have all the material here. All you're doing is an exam that already has CPT codes. If you combine it with an embolization, now you've actually offered a therapy to a patient that's dramatically, A, beneficial for them, and B, beneficial for your practice and your interrelationships with other providers in the hospital system that you work at.
[Dr. Chris Beck]
Bill, while I'm thinking about it, can you just drop us the name of the three-way that you use, the stopcock?
[Dr. Bill Majdalany]
That's a really good question because I used to use one that was made by Cook. It was this opaque, white plastic three-way. I don't believe Cook makes it anymore. Now I use a four-way, but I don't remember the actual manufacturer. We actually went through and tested multiple things, and we found that this is the one that actually works the best. Off the top of my head, I don't remember, but I can email that to you.
[Dr. Chris Beck]
I'll get with you offline, and I'll make sure that we post that. For some reason, I can't tell you how many times, anytime you're dealing with a caustic agent, everyone is looking for that special three-way, and then some places just don't do it that frequently. You're calling your main facility, and you're like, "What's the three-way that we use?" Then everyone is trying to scramble to figure it out. It's just a small piece of the puzzle, but it's a piece.
[Dr. Bill Majdalany]
Metal three-ways always work too, by the way. A lot of places will have metal three-ways.
[Dr. Chris Beck]
Yes, absolutely. You're right. If you can get hands on a reliable metal three-way supply, then you're good to go. All right. Hand injections, what kind of sedation do you use with yours typically?
[Dr. Bill Majdalany]
Moderate sedation. If we're just doing a simple lymphangiogram, really almost nothing.
[Dr. Chris Beck]
Local?
[Dr. Bill Majdalany]
Just local. Patients don't even have the NPO that they can eat, they can drink, whatever. I tell them, "Hey, we're just doing a diagnostic exam, plus-minus CT or MR, depending on what we're thinking for that." In some cases, I just do cone beam in the room if the CT or the MR is occupied, and you get a fairly high-quality study. the rapidity with which we can do cone beam at multiple stations now, it makes things very easy.
[Dr. Chris Beck]
Sure. I agree with that. How long does the procedure take you? I guess it depends on what procedure we're talking about. How about just a diagnostic, from groin injection to seeing the thoracic duct?
[Dr. Bill Majdalany]
I would say from groin injection to seeing the thoracic duct, and let's say the caveat of also having the patient in sequential compression devices.
[Dr. Chris Beck]
All right. That's a good tip.
[Dr. Bill Majdalany]
That speeds things up as well. I'd say if you do that, I would say 30 minutes.
[Dr. Chris Beck]
Very nice. If you don't mind me asking, at what temperature do you keep the dye?
[Dr. Bill Majdalany]
Just room temperature.
[Dr. Chris Beck]
I hear some people try and warm it up ahead of time. I don't know if that makes a big difference. Just keep it at room temp.
[Dr. Bill Majdalany]
Oh, I don't know if it makes a difference. I've never done it, but I've always just left it at room temperature.
(4) Efficient Lymphangiography Procedures
[Dr. Chris Beck]
You mentioned SCDs. Were there any other big unlocks? I don't know if you can take yourself back to a stage of the procedure or just doing diagnostic lymphangiography, things that you've learned along the way that have streamlined your process or your equipment, or how everyone Is ready to go as far as making it an efficient procedure.
[Dr. Bill Majdalany]
Absolutely. What I've started doing as I've changed jobs over the years is I always meet with my team in IR, and I go over it. I show them what the setup is. I just bring in olive oil or something, and do it with olive oil just to show them what it looks like, what to expect, and to make sure that everybody knows where all these different things are in the department because, oh, how often do we use 9-centimeter long, 25-gauge needles? Or if you only use 27-gauge, whatever gauge, it doesn't matter. The other things that I've really done is figuring out your inventory to your point, making sure that things are all compatible.
At different times, there's always been backordering of one thing or another. Most recently, it seems like some of the 1cc medallions have been out of stock, for instance. I always have a backup plan where we use a 3cc or whatever. As I've got along, I've realized a few areas where people tend to mess up. One is when we load the dye in the syringes, if you're a little bit sloppy in how you do it, some of the dye can spill around the hub. Over time it erodes the hub, and it may break it. If you're using polycarbonates, and you draw it up using either a longer needle or something and make sure that it doesn't overflow, and you do a connection that isn't necessarily wet to wet, and then purge all the air out, those things will actually allow you to use it for many, many, many hours without an issue.
Then I just take dye all the way through my three-way, my 1cc and my 10cc setup and across the tubing down to my needle. The 25-gauge 9-centimeter needles have an inner stylet similar to a Chiba style. I take that inner stylet out, and I connect it so that if you put the needle into the lymph node, you don't have to twist the tubing to the hub after you've already accessed it. It's ready to go. Then I give that patient just a little wheel with a 25-gauge needle, of lidocaine. Then I go through that. I start maybe 3 to 5 centimeters away from the lymph node, and I try to angle in the actual lay of the lymph node itself so that the needle is going across it.
Then I check in an orthogonal plane to make sure I'm not off to one side or the other too much. I do a small little injection, 0.1cc, and I'll watch it with fluoroscopy. Even that 0.1cc, it should start to move through the lymphatics. As little as 0.5 cc, it's going to actually go from one lymph node to another. Really doesn't take that much. You want to make sure you're getting a nice transmission through your lymph node, A, that you're not getting too much spillage outside. I know a little spillage isn't a big deal, but then B, you start to understand how much pressure it takes.
It really doesn't take much in that 1cc syringe to get some of that lymphatic dye to go from your access point to the next nodal stations. It's just starting small and low, checking with fluoroscopy. If you're having trouble seeing it, take a spot radiograph. the amount of visualization of 0.1cc of dye, it's not that much dye. I just make sure that things are well there. Then I Tegaderm my needle down. If I need to put 4x4s under it to keep it in that same plane, I do that, Tegaderm it down, and then just keep that slow injection.
[Dr. Chris Beck]
What is the location of the lymph node that you're aiming for exactly, for somebody who's never done this?
[Dr. Bill Majdalany]
What I typically do is I'll take a look along the greater saphenous vein and the saphenofemoral junction. There's usually quite a few right around there. Obviously, I want to access a lymph node below the level where there may be any issue.
[Dr. Chris Beck]
Of course.
[Dr. Bill Majdalany]
In a typical lymphangiogram, to get a nice pelvic lymphangiogram, right around the GSV is your money ball.
[Dr. Chris Beck]
The actual specific part of the lymph node where the needle is supposed to hit also?
[Dr. Bill Majdalany]
Fair. That's a very good question because I think a lot of people focus on, oh, I want to get a perfect loop in the center, in the cortex, the high limb, et cetera." I really just try to go across three-fourths of the lymph node. I really tried to do it in the long axis. That's why I then check in an orthogonal plane to make sure I'm not off one way to the other. That way that if you have any backflow along your needle, hopefully, it is exiting through other efferent lymphatic channels before it spills out into the tissue around the lymph node. I will say this, not necessarily the largest lymph nodes are not your friends.
[Dr. Chris Beck]
Really? Okay.
[Dr. Bill Majdalany]
They may be a big target,-
[Dr. Chris Beck]
Sure.
[Dr. Bill Majdalany]
-but there may be something pathologic about that lymph node that may not be transmitting as effectively as sometimes smaller lymph nodes. The other thing I'll say is that the ultrasonographic appearance of lymph nodes may change based on age, underlying disease processes, or potential treatments that they're on. Sometimes you have to get used to, oh, it's the hypoechoic appearance, or is it just one that's rounded and hyperechoic, et cetera? I think it really pays to just do a good-quality ultrasound of the vicinity in and around the saphenofemoral junction.
You need to go above, around CFV, and or below, and take a look at what's going on to understand what's going on in that disease process. To that end, it's very common for me to take a look at a patient's prior imaging. Everybody almost has a CT that's been through some type of surgery, right?
[Dr. Chris Beck]
Sure. Right.
[Dr. Bill Majdalany]
Often, a typical abdomen pelvis CT goes all the way down to the top third of the thigh. You've already imaged that whole area you want to see. You can get an idea what the lymph nodes look like, where the surgical clips may be, et cetera, and make sure that there's no AAA, or if there is, you know what's going on, if there's an aneurysm or horseshoe kidney and things like that, that you wouldn't be able to see fluoroscopically necessarily. Those are the things that I'm really looking for in terms of the abdomen and the pelvis. In and of itself, just taking a look at what you would expect the lymph node pattern to be and where the stations are, really gives you that heads-up before you go and do that ultrasound.
[Dr. Chris Beck]
Fair. All things being equal, say, you're thinking something around the thoracic duct for a level of injury or something in the chest, does right or left particularly matter to you or just whatever side you're more comfortable on?
[Dr. Bill Majdalany]
I will start on the side of the table that we use for most-- Most tables are set up for right groin access. By default, I just start there. What I do is once I have that access, I just put my injection apparatus down, I go and access the other side. What I do is I add additional tubing on the other side. Then I come back to the right side and I inject both sides simultaneously.
[Dr. Chris Beck]
Oh, nice.
[Dr. Bill Majdalany]
We play a little bit of a race to see which side moves up faster. You'll be surprised for whatever reason, one side may move up faster than the other. There is a relationship between the lymphatics, and veins, and venous drainage. Sometimes you'll see some degree of shunting from one side, whether they've had a prior surgery, prior DVT, some type of other pathology, to the lymphatics necessarily drain back to the venous system, whether it's at the thoracic duct terminus or at stations along the way. If one side isn't giving you the feeling that you want, that's why I always do both sides to increase the chance of getting that filling in the retroperitoneum, which is where the money is, at least from a thoracic duct standpoint.
I'll do both sides very often. Generally, most of my lymphangiograms only require between 10 and 12 ccs of dye before I've already seen the cisterna chyli, and I'm ready to do an advanced intervention at that point if needed.
[Dr. Chris Beck]
As far as accessing the cisterna chyli, any tips for that? Like, one, seeing it, recognizing it, and then accessing it in a way that sets you up for success if you're going to have an intervention that you're planning for.
[Dr. Bill Majdalany]
Yes, that's a very important question. Loaded. What I do is I follow that most opaque portion of my lymphangiogram with spot radiographs because almost necessarily, with fluoroscopy only, you're not seeing the leading edge of what's happening. It's likely the lymphatic dye has actually moved further up than you think it has on fluoroscopy alone. I'm always looking higher up than where the opacity is on fluoroscopy, and I'm taking a spot radiograph. Frequently, what happens is you'll see the dye shoot up through the thoracic duct fairly quickly.
It's really only when it is accumulating, that droplets appearance, that you start to re-see it on fluoroscopy. What I do is I really start taking a look. I take spot radiographs at the very beginning of the whole patient, chest, abdomen, pelvis. Then I'll take up MAG-ed spot radiographs somewhere between L4 and T8, just to see, hey, do they have any hardware or anything funny? What are the things that may impact my visibility of the lymphatics? Then once I have that opacification of those retroperitoneal lymphatics, I move up to that same MAG again, and I'm really paying attention to the flow dynamics.
It's not that I just want to see a big target there because that big target could be a lymph node, I want to see a target, and I want to see transmission from the target, not going to another lymph node because then I can access it and potentially pass a wire through it. As I've gone along, I've moved more to almost exclusively using a 21-gauge Chiba-type needle, not a trocar tip needle because the trocar tip has this diamond that extends a few millimeters beyond the actual needle itself. You think you're in, and you take the inner stylet out, well, that's actually a few millimeters ahead of where the rest of your needle is.
Whereas a Chiba, the inner stylet is flush with the tip. You take out the inner stylet, and your needle is actually still where it was when the inner stylet was there. I put a very gentle bend, maybe 10 to 15-degree bend on the Chiba. I approach with a bit of the angulation pointed towards the head. Maybe a 10 to 15-degree angle that way, or you can angle your II to help guide it. I try to make it as straight a pass as possible because with some degree of respiratory motion, enteral loops, distending, et cetera, with gas and things like that, it can really change the trajectory.
What you really want is a nice straight thing so you don't have unnecessary or redundant loops in your course from the skin to the lymphatics. Then I probe usually with a V-18 wire, and you really want to see it shoot up and straight. Every once in a while, it may be in the aorta or in the IVC. That happens. It's completely expected, generally very safe with a 21-gauge needle. Our forefathers in IR used to trocar aortas with a-
[Dr. Chris Beck]
That's right.
[Dr. Bill Majdalany]
-6 French needle catheters and things like that, and just pull out.
[Dr. Chris Beck]
Sure, the cost of doing business back then.
[Dr. Bill Majdalany]
We freak out about hitting it with a 21-gauge. It'll be okay.
[Dr. Chris Beck]
Sou're approaching a target. Once you think you're in, are you doing anything to confirm in the lateral projection, or–
[Dr. Bill Majdalany]
I think that's a great point. Sometimes I'll use the lateral projection if there isn't enough dye filling. If the dye is already filled, the thoracic duct and the wire is clearly intraluminal and moving with that type of intraluminal feel you expect it to have, as opposed to having some resistance or feeling weird in the retroperitoneal fat or when you're not really in a vein, et cetera, then I don't tend to go lateral. I always encourage it, particularly as you get more experience with the feel.
[Dr. Chris Beck]
Once you have wire access, your wire shoots up, you feel like you have whatever working wire you have, I think you mentioned V-18, what's your next line as far as having stable access, bareback, versus if you're planning, and we're assuming now that you're planning something like an advanced intervention like an embo?
[Dr. Bill Majdalany]
My go-to catheter ends up being a 2.4 Progreat. You can get a wide variety of sizes of coils and anything else to flow through a Progreat pretty easily. If you want to do better-quality diagnostic imaging, it's obviously easier to inject through a 2.8 Progreat rather than a 2.4. The reason I like the Progreats is they have a little stiffness to them. They're a little bit more reinforced than some of the other catheters, like an STC, for instance. I feel like you have that ability, and they tend to track pretty well. I think a lot of Terumo products are known for the trackability, for instance.
I feel like that tracks pretty easily over the V-18. On occasion, if I've ever had trouble getting it in, maybe my angle is a little bit weird or it's not perfectly straight. What I do if I have a V-18 in is I take the inner metal and the inner dilator of a MAK-NV kit or an AccuStick that are about 3 French. I use that metal to support and get that other catheter in to help straighten out the tract, and then I can come back. At that point, because I've done that, I'll probably go in with a 2.8. If I ever want to change from a 2.4 to a 2.8, that's what I also do.
You can get the metal down pretty close to it. Then usually, the outer dilator with the 3 French will cross over. A couple of occasions where it's been a little bit challenging, I'll use a Navicross with a Progreat inside of it just to support to getting down there. In general, the bigger your access in there, the higher the risk that you're going to have gone through something that may cause you a problem at the end. In general, you want to keep it below 4 French.
(5) Lymphatic Embolization Techniques in Resource-Limited Settings
[Dr. Chris Beck]
Say there's some interventional radiologists who are at community hospitals where they don't have access to a liquid embolic. Can you still take on embolization procedures in the lymphatic system, or if you don't have a liquid embolic of some type, it's a non-starter as far as embolization procedures?
[Dr. Bill Majdalany]
No, you absolutely still can. For the central lymphatics, you can really embolize them quite well with coils, provided that you pack your coils tight, and you have a fairly long coil pack. You're not just thinking a couple of coils like you would in a end vessel in the kidney or something. You have to remember that the lymphatics don't have the same degree of clotting factors and platelets that blood does, and coils necessarily depend on that. In the absence of that, you have to really have more of a mechanic occlusion from what you're putting in there.
Now, you're not going to do nodal embolization without a liquid embolic necessarily because most often we do nodal glue embolization. Does glue help or onyx help when doing the embolizations? That's how it was originally described because the coil is really to create a matrix for the glue to stick to. Then the glue, particularly in some of the more advanced things when you need it to travel and eliminate multiple weird things, is something there. Can you do an embolization with just coils? You have an extravasating transected duct, you absolutely can.
You can also use MVP plugs, you can use Amplatzers, all these things in multiple combinations. You just make sure that you lay enough of it down and do a confirmatory injection with non-ionic iodinated contrast. I do that at the end anyway, unless I'm using a liquid embolic, just to show that my coil pack in and of itself does it, has achieved what I want it to do. I think there's nothing wrong with that at all.
[Dr. Chris Beck]
How often do you try and access in the neck to just go a direct stick at the thoracic duct?
[Dr. Bill Majdalany]
I've done that a fair amount. More often than not, it's in the setting of a non-traumatic chylothorax or something that is going to potentially require a larger platform, whether stent delivery or otherwise. Whether I go retrograde transvenous or direct transcervical, it somewhat depends on the patient and the circumstance. Almost invariably, I still do lymphangiography before. I think there's very little downside to do lymphangiography. It's extremely safe. It may have a potential therapeutic benefit, and you can see it fluoroscopically as it gets up there. That may aid you in doing a direct access, whether you use ultrasound and fluoro, or ultrasound alone, or fluoro alone. It just gives you more options how to visualize your potential target.
[Dr. Chris Beck]
Are there ever situations where you found it helpful to get access from below, and then work your wire in your catheter up, out the egress of the thoracic duct, and then you work your way venous, and then floss your way back from the arm through the neck and then down?
[Dr. Bill Majdalany]
Yes, absolutely. I do that very, very routinely. Actually, I have more recently been doing my transvenous access just in the groin. It's already prepped, and you don't have to change where you're working from. I'll do right groin venous access, go up there, snare my wire, and pull myself in. That way, I don't have to move around from, oh, this arm to over here, et cetera.
[Dr. Chris Beck]
Oh, that's slick.
[Dr. Bill Majdalany]
You get your wire, and you bring it down to the right atrium, snare it, pull yourself down, pull your sheath up, and then take your platform down and around. Whether it's doing advanced things like IVIS of the thoracic duct, measuring pressures, delivering stents, plasty, whatever, you now have a stable platform. Most patients, a 65-centimeter sheath is going to easily get you there. Then now, things within 100 centimeters are easily going to get you down and around most of the thoracic duct as well.
(6) Evolving Landscape of Lymphatic Intervention
[Dr. Chris Beck]
Oh, very slick. Say a Backtable listener is now feeling very inspired by this episode and they want more-- We actually do have some good episodes on this, and we'll link to them in the show notes. Other than having to learn this over multiple years with multiple sources, do you have any good resources that you can point people, either like, "Hey, this is just where you start, this is the ABCs of lymphangiography," or, "This is a good understanding of the lymph system," whether it's papers, lectures that you've listened to, or even given?
[Dr. Bill Majdalany]
Absolutely. At the risk of sounding like I'm plugging myself,-
[Dr. Chris Beck]
No, plug away, dude.
[Dr. Bill Majdalany]
-there was an issue of seminars of interventional radiology maybe in 2020 or 2021. I was a guest editor, but the whole issue was dedicated to lymphatic imaging and intervention. It's 12 different articles written by 9 different authors. You have a good lay of the land from all around. It's broken down to lymphatic anatomy and physiology, and then based on traumatic chylothorax, how to approach that with algorithms, non-traumatic chylothorax, chylous ascites, and lymphoceles, hepatic lymphangiography, et cetera. It really covers a lot. Prior to that, one of the gurus, Max Itkin, had a similar thing in techniques. That was a few years before maybe 2016, 2017, but those two things really have a lot of the information, including the setups of how to do it, et cetera.
[Dr. Chris Beck]
We'll actually link to both of those references, seminars and techniques whenever they cover an entire topic on something. That can actually be just pure gold. Those are fantastic. You were the editor for it. Who were some of the other contributing authors?
[Dr. Bill Majdalany]
Max Itkin and Greg Nadolski, the group out of Memorial Sloan Kettering with Ernesto Santos, Wally, Waleska Pabon-Ramos from Duke. I actually had invited-- One of the articles was from plastic surgery on the management of lymphoedema. I think it's really important to hear the perspective of our plastics colleagues. What could they do for us? What can they do for these patients? Because almost always, we'll see somebody with leg swelling, and we're like, "I don't know what to do for this patient." Debbie Rabinowitz discussing pediatrics, Matt Hawkins in Indigo discussing lymphatic malformations, et cetera, et cetera. A good cross-section across the country, domestic and international. Claus Pieper from Germany, talking about different techniques for MR lymphangiography as well. He's a guru in that.
[Dr. Chris Beck]
Very cool. Is there anything that I didn't ask about-- Actually, how about this? If you just had to sum it up and say, you've been at four different institutions, what has been the top three takeaways or success points for you as far as being able to build this practice at each place that you go to?
[Dr. Bill Majdalany]
I think number one is just giving it a try. Like I said, almost any IR practice at some point has to do a para, a thora, a chest tube, something more than other clinical services are able to do, or maybe needs imaging, depending on your local practice pattern. Understanding how to work it up, and then coming back and adding value to that, to the care of the patient, I think gets you a lot of respect from the other people who are taking care of patients. It's easy to shy away and be like, "Okay, hey, I stuck the needle in, and I'm walking out. Hey, you guys just pull it when the patient is done and send them up."
You sit there and you see the fluid, and you say, "Oh, hey, take that next step, and say, I'm going to send it for fluid testing based on what I see." If it's a chylous, I want to send it for triglycerides. What if it's non-chylous? One of the things that I've really learned and really talked to people a lot about is how do you work up lymphoceles? There's always this misconception that people want to send it for triglycerides, but that's actually not what you should be sending it for. What you should be sending it for is a cell count because the triglycerides don't filter into the lymphatic system at the level of the groin.
They filter in from the mesentery and that comes in at the cisterna chyli. It's a much higher area. I've seen this in partners at different institutions. They say, "Oh, I sent it for triglycerides. There's no triglycerides, it's not a lymphatic leak." Actually, triglycerides tell you that it's a chylous leak. They tell you that it's a lymphatic leak. What you really want to send it for is a cell count, and what you see is a preponderance of lymphoceles. Typically, greater than 70%, 80&, 90% of the cell count will be lymphoceles. That's what I always tell people is that, it has that appearance. It looks like urine.
The triglycerides will be low. You'd send it for a urine creatinine to work it up. The creatinine is low, but the lymphocyte count is out of the roof. That's how you then know that it's going to be a lymphocele. You do a lymphangiogram. Now you've done a tremendous service for the patient. You've fixed their problem with a 25-gauge needle, that otherwise would be marsupialization or something else. I think there's always this misconception of it's a lymphatic leak. We're going to do dietary modification. The dietary modification doesn't fix a groin leak. The small bowel doesn't circulate in that way.
[Dr. Chris Beck]
It's the back pressure.
[Dr. Bill Majdalany]
Yes, exactly. What I always tell people is that there is an understanding of lymphatic anatomy physiology. It's a very distinct circulatory system. It's very different from how arteries and veins work because it has three different and separate components, which don't communicate until they get to the cisterna chyli. Each component is unique. The mesenteric component is going to be lipid-rich. The hepatic component is going to be protein-rich. The peripheral component is going to be electrolyte and lymphocyte-rich. Knowing how to test for a leak in each component is the most important thing.
[Dr. Chris Beck]
That's a good tip. Why is it that IRs shy away from this? Do you think it's under-recognition? Under appreciation? We're scared of it? Under training? Under education? Combination of all these factors?
[Dr. Bill Majdalany]
The typical medical student gets very little teaching about lymphatics. Hours, or oh, you hear about lymph nodes and metastasis. In and of itself, the actual understanding of the lymphatic anatomy and physiology is not something I was ever taught in medical school. Certainly, even through radiology residency, had I not gone through the residency that I'd gone through, I would not have been exposed to it. I can say that a large majority of people, as recently as 10 years ago, did not have education in this. At least even in the IR spectrum.
Now it's routinely at many meetings. We discuss lymphatics and things like that. I think that's part of it. I think the other part of it is that there are so many things to do. There is this perspective, misconception potentially, of, oh, I don't want to have to get all of this inventory, or, oh, it takes a long time, or et cetera, et cetera, et cetera. It's just one more thing to learn. To me, it takes a routine procedure and you problem-solve and add a big benefit. Most importantly, I look at it from a building practice standpoint. It was not lost on me as a resident.
We worked with a thoracic surgeon so closely. A lot of academic places were not doing arterial stenting or even the IVC filters. Oh, who does the IVC filter at your hospital? This, that, the other. It's funny, when you think about it. It was not lost on me that the thoracic surgeons relied on us for everything when it came to their patients. Whether it was, if they had a DVT, we would do the thrombectomy, the IVC filter, the enteral intervention. The arterial intervention, if they were doing a gastric pull-up and they needed a celiac stent. The thoracic duct embolization surgeon said it was a way that practice and relationships were built.
When you can solve a problem for somebody else, they're going to go to you because they trust you, when you can solve their hard problems, to solve their simpler problems that a lot of other people could trust. Particularly when you have that face-to-face interaction, they know that you care about their patients. They know that you help them achieve excellent outcomes. To me, that is a cornerstone of lymphangiography and lymphatic interventions is you're solving somebody else's problem for them. They're going to reciprocate, and they're going to want to come to you to solve their easier problems when you can help them with their hard problems.
[Dr. Chris Beck]
I don't know about the rest of the audience, but if that doesn't get you excited about getting into this and knocking down some of the roadblocks and charging full steam ahead at lymphangiography, I don't know what it is. Good plug, I like that. Thanks, Bill. Anything that I didn't ask you, Bill, that we should have talked about? Don't get me wrong. I still think Backtable, we're still scratching the surface of this, and we're going to have a lot more episodes to do on it, but anything else left unsaid that you'd like to plug or talk about?
[Dr. Bill Majdalany]
As I say, the last thing that I'll say in regards to lymphatics is that this space has dramatically evolved in the last 10 years. We went from thoracic duct embolization, now we talk about hepatic lymphatic embolization, thoracic duct stenting, thoracic duct recanalization, trying to understand the pressures, using the thoracic duct as a way to decrease portal pressure in patients with ascites and variceal bleeding and understanding new diagnoses of this protein-losing enteropathy, protein alveolar proteinosis, plastic bronchitis, et cetera.
It's not just the iatrogenic leaks. It's all these other things that gets back to the lymphatics are interrelated through every organ and every circulation throughout the body. This is going to continue to evolve. At some point, I predict that we will have trans-lymphatic interventions for oncology. I do think that we will continue to understand the space of endocrine and how the lymphatics serve as a reservoir for hormones and understanding fluid balance in the body, and heart failure, and ascites, and how the lymphatics have an interplay with that, and the pressures. I think these are all things that are going to continue to happen.
[Dr. Chris Beck]
In your estimation, this is my takeaway of this, one, in our understanding of the lymphatic system, I don't know if we're at elementary school level, but maybe junior high. It's only going to continue to evolve if you're a young interventional radiologist looking to cut their teeth, or publish, or just develop a practice. This seems like green pastures, in my opinion.
[Dr. Bill Majdalany]
Absolutely. I'd say green pastures, blue water, I think there's a lot to do. I see, the group out of France did, [unintelligible 00:50:26] in his JVIR article, measuring pressures in the thoracic duct pre-imposed stenting for patients with ascites who couldn't get transplants and were non-TIPS candidates, et cetera. How we could still help a third of them who are medically refractory resolve their ascites. This is dramatic. That is a new paradigm. Say, okay, I can't give somebody a TIPS. We all see this, oh, maybe their MELD is elevated or whatever. Understanding which patients to treat, which ones are going to have better outcomes than other is to me that next cool thing. How we can use that to change the course of patients who others would say, "Oh, hey, they have really terrible liver function." No one even thinks about intervening through the lymphatics, but it's there.
[Dr. Chris Beck]
Got you. All right, Bill, well said. Any plug for the University of Vermont Medical Center for any aspiring medical students who might be listening?
[Dr. Bill Majdalany]
I'll tell you, I'm very excited to say that actually, just two weeks ago, we will be launching our integrated IR residency. We've had the independent, but we're going to start recruiting for the integrated. Well-rounded practice, really happy place to live. You get to ski at some of the best places in the winter. You get to spend a lot of summers on the lake and a lot of time hiking, seeing beautiful fall foliage, farm-to-table goodness, and just an awesome history decor. As I always say, you have all of the awesome stuff without the sphincter ton of some of the bigger programs.
[Dr. Chris Beck]
Well said. All right, guys, on that note, to our Backtable audience, thank everyone for listening. If you enjoyed the show, if you enjoyed the podcast, but want more, check out the show notes on this episode. Those can be found at https://www.backtable.com. Special thank you to the medical students who have helped put those together. That work is not unnoticed. For others interested in supporting the show, like, subscribe, and share this podcast on social media, or don't do any of that, just tell somebody about it. Old-fashioned word of mouth is super helpful as we continue to build this community. That about wraps it up. We'll see you next time on The Backtable Podcast. Bill, thanks for coming on again.
[Dr. Bill Majdalany]
Thank you so much, Chris.
Podcast Contributors
Dr. Bill Majdalany
Dr. Bill Majdalany is an associate professor and interventional radiology program director at Emory University in Atlanta, Georgia.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2024, September 3). Ep. 477 – Building a Successful Lymphangiography Practice [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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