Treatment Of A Lymphocele After Endovascular Aortic Aneurysm Repair: A .

IBIMA PublishingInternational Journal of Case Reports in CRM/ijcrm.htmlVol. 2014 (2014), Article ID 478028, 5 pagesDOI: 10.5171/2014.478028Case ReportTreatment of a Lymphocele after EndovascularAortic Aneurysm Repair: a Case ReportYoen T.K. van der Linden, Koop Bosscha and Olivier H.J. KoningJeroen Bosch Hospital, ’s-Hertogenbosch, NetherlandsCorrespondence should be addressed to: Yoen T.K. van der Linden; y.v.d.linden@jbz.nlReceived date: 1 December 2013; Accepted date: 9 April 2014; Published date: 2 July 2014Academic Editor: Roberto Di BartolomeoCopyright 2014. Yoen T.K. van der Linden, Koop Bosscha and Olivier H.J. Koning. Distributedunder Creative Commons CC-BY 3.0AbstractA lymphocele is one of the known postoperative complications after surgery in the inguinalregion, like lymph node resections and vascular cannulation. No standardized treatment isdefined. We report a case of a patient with a lymphocele after endovascular aortic aneurysmrepair and a review of the applicable literature. After an initial non operative policy,exploration using an intradermal injection of isosulfan blue dye in the webspace betweendigitus 1 and 2 of the ipsilateral foot leads to the identification of the lymphatic leak.Ligation of the leak and excision of the remaining lymphocele resolved the problem for thispatient.Keywords: EVAR, lymphocele, isosulfan blue, surgical treatmentIntroductionLymphocele formation is one of thecomplications after surgery in and aroundthe groin vessels. It has for example beenreported after arterial reconstruction,lymph node biopsies and vascularcannulation for cardiopulmonary bypass(Stadelmann et al (2002); Pagni et al(2009); York et al (2013); Pittaluga et al(2012); Sansone et al (2011)). A few isknown about the exact incidence oflymphocele after vascular surgery. Thereportedincidenceoflymphoceleformation after surgery varies by type ofprocedure. Two percent incidence has beenreported after varicose vein surgery(Pittaluga et al (2012)), 4% in renaltransplant recipients, of which 2%symptomatic (Choudhrie et al (2012)), and51% after pelvic lymph node dissection, ofwhich 15% is symptomatic (Orvieto et al(2011)). We report a patient with alymphocele after an endovascular aorticaneurysm repair (EVAR) procedure.No standardized treatment of groinlymphoceles is defined (Sansone et al(2011); Shermak et al (2005); Porcellini etal (2002)). Treatment options vary fromobservation, to using sclerosing agents, tooperative resections. Most of thesetreatment strategies have a highCite this Article as: Yoen T.K. van der Linden, Koop Bosscha and Olivier H.J. Koning (2014), “Treatment ofa Lymphocele after Endovascular Aortic Aneurysm Repair: a Case Report", International Journal of CaseReports in Medicine, Vol. 2014 (2014), Article ID 478028, DOI: 10.5171/2014. 478028

International Journal of Case Reports in Medicine2recurrence rate of up to 50 percent(Stadelmann et al (2002)).Case ReportAn 81 year old male underwent EVAR forhis abdominal aortic aneurysm in a centrewhere 50-60 EVAR procedures a year areperformed. During the EVAR procedure thegroin vessels are exposed by using atransverse incision. No special care is givento lymphatic tissue. After surgery, thepatient developed a tumor in his right groinat the site of the incision (figure 1).Figure 1: Image of the lymfocele before incisionOver months the tumor increased in sizeresulting in progressive pain. Ultrasoundexamination showed a low density laesionof 7,5 by 2,3 centimeter without flow orrelation to vascular structures, matching alymphocele or resorbing haematoma.Aspiration of the lymphocele resulted inshort relieve of his complaints; however,almost immediate recurrence was seen.Eight months after the EVAR urgical ProcedureThe patient was operated under generalanesthesia using Cefazolin as antibioticprophylaxis.Isosulfan blue was injected intradermallybetween digitus 1 and 2 in the webspaceon/nearby the dorsum of the right foot(figure 2).Figure 2: Image of the right foot immediately after injecting isosulfan blue in thewebspace between dig 1 and 2T.K. van der Linden, Koop Bosscha and Olivier H.J. Koning (2014), International Journal of Case Reports inMedicine, DOI: 10.5171/2014. 478028

3International Journal of Case Reports in MedicineAfter incision and exploration, openlymphatics were identified by bluecoloration. The lymphocele and leakinglymphatics were identified (figure 3),excision of the lymphocele and ligation ofthe leaking lymphatics was performedusing non resorbable suture material. Afterreaching haemostasis, the wound wasclosed subcutaneously and cutaneouslyboth using absorbable sutures.Figure 3: Peroperative vue of the inguinal region after injecting isosulfan blue.Identification of the leaking lymphatic branches(2013); Pittaluga et al (2012); Porcellini etPostoperative Managemental (2002)).One day postoperatively, the patient wasdischarged from the hospital. Nopostoperative complications were seen.One month after excision of thelymphocele, the patient was seen at ouroutpatient clinic. The complaints of painwere resolved and no recurrence of thelymphocele occurred. Five months aftersurgery no recurrence of the lymphocelewas seen. On the dorsum of the foot theblue dye was still visible.DiscussionTo our knowledge, this is the first report oflymphocele and it is a successful treatmentafter EVAR. Lymphocele is reported as awell known complication after vascularcannulation for cardiopulmonary bypass(Stadelmann et al (2002)). Some authorsmention open aortabiiliac reconstructionsurgery or saphenous vein harvestprocedures as risk factors (York et alIn 1933 Hudack et al reported the use ofdyes in lymphatic mapping. In recent yearsPatent Blue V or isosulfan blue is used forsentinel node evaluation in differentoncological patients (Viehl et al (2012);Berk et al (2005)). Isosulfan blue is provento be a safe dye, with a rare rate of allergicreactions (Bezu et al (2011)).Some studies using isosulfan blue in theoperative treatment of lymphoceles arereported. Stadelmann et al (2002) treated19 lymphoceles in 17 different high riskpatients, concluding that the use ofisosulfan blue for identifying leakinglymphatic channels is successful. Of these17 patients, none of the patients had anEVAR procedure; whereas three patientshad an aortofemoral bypass. In all 19surgically treated lymphoceles two woundabscesses and one superficial haematomawere reported, whereas no recurrence ofthe lymphocele was seen. In the study ofStadelmann isosulfan, blue dye wasT.K. van der Linden, Koop Bosscha and Olivier H.J. Koning (2014), International Journal of Case Reports inMedicine, DOI: 10.5171/2014. 478028

International Journal of Case Reports in Medicine4circumferentially injected into the distalextremity at the level of the ankle; the legwas then massaged and elevated to speedthe migration of the dye. After an averagefollow up of 18,8 months all patients had avery faint residual blue hue at the injectionsite. For this reason we think it is morepatient friendly to inject the dye in thewebspace between digitus 1 and 2 of thefoot.In a study of Pagni et al (2009), twopatients with persisting lymphoceles afternon-surgical treatment were surgicallytreated. Isosulfan blue was usedintraoperatively to map the lymphaticleakage. Complete resolution of thelymphocele occurred after ligation of theopen lymphatics. As in our case theyinjected isosulfan blue intradermally in thewebspace of the ipsilateral foot.The standard surgical approach forlymfocele is excision of the lymfocele.Isosulfan blue can assists in identifying theleaking branches and facilitates in makingthe right excision, after identifying leakinglymphatics, ligation is possible.“Symptomatic lymphocoeles post renaltransplant.” Saudi J Kidney Dis Transpl,23(6): p. 1162-8.4. Hudack, S.S. and McMaster P.D., (1933)“The Lymphatic Participation in HumanCutaneous Phenomena : A Study of theMinute Lymphatics of the Living Skin.” JExp Med, 57(5): p. 751-74.5. Orvieto, M.A., Coelho R.F., Chauhan S.,Palmer K.J., Rocco B. and Patel V.R. (2011)“Incidence of lymphoceles after robotassisted pelvic lymph node dissection.” BJUInt, 108(7): p. 1185-90.6. Pagni, R., Mariani C., Minervini A.,Morelli A., Giannarini G. and Morelli G.(2009) “Treatment with intraoperativePatent Blue V dye of refractory lymphoceleafter inguinal lymphadenectomy forsquamous cell penile carcinoma.” Urology,74(3): p. 688-90.7. Pittaluga, P. and Chastanet S. (2012)“Lymphatic complications after varicoseveins surgery: risk factors and how to avoidthem.” Phlebology, 27 Suppl 1: p. 139-42.ConclusionWe report a case of successful surgicaltreatment of a symptomatic groinlymphocele after EVAR. Isosulfan blue dyewas helpful in identifying the lymphaticleakage.AcknowledgementsThe authors declare that they have noconflict of interest.References1. Berk, D.R., Johnson D.L., Uzieblo A.,Kiernan M. and Swetter S.M. (2005)“Sentinel lymph node biopsy for cutaneousmelanoma: the Stanford experience, 19972004.” Arch Dermatol, 141(8): p. 1016-22.2. Bezu C., Johnson D.L., Uzieblo A.,Kiernan M. and Swetter S.M. (2011)“Anaphylactic response to blue dye duringsentinel lymph node biopsy.” Surg Oncol,20(1): p. e55-9.8. Porcellini, M., Iandoli R., Spinetti F.,Bracale U. and Di Lella D. tions of the lower limbs:outpatient conservative management.” JCardiovasc Surg (Torino), 43(2): p. 217-21.9. Sansone, F., del Ponte S., Zingarelli E.and Casabona R. (2011) “The 'packing ofthe groin' technique: an innovativeapproach for groin lymphocele.” InteractCardiovasc Thorac Surg, 13(4): p. 367-9.10. Shermak, M.A., Yee K., Wong L., JonesC.E. and Wong J. (2005) afterarterialbypasssurgery.” Plast Reconstr Surg, 115(7): p.1954-62.11. Stadelmann, W.K. and Tobin G.R.(2002) "Successful treatment of 19consecutive groin lymphoceles with theassistance of intraoperative lymphaticmapping." Plast Reconstr Surg, 109(4): p.1274-80.3. Choudhrie A.V., Kumar S., Gnanaraj L.,Devasia A., Chacko N. and Kekre N.S. (2012)T.K. van der Linden, Koop Bosscha and Olivier H.J. Koning (2014), International Journal of Case Reports inMedicine, DOI: 10.5171/2014. 478028

5International Journal of Case Reports in Medicine12. Viehl, C.T., Guller U., Cecini R., Langer I.,Ochsner A. and Terracciano L. (2012)"Sentinel lymph node procedure leads toupstaging of patients with resectable coloncancer: results of the Swiss prospective,multicenter study sentinel lymph nodeprocedure in colon cancer." Ann Surg Oncol,19(6): p. 1959-65.13. York, J.W., Johnson B.L., Cicchillo M.,Taylor S.M., Cull D.L. and Kalbaugh C.(2013) "Aortobiiliac bypass to the distalexternal iliac artery versus aortobifemoralbypass: a matched cohort study." Am Surg,79(1): p. 61-6.T.K. van der Linden, Koop Bosscha and Olivier H.J. Koning (2014), International Journal of Case Reports inMedicine, DOI: 10.5171/2014. 478028

a Lymphocele after Endovascular Aortic Aneurysm Repair: a Case Report", International Journal of Case Reports in Medicine, Vol. 2014 (2014), Article ID 478028, DOI: 10.5171/2014. 478028 Case Report Treatment of a Lymphocele after Endovascular Aortic Aneurysm Repair: a Case Report Yoen T.K. van der Linden, Koop Bosscha and Olivier H.J. Koning