Direct puncture and NBCA embolization for refractory lymphatic leakage after inguinal lymphadenectomy in the absence of puncturable lymph nodes guided by lymphoscintigraphy

Lymphatic leakage is a recognized complication of lymphadenectomy. Intranodal lymphangiography is commonly used to identify lymphatic leakage; however, the procedure may not be feasible in cases where no puncturable lymph nodes remain following inguinal lymphadenectomy. We report a case of refractory lymphatic leakage occurring after inguinal lymphadenectomy that was managed by direct puncture and N-butyl cyanoacrylate (NBCA) embolization of a lymphocele and lymphopseudoaneurysm with lymphoscintigraphy employed for localization. A 70-year-old woman experienced persistent lymphatic leakage following left inguinal and external iliac lymphadenectomy for melanoma. Lymphoscintigraphy with single photon emission computed tomography/computed tomography revealed 2 disrupted lymphatic pathways along the great saphenous and femoral veins. Intense tracer accumulation at the inguinal stump along the great saphenous pathway indicated fluid collection, whereas tracer presence along the femoral pathway extended near the drainage catheter without focal pooling suggested communication with the drain tract. Due to the absence of puncturable lymph nodes, intranodal lymphangiography was not feasible. We punctured and embolized the fluid collection along the great saphenous pathway using an NBCA-ethiodized oil mixture. Despite this intervention, lymphatic leakage persisted; therefore, we accessed another small fluid collection along the femoral vein. Ethiodized oil injection demonstrated continuity with the drainage catheter which was consistent with a lymphopseudoaneurysm. Following embolization, the external lymphatic leakage resolved within several days. This case illustrated that lymphoscintigraphy can effectively identify major sites of leakage and guide intervention; however, intense tracer accumulation does not necessarily indicate the sole source of leakage when multiple lymphatic pathways are disrupted.