Standardizing Upper Extremity Indocyanine Green Lymphography In A Lymphedema Outpatient Setting
Itay Wiser, MD, PhD1, Andrew Weinstein, MD2, Elizabeth Kenworthy, MD1, Babak Mehrara, MD1, Joe Dayan, MD1.
1Memorial Sloan Kettering, New York, NY, USA, 2New York Presbyterian, New York, NY, USA.
Purpose: Indocyanine green (ICG) lymphography is increasingly used for upper extremity lymphedema diagnosis in the outpatient settings. Still, it has no internationally accepted standardized protocol. The purpose of this study was to determine the injection location and combination, and the time of visualization that would produce an optimal upper extremity lymphatic imaging. Methods: ICG lymphography was performed on healthy upper extremities. optimal ICG injection pattern was determined by injecting ICG to the sub-dermis in 6 different combinations that included up to 2 locations in the interdigital web spaces or wrist ulnar border. Optimal ICG imaging was determined by comparing lymphatic visualization at 5, 30- and 60-minutes following injection. Outcome measures included number of visualized lymphatic pathways, lymphatic vessels and lymph nodes. Results: ICG injection to the 1st and 3rd web spaces Compared with other injection patterns was associated with higher lymphatic vessel count in the wrist (5.3±1.3 vs. 3.1±0.9, p<0.001), forearm (4.4±1.2 vs. 2.4±0.9, p<0.001), antecubital fossa (4.5±1.8 vs. 2.9±1.0, p=0.04) and the upper arm (3.1±1.4 vs. 1.9±0.7, p=0.01), and achieved better visualization of dual lymphatic pathways in the wrist (80% vs. 32%, p=0.001), forearm (76% vs. 32%, p=0.002), upper arm (64% vs. 28%, p=0.011), and the complete upper extremity (44% vs. 0%, p<0.001), and the axillary lymph node (100% vs. 68%, p=0.002). Imaging at 30 minutes compared to 5 minutes after ICG injection had significantly higher visualization of lymphatic vessel number in the wrist (4 vs. 3, p=0.028), antecubital area (4 vs. 2, p<0.001), and upper arm (3 vs. 1, p<0.001), and more frequent visualization of medial (48% vs. 84%, p=0.016) and lateral (60% vs. 92%, p=0.018) arm lymphatic pathways, and axillary lymph nodes (100% vs. 16%, p<0.001). No significant visualization differences were observed between 30 and 60 minute time points. Conclusion: ICG lymphography provides a detailed view of the upper extremity lymphatic system, allowing a direct assessment in an outpatient settings. ICG Injection pattern of 1st and 3rd web spaces together with imaging time points at 5 and 30 minutes, provided the optimal lymphatic visualization in normal upper extremity.
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