Lymphorrhea following Tunneled Femoral Central Venous Catheter Placement: Avoidance and Management of a Rare Complication

Lymphatic injury and chylothorax are known, albeit rare, complications of both right and left internal jugular central venous catheter placement. ^{1 2} Some reports suggest that these complications occur more frequently when lines are placed in the presence of other complicating factors such as infection or thrombosis. ^{3 4 5 6 7 8} Although rare, the potential for a peripheral lymphatic injury is present during vascular access adjacent to the inguinal nodal cluster. A case of iatrogenic peripheral lymphatic injury during placement of a femoral tunneled central venous catheter (TCVC) is described. We review peripheral lymphatic anatomy, suggest approaches to avoid inadvertent lymphatic injury, and discuss management strategies of a peripheral lymphatic injury.

Case Presentation

A 34-year-old female with end-stage renal disease (ESRD) presented with bacterial peritonitis requiring the removal of her indwelling peritoneal dialysis catheter. She was referred to interventional radiology (IR) for placement of a TCVC to initiate hemodialysis prior to discharge. Preprocedural imaging revealed chronic occlusions of the right and left internal jugular veins and the superior vena cava (SVC). In keeping with the clinical practice guidelines for dialysis access, the IR service placed a right femoral TCVC using ultrasound and fluoroscopic guidance ( Fig. 1 ). ⁹

Fig. 1.

A 34-year-old female with end-stage-renal disease had bilateral brachiocephalic and superior vena cava venous occlusions. A tunneled dialysis catheter was placed through a right common femoral vein access.

The patient noticed that the dressings at the catheter exit site would be saturated within hours with thin, clear fluid. She experienced continued drainage of clear to light yellow fluid around the access site of the catheter for several days despite pressure dressings ( Fig. 2 ). The appearance of the fluid and location of injury suggested a peripheral lymphatic injury. Targeted ultrasound of the right, anterior thigh around the catheter revealed the tunneled portion of the catheter immediately adjacent to and possibly traversing an inguinal chain lymph node ( Fig. 3a, b ). Using sonographic guidance, a 25-gauge needle was positioned within the transected inguinal lymph node. Nodal lymphangiography with Lipiodol (Guerbet, Princeton, NJ) promptly revealed a lymphatic injury with leakage of contrast along the catheter tunnel ( Fig. 4a–g ). Lipiodol was exchanged for a 2:1 mixture of n -butyl cyanoacrylate glue (TruFill; Codman and Shurtleff, Raynham, MA) and lipiodol. A total of 1 mL of the adhesive mixture was used to perform intranodal glue embolization to seal the injury.

Fig. 2.

A 34-year-old female with end-stage-renal disease had unremitting leakage of thin, clear fluid after placement of a tunneled right common femoral vein dialysis catheter. Black arrows point to the fluid that continued to leak and saturate dressings for multiple days.

Fig. 3.

Targeted ultrasound along the tunneled right common femoral dialysis catheter in transverse ( a ) and longitudinal ( b ) planes reveals that the catheter (black arrow) may have injured an adjacent lymph node (white arrows).

Fig. 4.

Intranodal lymphangiography and nodal glue embolization. ( a ) A 25-gauge needle was placed into the lymph node (black arrow) identified in Fig. 3 and a hand injection of ethiodized oil was initiated. ( b ) Nearly immediately, while continuing the contrast injection (black arrow), extravasation of ethiodized oil is seen along the catheter (white arrows). ( c ) The injection was continued (black arrow) with leakage accumulating within the tract (white arrows). ( d ) As the needle based injection (black arrow) continued, leakage (white arrow) further highlighted the tract and catheter cuff (white arrowhead). ( e ) As the injection continued (black arrow), the leakage worsened within the tract (white arrow) and came to the skin surface at the exit site (white arrowhead). ( f ) Ethiodized oil was exchanged for n -butyl cyanoacrylate glue and nodal glue embolization, which is less radiopaque (white arrow), was performed through the same needle (black arrow). ( g ) After removal of the needle glue cast remains, which successfully sealed the injury (white arrow). A second lymphatic vessel is highlighted (black arrow) which was preserved.

Over the next few days, the volume of leakage around the catheter decreased and subsequent lymphangiography confirmed no further lymphatic leakage. Unfortunately, the patient developed bacteremia from the same species as the previously explanted peritoneal catheter and the right femoral catheter was also removed. Following repeat negative blood cultures, a new femoral TCVC was placed on the contralateral side with a laterally coursing tunnel ( Fig. 5 ). The patient experienced no further pericatheter lymphatic leakage and was discharged uneventfully.

Fig. 5.

A tunneled dialysis catheter was placed through a left common femoral vein access and tunneled with a more lateral course (black arrows) when compared with previous access on the contralateral side ( Fig. 1 ).

Discussion

Central lymphatic injuries can occur during placement of right or left internal jugular venous catheters due to anatomic variability and the proximity of the thoracic and right lymphatic ducts to the venous angle. Peripheral lymphatic injuries are an uncommon complication of TCVC with little evidence-based literature to guide the clinical IR. Herein, we will review lymphatic anatomy, discuss the differential diagnoses of leakage around TCVC, and suggest approaches for avoidance and treatment of a peripheral lymphatic injury.

The lymphatic circulation has three dominant components which all coalesce at the cisterna chyli and thoracic duct: the hepatic, enteral, and peripheral circulations. While the hepatic circulation is protein rich and the enteral circulation is lipid rich, peripheral lymph is compositionally like blood plasma, albeit with a higher concentration of lymphocytes. ¹⁰ The peripheral lymphatic anatomy is made up of three different types of vessels. Initial lymphatics are the site of lymph formation, cover the largest surface area, and are most adjacent to capillaries. Initial lymphatics drain to collecting lymphatics, which are distinguished by a smooth muscle layer and one-way valves. Collecting lymphatic channels communicate between lymph nodes and coalesce into lymphatic trunks, which deposit lymph into the large veins (namely, the right and left subclavian veins) for return to the systemic circulation. ^{11 12} In this case, the injury occurred at the level of the femoral veins, which are surrounded by a rich network of superficial and deep collecting lymphatic channels. ¹³ Injury to these lymphatic structures during femoral central line placement can be avoided by tunneling more laterally, and using ultrasound to visualize the planned tunnel tract to avoid lymph nodes.

Leakage around a TCVC is most often serosanguinous or bloody and usually occurs after insertion in patients on anticoagulation, with an underlying coagulopathy such as thrombocytopenia, and/or ESRD. A lymphatic leak should be considered when the drainage is clear to light yellow fluid, especially following interventions in or around vessels or major lymph node clusters. Venous oozing and infectious drainage should be considerations in the differential diagnosis as well. However, the fluid color, consistency and composition of the fluid, timing of the development of drainage, as well as imaging findings can aid with diagnosis. For instance, a peripheral lymphatic injury will have odorless, clear, and thin fluid; have lymphocyte predominance; and occur within hours to days of the procedure. ¹⁴ In contradistinction, infectious drainage is turbid, malodorous, neutrophil predominant, and occurs 7 to 14 days later.

Peripheral lymphatic injury resulting in lymphorrhea can be managed equivalently to a ruptured lymphocele. ¹⁴ Conservative treatment can include watchful waiting and local pressure if the leak is not robust or bothersome to the patient. However, if the leak is not improving, has features of infection, or if the patient is decompensating, then a more aggressive approach is warranted. Large-volume leaks may require volume replacement with monitoring and replacement of electrolytes. In the case of the patient in this report, more aggressive treatment was pursued to salvage an otherwise well-functioning TCVC in a patient with dwindling vascular access options. We utilized lymphangiography and nodal glue embolization, as diagnostic and therapeutic strategies, as has been previously utilized in other instances for lymphatic injury and chylous leaks. ^{15 16 17 18 19 20} Should percutaneous and endovascular approaches fail, operative approaches remain as possible options for lymphatic leaks. ^{21 22}

Conclusion

Lymphatic injury during placement of femoral central venous catheters is rare, but should be suspected if the leakage is thin, clear, and has elevated lymphocytes. Lymphangiography and nodal glue embolization can serve as diagnostic and therapeutic approaches to attempt salvage of the access.