Optimal Location of Indocyanine Green (ICG) Injection for Imaging of Normal Upper Extremity Lymphatics
Joe H. Dayan, MD, Elizabeth Kenworthy, MD, Jung-Ju Huang, MD, Itay Wiser, MD, PhD, Andrew Weinstein, MD, Richa Verma, MD, Svetlana Kleyman, MD, Babak J. Mehrara, MD.
Memorial Sloan Kettering, New York, NY, USA.
Introduction
Indocyanine green (ICG) lymphangiography is used routinely in the workup of patients with lymphedema before lymphatic surgery however there is no internationally accepted standardized protocol for the location of injections. The purpose of this study was to determine the effect of various ICG injection sites on ICG lymphatic distribution, and assess the injection site combination that produces optimal lymphatic visibility.
Methods
ICG lymphangiography of the upper limb was evaluated in the healthy arm of lymphedema patients. ICG was injected into either 1st, 2nd, 3rd webspaces or wrist ulnar border in 5 different combinations. Number of lymphatic vessels were compared between different ICG injection locations. Dynamics of lymphatic uptake were measured at the wrist, forearm, antecubital fossa and upper arm 30 minutes following injection. Paired T-test was used to compare lymphatic vessel count between various injection sites.
Results
ICG injection combination that included the 3rd webspace had significantly increased number of lymphatics visualized in the wrist / forearm area (5.2±1.0 vs. 3.3±1.9, p=0.003 and 4.6±1.4 vs. 2.8±1.2, p=0.009; respectively). Dorsal ulnar pathway in the forearm was demonstrated more frequently using 3rd webspace injection (94% vs. 50%; p=0.007).
Conclusion
This study suggests that optimal imaging of the lymphatics in the upper extremity results from injection into the 1st and 3rd webspace of the dorsum of the hand. The work presented in this paper proposes a standard technique to further the use of ICG as a validated diagnostic and assessment tool.
Comparison of Different ICG Injection Location Combinations Effect on Number of Lymphatic Vessels Demonstrated
| Injection site | Dorsal-ulnar & radio-volar | Radial-volar | Total |
| 1st + 3rd | 15 | 5 | 20 |
| 3rd | 1 | 0 | 1 |
| 1st +2nd | 0 | 2 | 2 |
| 2nd + Ulnar | 1 | 1 | 2 |
| 1st +Ulnar | 0 | 2 | 2 |
| Total | 17 | 10 | 27 |
•
Chi-square for 3rd webspace: p= 0.007
Back to 2018 Posters
