LETTERS TO THE EDITOR Regarding “Treatment of postoperative high-volume lymphatic complications using isosulfan blue” In the recent manuscript by Drs Bounds and Endean, 1 “Treatment of postoperative high-volume lymphatic complications using isosulfan blue,” the authors high- light the use of isosulfan blue for identification of lymphatic injuries in postoperative patients. The authors evaluated 32 patients with 33 complications including high-output lymphocele formation (n ¼ 11 [33%]) and lymphocutaneous fistulas (n ¼ 22 [66%]). Most patients underwent femoral or saphenous vein harvests (n ¼ 17 [52%]) or femoral artery exposure (n ¼ 13 [41%]). All 33 lymphatic complications were treated with isosulfan blue-directed ligation. In addition to surgical identification and ligation, several complementary approaches may allow the iden- tification and correction of lymphatic injuries without requiring a return to the operating room. 2-4 Early percu- taneous therapies used to treat lymphoceles include drainage and sclerotherapy. 2 While percutaneous drainage alone provides clinical success rates ranging from 70% to 100%, instillation of a sclerosing agent has shown sustained rates as high as 98% in larger cohort studies, which are comparable to the rates seen with sur- gical management. 2 More recent advances in the treatment of lympho- celes and lymphocutaneous fistulas include direct percutaneous lymph node access with subsequent embolization. 3,4 Endolymphatic embolization for the treatment of thoracic duct injury 3 has grown to include lymphatic injuries in multiple other territories. 4 The technique involves the placement of a small-gauge needle into local lymph nodes under ultrasound guid- ance. 4 Ethiodized oil is then injected, under periodic fluoroscopic imaging, to identify extravasation of oil from the lymphatic system. 4 After identification of the site of injury, the lymphatic node or duct closest to the area of injury is accessed, followed by embolization with a liquid embolic agent. 4 Ethiodized oil itself may incite a fibrotic response, leading to lymphatic occlu- sion rates of 35% in high-output leaks and 75% in low-output leaks. The addition of embolization with a liquid embolic agent has demonstrated 100% occlu- sion rates in several iatrogenic scenarios ranging from cannulation injury in heart transplantation to chylous ascites after tumor resection to pelvic laparoscopy, 4 all with immediate improvement in symptoms and drain outputs. The output from high-output lymphatic leaks has been shown to decrease by 88% within the first postprocedure day following embolization. Furthermore, a recent case series showed a sustained response out to 4 months (mean of 134 days) after prostatectomy. 4 While further studies are needed to validate these techniques, initial studies have shown good efficacy in the management of these injuries. All patients in the authors’ study 1 returned to the operating room for exploration under general anes- thesia. Intranodal lymphangiography and embolization may be performed under local anesthesia or moderate sedation. 3,4 This may facilitate treatment in those who have deteriorated from comorbid medical conditions, complications, or prolonged hospital stays after the initial operation. Establishment of a multidisciplinary team, including surgeons and interventional radiolo- gists, is beneficial for the management of lymphatic injuries. Jason A. Fisher, MD, MS Department of Surgery Icahn School of Medicine at Mount Sinai New York, NY Jacob J. Bundy, MD, MPH Joseph J. Gemmete, MD, FSIR Division of Vascular and Interventional Radiology Department of Radiology University of Michigan Medical Center Ann Arbor, Mich Ravi N. Srinivasa, MD Department of Interventional Radiology University of California Los Angeles, Calif Jeffrey Forris Beecham Chick, MD, MPH Cardiovascular and Interventional Radiology Inova Alexandria Hospital Alexandria, Va REFERENCES 1. Bounds MC, Endean ED. Treatment of postoperative high- volume lymphatic complications using isosulfan blue. J Vasc Surg Venous Lymphat Disord 2018;6:737-40. 2. Akhan O, Karcaaltincaba M, Ozmen MN, Akinci D, Karcaaltincaba D, Ayhan A. Percutaneous transcatheter ethanol sclerotherapy and catheter drainage of postoperative pelvic lymphoceles. Cardiovasc Intervent Radiol 2007;30: 237-40. 3. Johnson OW, Chick JF, Chauhan NR, Fairchild AH, Fan CM, Stecker MS, et al. The thoracic duct: clinical importance, anatomic variation, imaging, and embolization. Eur Radiol 2016;26:2482-93. 309