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Case series
Percutaneous sclerotherapy of microcystic lymphatic malformations: the use of an innovative gravity-dependent technique
  1. Alejandro Berenstein1,
  2. Maximilian Jeremy Bazil1,
  3. Michelle Sorscher1,
  4. Francine Blei2,
  5. Reade De Leacy1,
  6. Tomoyoshi Shigematsu1,
  7. Milton Waner2,
  8. Johanna T Fifi1
  1. 1Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  2. 2Otolaryngology, Hofstra University North Shore LIJ School of Medicine, Hempstead, New York, USA
  1. Correspondence to Dr Johanna T Fifi, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Johanna.Fifi{at}


Background In the last few decades there has been development of innovative therapies for the treatment of craniofacial lymphatic malformations. Percutaneous sclerotherapy has demonstrated efficacy in the management of macrocystic lymphatic lesions, but it is less suitable for microcystic lesions given their size. The gravity-dependent technique is a novel augmentation of standard percutaneous sclerotherapy: the technique enables a sclerosing agent to permeate the small microchannels seen in microcystic lesions that would otherwise be difficult to treat.

Methods Between 2005 and 2021, 124 patients with microcystic or mixed lymphatic malformations were treated using a novel gravity-dependent sclerotherapy technique. Bleomycin at a maximum dose of 15 IU per session was used as the main sclerosing agent. Fluoroscopy and ultrasound were used to ensure proper positioning of the catheter prior to injecting the sclerosing agent. The response to treatment was assessed clinically and with cross-sectional imaging.

Results Nearly all cases showed significant improvement after the gravity-dependent technique. There have been no permanent complications from sclerotherapy treatment. There was a mild transient adverse effect from bleomycin in one case of erythema and tenderness that lasted several weeks then ameliorated.

Conclusions The gravity-dependent sclerotherapy technique is a suitable treatment option for microcystic lymphatic malformations.

  • Vascular Malformation
  • Technique

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  • Contributors AB invented the technique and applied the technique in his practice to the majority of patients. FB, MS, MW, TS, and JTF also contributed to patient care and technique development. MJB helped draft the manuscript in conjunction with FB, TS, and JTF and all authors edited the document prior to submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.