Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial

Successful Percutaneous Thoracic Duct Embolization for Chylothorax After Total Arch Replacement

Chylothorax after cardiac surgery is a rare complication associated with severe morbidity and mortality. This report documents successful treatment with percutaneous thoracic duct embolization for chylothorax after total arch replacement. A 69-year-old man underwent replacement of the aortic arch to treat a ruptured aortic aneurysm. After surgery, the left thoracic drain discharged 2,000 to 3,000 mL serosanguineous fluid per day, even though the patient took nothing orally and was administered subcutaneous octreotide therapy. On postoperative day 9, percutaneous thoracic duct embolization was performed, and the drain could be removed. The chylothorax did not recur, and the patient was discharged on postoperative day 17.

Thoracic Duct Occlusion Leading to Intermittent Left Supraclavicular Swelling and Pancreatitis

Intermittent left supraclavicular swelling is an uncommon and elusive condition that can lead to extensive diagnostic workups to determine the etiology and treatment. One potential cause is partial, intermittent, or complete thoracic duct occlusion (TDO). We report on a patient who presented with chronic, intermittent left supraclavicular swelling and abdominal pain that was relieved by thoracic duct angioplasty. Thoracic duct occlusion should be included in the differential diagnosis of left supraclavicular swelling. Lymphatic imaging can facilitate the diagnosis and allows for potential percutaneous treatment. Laryngoscope, 134:1313-1315, 2024.

Novel Interventional Radiology for the Treatment of Various Lymphatic Leakages: Lymphatic Intervention and Embolization

Little progress has been made in modern lymphatic medicine since Dr. Kinmonth first described pedal lymphangiography in the 1950s. The clinical need for an effective treatment modality for managing lymphatic leakage greatly increased only after intranodal lymphangiography, which enabled the depiction of the exact location of the leakage. This review introduces five hypotheses that have been proposed while addressing various clinical scenarios involving lymphatic leakage: (1) various embolization techniques can be used to prevent lymphatic leakage; (2) lymph node embolization can treat postoperative pelvic lymphoceles that are refractory to sclerotherapy; (3) the technical success rate of thoracic duct cannulation can be improved by using retrograde thoracic duct access as a bail-out method; (4) non-traumatic chylothorax can be managed by understanding the underlying pathophysiology; and (5) chylous ascites can be managed by understanding the underlying pathophysiology. Five retrospective observational studies, one randomized prospective clinical trial, and two case reports (letters to the editor) were published after the hypotheses were validated. We provide a new systematic approach to lymphatic intervention by describing the process of the current comprehensive research.

The essential role of thoracic duct embolization in management of traumatic iatrogenic chylothorax

This study aims to describe a case series of patients who underwent thoracic duct embolization (TDE) to treat traumatic iatrogenic chylothorax (TIC). Three patients were included: Case #1, a 49-year-old woman with follicular lymphoma developed a TIC following video-assisted thoracoscopic surgery to resect a solid right paravertebral mass and was treated with TDE using microcoils and N-butyl cyanoacrylate (NBCA) glue. Case #2, a 68-year-old man with cardiac amyloidosis developed a TIC following heart transplantation and was treated with TDE using microcoils and ethylene vinyl alcohol copolymer. Case#3: A 6-year-old patient with congenital heart disease developed a TIC following a Fontan procedure and was treated with TDE using NBCA glue. All lesions were identified during lymphangiography and TDE was successfully performed in all cases. TDE is a safe and valuable technique that provides minimally invasive treatment for TCI.

Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions

ABSTRACT

Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.

Guidelines for Central Venous Port Placement and Management (Abridged Translation of the Japanese Version)

The central venous port has been widely used for patients who require long-term intravenous treatments, and the number of palcement has been increasing. The Japanese Society of Interventional Radiology developed a guideline for central venous port placement and management to provide evidence-based recommendations to support healthcare providers in the decision-making process regarding the central venous port. The guideline consisted of two parts: (i) a comprehensive review of topics including preoperative preparation, techniques for placement or removal, complications, and maintenance methods and (ii) recommendations for the six clinical questions regarding blood vessels for central venous port placement, port implantation site, prophylactic antibiotic therapy, imaging guidance for puncture, disinfectant prior to accessing the central venous port, and the optimal procedure at the end of drug administration via the central venous port, generated on the basis of the rating quality of evidence by systematic review.

Cholecystitis-an uncommon complication following thoracic duct embolization for chylothorax: A case report

BACKGROUND

Chylothorax is an uncommon condition in which chyle leaks into the pleural cavity, and biliary peritonitis is a rare complication of thoracic duct embolization in clinical practice.

CASE SUMMARY

We describe the case of a 50-year-old woman who presented with chylothorax and underwent thoracic duct embolization using a coil and a mixture of histoacryl glue and lipiodol. The patient developed upper abdominal pain and fever after the intervention. She was diagnosed with biliary peritonitis and treated with cholecystectomy at Hanoi Medical University Hospital.

CONCLUSION

Although thoracic duct embolization is considered a safe and minimally invasive procedure, it is not without risk. Following thoracic duct embolization, severe or persistent abdominal pain should be explored utilizing imaging data and laboratory results to determine problems as soon as possible.

Management of lymphoma-associated chylothorax by interventional radiology and chemotherapy: a report of five cases

Chylous effusion is associated with lymphatic obstruction or leakage in mediastinal or abdominal lymph nodes, and is a rare but troublesome complication in patients with malignant lymphomas. Although there is no standard of care, it is often treated with simultaneous chemotherapeutic and non-chemotherapeutic interventions. Here, we describe the cases of five patients with lymphoma-associated chylothorax with the aim of clarifying an effective treatment strategy. All patients achieved a partial response or better for lymphoma. All patients underwent interventional radiology (IVR) procedures, including lymphangiography (LAG) and thoracic duct embolization (TDE). Complete resolution of chylothorax was eventually achieved by IVR procedures or pleurodesis in all patients. No patients experienced serious adverse events related to LAG/TDE. Treatment of chylous effusion required months for most patients (range: 0.2-4.8 months). Our data suggest that a combination of chemotherapy and LAG/TDE is effective for refractory lymphoma-related chylous effusion.

Transcatheter interventions in patients with a Fontan circulation: Current practice and future developments

The Fontan operation represents the last of multiple steps that are offered a wide range of congenital cardiac lesions with a single ventricle (SV) physiology. Nowadays this surgical program consists of a total cavopulmonary connection (TCPC), by anastomosing systemic veins to the pulmonary arteries (PAs), excluding the right-sided circulation from the heart. As a result of imaging, surgical, percutaneous, and critical care improvements, survival in this population has steadily increased. However, the Fontan physiology chronically increases systemic venous pressure causing systemic venous congestion and decreased cardiac output, exposing patients to the failure of the Fontan circulation (FC), which is associated with a wide variety of clinical complications such as liver disease, cyanosis, thromboembolism, protein-losing enteropathy (PLE), plastic bronchitis (PB), and renal dysfunction, ultimately resulting in an increased risk of exercise intolerance, arrhythmias, and premature death. The pathophysiology of the failing Fontan is complex and multifactorial; i.e., caused by the single ventricle dysfunction (diastolic/systolic failure, arrhythmias, AV valve regurgitation, etc.) or caused by the specific circulation (conduits, pulmonary vessels, etc.). The treatment is still challenging and may include multiple options and tools. Among the possible options, today, interventional catheterization is a reliable option, through which different procedures can target various failing elements of the FC. In this review, we aim to provide an overview of indications, techniques, and results of transcatheter options to treat cavopulmonary stenosis, collaterals, impaired lymphatic drainage, and the management of the fenestration, as well as to explore the recent advancements and clinical applications of transcatheter cavopulmonary connections, percutaneous valvular treatments, and to discuss the future perspectives of percutaneous therapies in the Fontan population.

Management of chyle leaks following esophageal resection: a systematic review

BACKGROUND

Chyle leakage is an uncommon but potentially life-threatening complication following esophageal resections. The optimal management strategy is not clear, with a limited evidence base.

METHODS

Searches were conducted up to 31 December 2020 on MEDLINE, Embase, and Web of Science for randomized trials or retrospective studies that evaluated the management of chyle leakage following esophageal resection. Two authors independently screened studies, extracted data, and assessed for bias. The protocol was prospectively registered on PROSPERO (CRD: 42021224895) and reported in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines.

RESULTS

A total of 530 citations were reviewed. Twenty-five studies, totaling 1016 patients met the inclusion criteria, including two low-quality clinical trials and 23 retrospective case series. Heterogeneity of study design and outcomes prevented meta-analysis. The overall incidence of chyle leak/fistula was 3.2%. Eighteen studies describe management of chyle leaks conservatively, 17 by surgical ligation of the thoracic duct, 5 by pleurodesis, and 6 described percutaneous lymphangiography with thoracic duct embolization or disruption.

CONCLUSIONS

The evidence base for optimal management of chyle leakage postesophagectomy is lacking, which may be related to its low incidence. There is a paucity of high-quality prospective studies directly comparing treatment modalities, but there is some low-certainty evidence that percutaneous approaches have reduced morbidity but lower efficacy compared with surgery. Further high-quality, prospective studies that compare interventions at different levels of severity are needed to determine the optimal approach to treatment.

[Modern Treatment Options for Postoperative Chylothorax: a Systematic Review]

BACKGROUND

 Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective, randomised trials, the evidence-based treatment rests upon personal experience, but ideally taking into account retrospective analysis.

MATERIAL AND METHODS

 The aim of this review is to provide a comprehensive overview of the currently available modern treatment options. Another aspect is to show their advantages and disadvantages. For this purpose, a literature search was performed using the "PubMed" database. Publications older than ten years were excluded from this review. The literature search employed the keyword "chylothorax". The priority was set on publications including a comparative assessment of treatment approaches. The authors relied on many years of clinical experience to critically analyse and evaluate the treatment options and the given recommendations.

RESULTS

 The success rate of the conservative treatment methods ranges widely, depending on the underlying cause of the disease (3-90 %). Non-invasive or semi-invasive procedures are successful in 50 to 100 % of the cases, also depending on the aetiology. After unsuccessful conservative treatment of operable patients, the standard surgical therapy consists of thoracic duct ligature, which is usually performed thoracoscopically. Alternatively, pleurodesis or the placement of a permanent chest drain (PleurX) or a pleuroperitoneal shunt may be performed. The success rate of these procedures is between 64 and 100 %. The morbidity and mortality rate can reach values up to 25 %.

CONCLUSION

 Treatment of a chylothorax should be started conservatively. Subsequently, a more aggressive therapy may be gradually considered, based on the patient's health and the amount of the secretion. Interventional radiological procedures are safe, successful, and have a legitimate place alongside conservative or surgical treatment. However, they are currently only available in some larger centres.

Chylothorax after esophagectomy treated with inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization

Chylothorax after esophagectomy is a serious complication that is associated with major morbidity due to dehydration and malnutrition. Reoperation with ligation of the thoracic duct is considered for patients with high-output chyle leaks that have failed conservative management. In this report, we present the treatment options for chylothorax after esophagectomy: inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization. A 74-year-old man with esophageal cancer had been operated with thoracoscopic esophagectomy. Six days after surgery, he presented with high-output chyle leaks. Conservative treatment did not result in a significant improvement. Inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization were performed 13 days after surgery and were technically and clinically successful. Inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization are an effective treatment option, especially for patients after esophagectomy with reconstruction performed via the posterior mediastinal route, without the potential for damage the gastric tube and omentum.

Application of ultrasound-guided intranodal lymphangiography and embolisation in cancer patients with postoperative lymphatic leakage

BACKGROUND

Traumatic lymphatic leakage is a rare but potentially life-threatening complication. The purpose of this study was to introduce ultrasound-guided intranodal lymphangiography and embolisation techniques for postoperative lymphatic leakage in patients with cancer.

METHODS

From January 2018 through June 2020, seven cancer patients (three males, four females, aged 59-75 years [mean 67.57 ± 6.11 years]) developed lymphatic leakage after abdominal or pelvic surgery, with drainage volumes ranging from 550 to 1200 mL per day. The procedure and follow-up of ultrasound-guided intranodal lymphangiography and embolisation were recorded. This study retrospectively analysed the technical success rate, operative time, length of hospital stay, clinical efficacy, and complications.

RESULTS

The operation was technically successful in all patients. Angiography revealed leakage, and embolisation was performed in all seven patients (7/7, 100%). The operative time of angiography and embolisation was 41 to 68 min, with an average time of 53.29 ± 10.27 min. The mean length of stay was 3.51 ± 1.13 days. Lymph node embolisation was clinically successful in five patients (5/7, 71.43%), who had a significant reduction in or disappearance of chylous ascites. The other two patients received surgical treatment 2 weeks later due to poor results after embolisation. All patients were followed for 2 weeks. No serious complications or only minor complications were found in all the patients.

CONCLUSIONS

Ultrasound-guided intranodal lymphangiography and embolisation were well tolerated by the patients, who experienced a low incidence of complications. Early intervention is recommended for cancer patients with postoperative lymphatic leakage.

Management options for post-esophagectomy chylothorax

Chylothorax, although an uncommon complication of esophagectomy, is associated with high morbidity and mortality if not treated promptly. Consequently, knowledge of the thoracic duct (TD) anatomy is essential to prevent its inadvertent injury during surgery. If the TD is injured, early diagnosis and immediate intervention are of paramount importance; however, there is still no universal consensus about the management of post-operative chylothorax. With increasing advances in the spheres of interventional radiology and minimally invasive surgery, there are now several options for managing TD injury. We review this topic in detail to provide a comprehensive and practical overview to help surgeons manage this challenging complication. In particular, we discuss an appropriate step-up approach to prevent the morbidity associated with open surgery as well as the metabolic, nutritional, and immunological disorders that accompany a prolonged illness.

Traumatic Chylothorax: Approach and Outcomes

Traumatic chylothorax occurs more often now than in historic reports. In part, this is due to the increased ability to perform more advanced and aggressive thoracic resections and cardiovascular surgeries as well as the improved mortality of cancer patients. If untreated, chylothorax can result in significant morbidity and mortality, particularly in patients with underlying malignancy. Thoracic duct embolization for chylothorax was the first successful lymphatic intervention and has been performed for over 20 years. An overview of the clinical and technical approach to thoracic duct embolization for traumatic chylothorax is presented in addition to a review of outcomes.

Complications during Lymphangiography and Lymphatic Interventions

Lymphangiography as a diagnostic procedure dates back to the 1950s and was widely performed for several decades until being supplanted by other advanced imaging techniques. With the advent of thoracic duct embolization to treat chylothorax, Constantin Cope ushered in a transition from lymphangiography as a diagnostic procedure to a precursor for lymphatic intervention. Subsequently, technical modifications and applications of lymphatic embolization to other medical conditions have greatly expanded the scope and application of lymphangiography and lymphatic intervention. Although there is increasing familiarity with lymphatic interventions, few interventionalists have performed a high enough volume to be aware of potential complications and their management. Potential complications of lymphangiography and those encountered while performing lymphatic interventions are discussed along with approaches to minimize their risk and management strategies should they occur.

Nodal and Pedal MR Lymphangiography of the Central Lymphatic System: Techniques and Applications

Novel lymphatic imaging and interventional techniques are increasingly used in the diagnostic workup and treatment of pathologies of the central lymphatic system and have opened a new field of interventional radiology. The mainstay of lymphatic imaging today is magnetic resonance lymphangiography (MRL). It provides information on the anatomy of the central lymphatic system, lymphatic flow, as well as lymphatic pathologies and therefore is a valuable tool for treatment planning. There are two techniques to perform contrast-enhanced MRL: nodal dynamic contrast-enhanced MRL (nodal DCE-MRL) and interstitial transpedal MRL (tMRL). Nodal DCE-MRL yields superior information on lymphatic flow dynamics and is therefore best suited for suspected lymphatic flow pathologies and lymphatic malformations. tMRL is a technically simpler alternative for central lymphatic visualization without the need for sonographically guided lymph node cannulation. This review article describes current MRL techniques with a focus on contrast-enhanced MRL, their specific advantages, and possible clinical applications in patients suffering from pathologies of the central lymphatic system.

Refractory chylous effusions in lymphangioleiomyomatosis patient post lung transplant

Lymphangioleiomyomatosis is a rare systemic disorder of unknown etiology that affects young women almost exclusively. Chylous effusions are known to be associated with lymphangioleiomyomatosis and may be difficult to treat. We present the case of a 37-year-old female who received bilateral lung transplantation for lymphangioleiomyomatosis complicated by refractory chylothorax and chylous ascites, ultimately controlled through repeated, open surgical procedures and percutaneous lymphatic embolization interventions. The combined surgical and interventional radiological approach, while not novel in their own right, suggests that a multi-modal interventional approach may be required in refractory cases.

Utility of planning MRI in percutaneous thoracic duct embolization for chylothorax

PURPOSE

Percutaneous thoracic duct embolization (TDE) is an accepted treatment for leaks of the central lymphatic ducts. In this study, we correlate the imaging findings on pre-procedural MRI lymphangiography with findings on conventional lymphangiography, and with operator ability to perform a technically successful TDE. The aim was to examine whether MRI is a good screening mechanism to support an invasive procedure in strong candidates, and avert one in poor candidates.

MATERIALS AND METHODS

MRI and conventional lymphangiograms of 96 patients (62 male and 34 female; mean age 63 ± 11 years, range 29-92 years) were retrospectively reviewed. The diameter and level of the best target for access were assessed for each study. Technical success rates were evaluated with respect to presence of a cisterna chyli, target duct size, and target level concordance.

RESULTS

Presence of a cisterna chyli on MRI significantly increased the likelihood of a successful TDE (68% vs. 42%, p = 0.03). Presence of a duct 4 mm or larger, by either modality, significantly improved the chance of successful TDE (for MRI, 65% vs. 41%, p = 0.04; for lymphangiography, 70% vs. 44%, p = 0.03). MRI was not helpful for localizing a lymphatic target, as less than half were seen within one and one-half vertebrae of the predicted level. There was a weak correlation (Pearson coefficient = +0.30) between duct size as measured on the two modalities. 95% of those without an identifiable target on MRI had a viable target on lymphangiography, and successful TDE was performed in 47% of those patients.

CONCLUSIONS

Identification of a cisterna chyli and/or 4 mm or greater target on pre-procedural MRI indicated higher likelihood of technically successful TDE. MRI did not help predict unsuccessful TDE procedures. Better target level concordance was not associated with improved technical outcomes.

Contrast-enhanced Interstitial Transpedal MR Lymphangiography for Thoracic Chylous Effusions

Background Abnormalities of the central lymphatic system (CLS) are increasingly treated by interventional radiology approaches. Planning of these procedures, however, is challenging because of the lack of clinical imaging tools. Purpose To evaluate the clinical usefulness of contrast agent-enhanced interstitial transpedal MR lymphangiography in the preinterventional workup of lymphatic interventions in patients with thoracic chylous effusions. Materials and Methods Patients with chylous effusions evaluated from January 2014 and December 2017 were included in this retrospective analysis of transpedal MR lymphangiography. Indications were chylothorax (n = 19; 76%), cervical lymphatic fistula (n = 2; 8%), and combined chylothorax and chylous ascites (n = 4; 16%). Patients underwent transpedal MR lymphangiography at 1.5 T with T1-weighted imaging after interstitial pedal of gadolinium-based contrast medium under local anesthesia. Contrast-enhanced MRI was evaluated for technical success, depiction of pathologic abnormalities of the CLS, and access site for lymphatic interventions (ie, clinically useful examination). Reader agreement for image quality and overall degree of visualization was assessed with weighted κ. Interrelations between overall image quality and degree of visualization of CLS structures were assessed by Spearman ρ. Efficacy of transpedal MR lymphangiography was calculated by using radiographic lymphangiography as the reference standard. Results Twenty-five patients (mean age, 54 years ± 18 [standard deviation]; 13 men) were evaluated. Eight percent (two of 25) of examinations failed (lymphoma in one patient and technical failure in one patient). Contrast agent injection was well tolerated without complications. Interrater agreement of image quality was excellent (κ = 0.96). The degree of CLS visualization correlated with overall image quality (ρ = 0.71; P < .001). Retroperitoneal lymphatics, cisterna chyli, and thoracic duct were viewed with an accuracy of 23 of 25 (92%), 24 of 25 (96%), and 23 of 25 (92%), respectively. Anatomic variations, a lymphatic pathologic abnormality, and interventional access routes were identified with an accuracy of 22 of 25 (88%), 23 of 25 (92%), and 24 of 25 (96%), respectively. Overall, 23 of 25 (92%) transpedal MR lymphangiograms provided clinically useful information. Conclusion Transpedal interstitial MR lymphangiography was well tolerated by the patient and identified specific pathologic abnormalities causing thoracic chylous leakages before lymphatic intervention. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Maki and Itkin in this issue.

Contemporary lymphatic interventions for post-operative lymphatic leaks

Post-operative lymphatic injuries are uncommon but increase morbidity and mortality in vulnerable patient populations. Post-surgical lymphatic leaks are most commonly a consequence of radical neck dissection, esophagectomy, and lung cancer resections or retroperitoneal surgeries such as radical nephrectomy and lymphadenectomy. Injury may occur anywhere along the lymphatic chains with most serious leaks occurring along the axial skeleton between the inguinal region and the left venous angle. The resultant clinical manifestations of a lymphatic leak are dependent on the location and severity of the lymphatic injury as well as patient factors. Treatment strategies are tailored toward the causative etiology, symptom severity, and daily leak volume with higher volume leaks warranting a more aggressive approach. Lymphangiography and lymphatic interventions, such as embolization, are increasingly applied for both the diagnosis and as a minimally invasive therapy for lymphatic injuries. Herein, a review of lymphatic anatomy, lymphangiography, and lymphatic interventions for the treatment of post-operative chylothorax, chylous ascites, and lymphocele is presented.

An uncommon therapeutic option for a challenging cause of pleural effusion

A 33-year-old nonsmoking Vietnamese man, without any past medical history was evaluated in another hospital in September 2018 for rapidly progressive shortness of breath. The chest radiograph showed a right pleural effusion. A thoracentesis was performed. On gross examination, the appearance of the pleural fluid was milky.

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Experiences in the treatment of refractory chylothorax associated with lymphoproliferative disorders

BACKGROUND

Chylothorax is a rare condition which can be associated with malignant lymphoproliferative disorders (LPDs). We retrospectively analyzed the results of the conservative treatment of 10 patients with persistent non-traumatic malignant chylothorax.

RESULTS

Conservative treatment lead to a decline of chylothorax after mean of 66 days and consisted of the treatment of the underlying disease and of simultaneous long-term supportive care (drainage of the thoracic cavity, dietary measures and nutrition management). In most cases (80%), chylothorax disappeared only after a successful therapeutic response of the underlying disease. Low-dose radiotherapy had very good effects in two patients.

CONCLUSION

Conservative treatment of malignant chylothorax can be considered a suitable method. Based on our results, successful treatment of the lymphoproliferative disorder seems to be a very important factor for the disappearance of chylothorax.

In Vitro Evaluation of the Polymerization Properties of N-Butyl Cyanoacrylate/Iodized Oil Mixtures for Lymphatic Interventions

PURPOSE

To evaluate polymerization of N-butyl cyanoacrylate (NBCA)/iodized oil mixtures for lymphatic interventions in vitro.

MATERIALS AND METHODS

Polymerization times of different NBCA/iodized oil mixtures (ratios of 1:0-1:7) were investigated in a static and dynamic experimental setup (performed in a lymph flow model in a silicone tube). Eight lymphatic samples with different triglyceride (TG) concentrations (low TGs, < 50 mg/dL; medium TGs, approximately 100-400 mg/dL; high TGs, > 700 mg/dL) were investigated. Morphologic changes during NBCA polymerization were monitored and recorded by video. Statistical analysis was performed with intergroup comparisons (Kruskal-Wallis test) and multiple regression analysis.

RESULTS

Static experiments showed increasing polymerization times with increasing concentrations of iodized oil as well as increasing concentrations of TGs. In the low-TG group, polymerization time increased from 14 s at a 1:1 ratio of NBCA to iodized oil to 1,336 s at a 1:7 ratio; times in the medium-TG group increased from 21 s (1:1) to 2,546 s (1:7), and those in the high TG group increased from 168 s (1:1) to 16,530 s (1:7). In dynamic experiments, prolongation of polymerization time was less pronounced. For low- and medium-TG groups, total occlusion of the silicon tube was observed in all cases during the embolization procedure at between 26 seconds (1:1 ratio) and 52 seconds (1:7). In the high-TG group, polymerization took considerably longer (between 43 s [1:1] and 467 s [1:7]) or failed completely.

CONCLUSIONS

Polymerization time of NBCA/iodized oil in lymph seems to be prolonged by increasing iodized oil and TG concentrations.

Lymphatic imaging and intervention in a pediatric population: Anesthetic considerations

The recent adoption of an improved lymphatic access technique coupled with Dynamic Contrast-enhanced Magnetic Resonance Lymphangiography has introduced the ability to diagnose and treat severe lymphatic disorders unresponsive to other therapies. All pediatric patients presenting for lymphatic procedures require general anesthesia presenting challenges in managing highly morbid and comorbid conditions both from logistical as well as medical aspects. General anesthesia is used because of the procedural requirement for immobility to accurately place needles and catheters, treat pain secondary to contrast and glue injections, and to accommodate additional procedures. We reviewed a one-year cohort of all pediatric patients in a newly created Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for lymphatic procedures. The patients ranged in age from 4 days to 17 years and weighed from 2.5 to 92 kg. There were 106 anesthetics for 68 patients. Patients were functionally impaired (98% ASA 3 or 4) and included significant comorbidities (79.4%). Concurrent with lymphatic imaging and intervention additional procedures were frequently performed (76%). They included cardiac catheterization, bronchoscopy, endoscopy, and drain placement (thoracic or abdominal). Paralysis and controlled ventilation was used for all interventions. Reversal of paralysis and tracheal extubation occurred in all patients not previously managed by invasive respiratory support. All patients having an intervention were admitted to intensive care for observation where escalation of care or complications (fever, hypotension, bleeding, or stroke) occurred in 25% in the first 24 hours.

Thoracic Duct Embolization: Analysis of Practice Patterns

BACKGROUND

Thoracic duct embolization (TDE) has become the standard treatment for atraumatic and traumatic chylothoraces. Numerous approaches to embolization including intranodal lymphangiography, transabdominal, and retrograde catheterization of the thoracic duct have become the preferred methods for the treatment of chyle leaks. The purpose of this study was to determine training, treatment techniques, outcomes, and practice patterns of practitioners performing TDE.

METHODS

From September to October of 2017, a 34-question survey focusing on training, treatment techniques, outcomes, and practice patterns of TDE was distributed through the Open Forum of the Society of Interventional Radiology Connect website. Fifty-four practitioners completed the entire survey. Percentages were calculated for answers to the questions. Chi-squared analysis was performed, comparing data from academic center respondents, private practice settings, and hybrid practice settings. P values < 0.5 were considered statistically significant.

RESULTS

All responses were from interventional radiologists. Forty-seven practitioners (87.0%) performed TDE in the United States, and 1 performed (1.9%) abroad; 6 practitioners (11.1%) did not perform TDE. Of all, 88.9% (n = 48) performed TDE in academic (n = 24; 50%), private (n = 17; 35.4%), or hybrid (n = 6; 12.5%) practice settings. For diagnostic lymphangiography, 100% (n = 48) performed intranodal pelvic lymphangiography. A 25-gauge needle was used by 77.1% (n = 37) to access pelvic lymph nodes, and most (83.3%; n = 40) reported using manual hand injection to administer ethiodized oil. Nine of 24 (37.5%) respondents in academic practice and 15 of 23 (65.2%) in private practice were successful in cannulating the thoracic duct >80% of the time. Most referrals were from thoracic surgery (n = 47; 97.9%).

CONCLUSIONS

TDE is performed by practitioners in both academic and private practice settings. Treatment techniques were similar for a majority of operators. Technical success rates were higher in private practice. Most referrals were from thoracic surgery.

Lymphatic Interventions for Chylothorax: A Systematic Review and Meta-Analysis

PURPOSE

To perform a systematic review and meta-analysis of published studies to evaluate the efficacy of lymphatic interventions for chylothorax.

MATERIALS AND METHODS

The MEDLINE, EMBASE, and Cochrane databases were searched for English-language studies until March 2017 that included patients with chylothorax treated with lymphangiography (LAG), thoracic duct embolization (TDE), or thoracic duct disruption (TDD). Exclusion criteria were as follows: a sample size of less than 10 patients, no extractable data, or data included in subsequent articles or duplicate reports.

RESULTS

The cases of 407 patients from 9 studies were evaluated. The pooled technical success rates of LAG and TDE were 94.2% (95% confidence interval [CI], 88.4%-97.2%; I² = 46.7%) and 63.1% (95% CI, 55.4%-70.2%; I² = 37.3%), respectively. The pooled clinical success rates of LAG, TDE, and TDD, on a per-protocol basis, were 56.6% (95% CI, 45.4%-67.2%; I² = 5.4%), 79.4% (95% CI, 64.8%-89.0%; I² = 68.1%), and 60.8% (95% CI, 49.4%-71.2%; I² = 0%), respectively. The pooled major complication rate of LAG and TDE was 1.9% (95% CI, 0.8%-4.3%; I² = 0%) and 2.4% (95% CI, 0.9%-6.6%; I² = 26.4%), respectively. The pooled overall clinical success rate of lymphatic interventions, on an intention-to-treat basis, was 60.1% (95% CI, 52.1%-67.7%; I² = 54.3%). Etiology of chylothorax was identified as a significant source of heterogeneity for the pooled clinical success rate of TDE and overall clinical success rate.

CONCLUSIONS

Lymphatic interventions have a respectable efficacy for the treatment of chylothorax.

Localization of thoracic duct using heavily T2W MRI for intractable post-esophagectomy chylothorax-a case report

Post-esophagectomy chylothorax is a rare yet serious complication. Herein we report the case of a patient with intractable post-esophagectomy chylothorax despite medical treatment with total parenteral nutrition and octreotide, as well as prophylactic and repeated thoracic duct mass ligation. The patient was eventually treated with localization of thoracic duct using T2-weighted magnetic resonance imaging (T2W MRI), followed by video-assisted thoracoscopic thoracic duct ligation.

Usefulness of CBCT and guidance software for percutaneous embolization of a lymphatic leakage after thyroidectomy for cancer

Lymphatic leakage can develop as an iatrogenic complication of thoracic, cardiac, and neck surgery. The management of this complication may be challenging and involves more specialists. Percutaneous, image-guided techniques may offer two advantages: mini-invasivity and ability to image and identify the anatomy and the site of the leakage. We report a case of refractory cervical chylous leakage after thyroidectomy and lymphadenectomy for cancer that was successfully treated with an ultrasound-guided intranodal lymphangiography and a percutaneous puncture of the leak performed using CBCT as imaging guidance.

Chlyous leak after radical oesophagectomy: Thoracic duct lymphangiography and embolisation (TDE)-A case report

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An unrecognised iatrogenic thoracic duct chyle leak carries significant morbidity and mortality.

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A case of chylothorax post oesophagectomy, treated by interventional radiology, is described.

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Lymphangiography identified aberrant thoracic ductal anatomy.

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Coiling and embolization following ductal injury is safe, effective and less morbid procedure.

Introduction

Chyle leak after oesophagectomy is highly morbid and may carry significant mortality if treatment is delayed. Identification of the site of leakage and surgery may be plagued by failure.

Presentation of case

We describe a case of chyle leak after oesophagectomy. Lymphangiography revealed the site of chyle leak to be an aberrant duct that would have been difficult to identify surgically. Radiological coiling and embolization successfully treated the leak.

Discussion

The gold standard for treatment of chyle leak or chylothorax after oesophagectomy was a re-operation, either open or throracoscopic, to ligate the thoracic duct. The interventional radiological technique employed in our case was not only efficacious in stopping the leak, but had the added advantage of identifying the site and highlighting the anatomy hence avoiding a morbid reoperation. The literature is reviewed.

Conclusion

The report and review confirm that lymphangiography followed by coiling and embolization for chylothorax post oesophagectomy is safe and effective in a majority of cases.

Nutritional support in adults with chyle leaks

We provide a practical approach to the complex management problem of chyle leaks that occur after surgical procedures or trauma, or when they occur spontaneously in association with malignancies. The volume of chyle loss causes significant problems due to loss of fluid, electrolytes, proteins, and lymphocytes, causing deleterious effects on wound healing and immunity. Enteral feeding is not always possible as long chain fatty acids are absorbed through the intestinal lacteals, the original source of chyle. Regular diets increase the leak and delay healing. Nutritional support involves coordinated care between healthcare providers to provide a combination of various modalities, including nil by mouth, parenteral nutrition, enteral feeding with formula modifications, and oral diet.

Lymphangiography to treat postoperative lymphatic leakage: a technical review

In addition to imaging the lymphatics and detecting various types of lymphatic leakage, lymphangiography is a therapeutic option for patients with chylothorax, chylous ascites, and lymphatic fistula. Percutaneous thoracic duct embolization, transabdominal catheterization of the cisterna chyli or thoracic duct, and subsequent embolization of the thoracic duct is an alternative to surgical ligation of the thoracic duct. In this pictorial review, we present the detailed technique, clinical applications, and complications of lymphangiography and thoracic duct embolization.