Long-Term Survival Following Inadvertent Transplant Lung Venous and Pleural Migration of Lipiodol after Attempted Embolization for Post-Lung Transplant (Ltx) Chylothorax

Abstract

<h3>Introduction</h3> Chylothorax is a rare complication after LTx resolving in a minority of cases with non-surgical management, primarily tube drainage, low-fat or parenteral nutrition and somatostatin analogues. In refractory chylothorax, surgical ligation and thoracic duct embolization have been used.¹ Thoracic duct embolization has been effectively undertaken with varying combinations of alcohol, coiling, glue or lipiodol (iodinated poppy seed oil).^2-3 Lipiodol is theorised to cause intraluminal inflammation and duct closure. Previous cases have reported profound lung injury with pulmonary embolization.^2,4-5 <h3>Case Report</h3> A 67-year-old woman underwent a left single LTx for Chronic Obstructive Pulmonary Disease. Her post-LTx course was complicated by acute kidney injury and pulmonary venous congestion with high chest drain output. 7 days post-LTx, a persistent chyle leak was noted. Failing medical management, methylene guided lymphangiography deployed 30ml lipiodol and alcohol into the cisterna chyli. Unfortunately, on subsequent imaging lipiodol had accumulated in the pleural space and the interstitium of the LTx with spread to the retrocural space and thoracic inlet (Fig. 1A). The patient remained in ICU for 3-weeks, requiring slow wean of invasive ventilation via tracheostomy. Despite initial concerns of permanent lung fibrosis post-lipiodol, there was progressive resorption over the next month. The patient was decannulated and discharged home without supplemental oxygen (Fig. 1B). She achieved her peak lung function 1 year following LTx (FEV1 50%, FVC 42%). Complete radiological clearance of lipiodol was noted at 3 years (Fig. 1C). She remains alive with stable Chronic Lung Allograft Dysfunction (FEV1 20%) 11 years following LTx with no recurrent pleural effusions. <h3>Summary</h3> This case shows long-term single LTx survival despite lipiodol escape during attempted embolization without development of fibrosis.