PO-04-059 THORACIC DUCT LEAK AFTER DEFIBRILLATOR IMPLANTATION

Abstract

Device implantation is a relatively low-risk procedure, however generator pocket complications can still occur. In this case, the device site was complicated by a thoracic duct chylous extravasation leading to lymphatic drainage into a device pocket. Case Report A 55-year-old male with ischemic congestive heart failure and reduced ejection fraction of 30-35% and left bundle branch block >150 milliseconds presented several months after cardiac resynchronization therapy-defibrillation (CRT-D) implantation with device site swelling. The physical exam was notable for an extremely swollen left arm consistent with lymphedema. This swelling slowly enlarged for the past 6 months after implantation. Concern was for device site complication with a slowly evolving hematoma that caused compressive lymph stasis. Decision was made for device extraction and reimplantation. Pictured below (Figure 1) shows that the device pocket actually was filled with lymphatic fluid. Upon further investigation, the thoracic duct was either damaged or obstructed and likely the culprit. The pocket was then evacuated with subsequent device extraction and reimplantation. No immediate complications were noted. Upon follow-up, the device site was normal, and left arm lymphedema was resolved. This case demonstrates a rare complication of device implantation that does not appear to be reported in our literature search. Typically hematoma, infection, erosion, migration, and Twiddler’s Syndrome are the most common complications in device pockets. The thoracic duct typically runs from the superior aspect of the cisterna chyli which is situated at the L2 vertebrae and runs to the lower cervical spine. Termination in 95% of patients are either the internal jugular vein, subclavian vein, or the angle between them. However, termination is typically posterior without a superficial course. Lymphatic obstruction tends to be late presenting and can be easily confused with venous obstruction leading to delays in care. Management of lymphatic drainage usually is removing the obstructive source, however, a low fat diet has shown benefit. Thoracic duct complications in device implantation are rare but can lead to delayed treatment and repeat procedures. Further investigation into such cases may be warranted.