Percutaneous Thoracic Duct Embolization Research Articles

Novel Use of Obsidio Conformable Embolic in Thoracic Duct Embolization

AbstractChylothorax is a potentially serious condition resulting from thoracic duct injury. When chyle output remains high despite medical management, invasive interventions such as surgical ligation or percutaneous thoracic duct embolization (TDE) may be necessary. Obsidio is a novel conformable embolic agent that shares properties of both coil and liquid embolic agents. A 37-year-old man presented with left-sided chylothorax, refractory to medical management, following a high-speed motorcycle collision. The thoracic duct was successfully embolized using Obsidio placed between coil packs with fibered coils. This case report demonstrates the first successful use of Obsidio for TDE in a patient with traumatic chylothorax.

Imaging and Interventions for Lymphatic and Lymphatic-related Disorders.

The lymphatic system is critical in fluid balance homeostasis. Yet, until recently, lymphatic imaging has been outside of mainstream medicine due to a lack of robust imaging and interventional options. However, during the last 20 years, both clinical lymphatic imaging and interventions have shown dramatic advancement. The key to imaging advancement has been the interstitial delivery of contrast agents through lymphatic-rich tissues. These techniques include intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography. These methods provide the ability to image and recognize lymphatic anatomy and pathologic conditions. Percutaneous thoracic duct catheterization and embolization became the first widely accepted interventional technique for the management of chyle leaks. Advances in interstitial lymphatic embolization, as well as liver and mesenteric lymphatic interventions, have broadened the scope of possible lymphatic interventions. Also, recent techniques of lymphatic decompression allow for the treatment of a variety of lymphatic disorders. Finally, immunologic studies of central lymphatic fluid reveal the potential of lymphatic interventions on immunity. These advances herald an exciting new chapter for lymphatic imaging and interventions in the coming years.

Feasibility study of percutaneous thoracic duct embolization with lower-limb intermittent pneumatic compression devices

To demonstrate intranodal thoracic duct embolization (TDE) for treating chyle leaks following thoracic surgery and the feasibility of applying lower-limb intermittent pneumatic compression devices during TDE. Between December 2017 and October 2020, 12 consecutive TDEs for post-operative chyle leaks were performed in 11 patients using intranodal lymphangiogram (IL) with an intermittent pneumatic compressive device applied to the lower limb. The procedure's duration, technical/clinical success, and complications were retrospectively evaluated. IL was successful at imaging the thoracic duct in all procedures (100%), and TDE had an intention- to-treat success rate of 92% (11/12). No related complications were observed during follow-up, which took place at a mean of 27 days. The time from the commencement of lymphangiogram until visualization of the thoracic duct was a mean of 21.6 min, and the mean overall procedure time was 87.3 min. This study supports IL-guided TDE as a safe and effective option to treat post-thoracic surgery chyle leaks. We revealed shorter lymphangiogram times compared with previously published studies, and we postulate that the application of intermittent lower-limb pneumatic compressive devices contributed toward this study's results by expediting the return of lymph from the lower limb. This study is the first to illustrate this approach in TDE and advocates for randomized controlled studies to further evaluate the influence of intermittent pneumatic compressive devices on the procedure.

First successful case of percutaneous transabdominal thoracic duct embolization (PTTDE) for chylous ascites resulting from laparoscopic gastric cancer surgery

A 61-year-old woman underwent laparoscopy-assisted distal gastrectomy (LADG) with extragastric lymph node dissection (D2). Two months later, she was readmitted to hospital to be treated for chylous ascites. Oral intake was discontinued and total parenteral nutrition started, but increasing body weight and decreasing serum albumin concentration was not controllable. Percutaneous transabdominal thoracic duct embolization (PTTDE) was performed on the 8th day after the readmission. Five days after PTTDE, oral intake was resumed. Seventeen days after PTTDE, the patient was discharged without recurrence of ascites. She has remained asymptomatic. We describe here the first patient with chylous ascites two months after LADG with D2 dissection for early gastric cancer who was successfully treated by PTTDE.

A medical epopee: recurrent fungal endocarditis, heart transplantation and chylopericardium

BackgroundCandida prosthetic endocarditis is associated with high mortality rates and valve replacement surgery, together with antifungal treatment, play a major role in eradicating the fungal infection.Valve reoperations in these scenarios may be relatively common due to the high infection relapse rates and, in some cases, heart transplantation may be an imposing therapy for infection resolution and for the heart failure related to the myocardial reoperation injury. Among the many postoperative complications related to heart transplantation, chylopericardium is a rare but challenging example.Case presentationWe report the case of a 55-year-old man who was admitted to our hospital with a 1-month history of progressive dyspnea and fatigue. His past medical history included four open-heart surgeries for aortic and mitral valve replacement due to recurrent Candida parapsilosis infective endocarditis. Transthoracic echocardiogram showed a markedly reduced left ventricular systolic function and normofunctioning bioprosthetic valves. An inotropic dependency condition led to heart transplantation surgery. In the early postoperative period, a persistent chylous fluid started to drain from the pericardial tube, compatible with the diagnosis of chylopericardium. The lack of clinical response to total parenteral nutrition and intravenous infusion of octreotide imposed the need of interventional radiology with diagnostic lymphography through cisterna chyli puncture and thoracic duct catheterization, confirming the presence of a lymphatic fistula. A successful treatment outcome was achieved with percutaneous thoracic duct embolization using coils and n-butyl-cyanoacrilate glue, possibiliting hospital discharge.ConclusionsFungal endocarditis requires combined treatment (surgical and antimicrobial) for eradication. Valve replacement, while necessary, may lead to severe ventricular deterioration and heart transplantation may be the only viable therapeutic solution. Among the several postoperative complications of heart transplantation, chylopericardium is an uncommon and defiant example. Advances in interventional radiology like the percutaneous embolization allow a less invasive and highly efficient approach for this complication.

Utility of planning MRI in percutaneous thoracic duct embolization for chylothorax

PurposePercutaneous 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 methodsMRI 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. ResultsPresence 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. ConclusionsIdentification 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.

Lymphovenous Anastomosis for the Treatment of Chylothorax in Infants: A Novel Microsurgical Approach to a Devastating Problem

Therapeutic, V.

Magnetic Resonance Lymphangiography and Lymphatic Embolization in the Treatment of Pulmonary Complication of Lymphatic Malformation.

Lymphatic malformations (LMs; especially those involving the central conducting lymphatic channels) are characterized by dysplastic and incompetent lymphatic channels in multiple tissues and organs. The major cause of mortality and morbidity in patients with thoracic LM is deterioration of pulmonary function due to chronic chylous effusions and progressive interstitial lung disease. The etiology of these pulmonary processes is unknown, although lymphatic involvement is certain. Understanding of the changes in the lymphatic anatomy in patients with LM has been hindered by difficulty of imaging of the lymphatic system. Recently developed dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) allows dynamic MR imaging of the lymphatic system by injecting gadolinium contrast agent in the groin lymph nodes. Using this technique, pathological lymphatic flow from the central lymphatic system and/or retroperitoneal and mediastinal masses into lung parenchyma ("pulmonary lymphatic perfusion syndrome") has been demonstrated in patients with LM. This abnormal lymphatic perfusion overflows pulmonary parenchyma and results in deterioration of pulmonary function due to interstitial process and/or compression effect of chylous effusions. Percutaneous thoracic duct embolization or lymphatic interstitial embolization of the lymphatic masses results in cessation of the pulmonary lymphatic overflow and significant improvement in pulmonary symptoms in these patients.

全弓部大動脈置換術後乳糜胸に対して経皮的胸管塞栓術を行った1例

症例は70歳男性．CTで指摘された最大径55 mmの遠位弓部大動脈瘤に対して胸骨正中切開で全弓部大動脈置換術を行った．術翌日より左胸腔ドレーンが白濁し量が増え乳糜胸と診断した．保存的治療として絶食，オクトレオタイドの皮下注射を19日間行ったが改善しなかったため経皮的胸管塞栓術を行った．術当日より食事を開始したがドレーンからの排液は減少し経過良好で術後49日目に退院することができた．

Abstract No. 462 - Lymphatic intervention for various kinds of lymphorrhea

tion has been shown to be effective in the treatment of recurrent chylous effusions. Many embolic agents have been described in the successful occlusion of the thoracic duct. In this study, we evaluate the role and efficacy of using EVOH copolymer (Onyx) in the treatment of traumatic chylous pleural effusions. Background: A retrospective review was performed of consecutive patients with post-operative chylous pleural effusions treated with thoracic duct embolization using EVOH copolymer at a single institution from 2012-2014. Demographic data, surgical history, procedure details, and toxicities were systematically reviewed. Clinical Findings/Procedure Details: 4 patients (M1⁄42) were identified that met inclusion criteria. Median age at treatment was 67. Median follow was 125 days (range 24-246). Two patients had undergone robotic assisted surgery and 2 had undergone open thoracotomy. 3 patients had thoracic duct ligation performed at the time of their initial surgery. Median time from surgery to embolization was 7 days (range 3-15). Daily chest tube drainage range was 150 -2000 ml. All patients underwent bilateral ultrasound guided inguinal nodal lymphangiogram. The thoracic duct was then accessed using a 21 or 22 gauge Chiba needle. A thoracic duct leak was identified in 3 patients. Coils were placed initially in the central duct prior to embolization of the leak limit potential systemic flow. Onyx 34 (ev3 Neurovascular, Irvine, California) was used in 4 patients with additional Onyx 18 in 1 patient for embolization. Volume used was 1-2 ml in all patients. All patients had resolution of the chylous effusion within 1 day of embolization. The subjects were discharged from the hospital between 4-7 days post-procedure. 30 days post-procedure complications included an abdominal wall hematoma in 1 patient who was subsequently started on anticoagulation. No patients developed recurrent chyle leaks during the follow up period. Conclusion and/or Teaching Points: EVOH copolymer is a safe and effective agent for percutaneous thoracic duct embolization. This is the largest reported series to date demonstrating the efficacy of this embolic agent in treating chylous effusions in the post-traumatic setting.

Chylothorax: Percutaneous Embolization of the Thoracic Duct

Thoracic duct embolization is a percutaneous, image-guided intervention used in the management of chylothorax. Chylothorax, or chylous leak in the chest, is a rare condition that represents a spectrum of disorders that have in common leakage of intestinal lymph (chyle) into the thorax. Although conservative and surgical management are the standard of care, we present an overview of lymphangiography and percutaneous thoracic duct embolization.

Abstract 17341: A 19-Year-Old Female with Recurrent Chylopericardium

A 19-year-old female initially presented to an outside hospital with worsening shortness of breath over the course of hours. Echocardiogram revealed a large pericardial effusion with tamponade physiology. An urgent pericardiocentesis followed by a pericardial window yielded 600cc of cloudy fluid, and work-up for infectious, auto-immune, and malignant etiologies was unrevealing. She was discharged home, but over the next four weeks developed a repeat pericardial effusion requiring another pericardiocentesis yielding 750cc of cloudy fluid. She then presented to our hospital two weeks later with progressive shortness of breath. Echocardiogram revealed a large pericardial effusion with evidence of early tamponade physiology. Our differential diagnosis for her recurrent pericardial effusions remained broad, with infectious and malignant etiologies at the top of consideration. Computed tomography of the chest demonstrated the pericardial effusion and mild mediastinal adenopathy. She underwent another pericardial window with removal of 600cc of milky fluid, and fluid analysis was notable for a markedly elevated triglyceride level consistent with a diagnosis of chylopericardium. Work-up for malignancy as an etiology for recurrent chylopericardium was negative. A percutaneous lymphangiogram was then performed, which revealed a significant leak in the superior aspect of the thoracic duct into the pericardial space. Percutaneous embolization of the thoracic duct was performed using detachable coils along with embolic glue, resulting in resolution of the leak. She has since remained asymptomatic, and follow-up echocardiogram was without recurrence of any pericardial effusion. This case of idiopathic recurrent chylopericardium as the cause for pericardial effusion represents a rare manifestation of a relatively common cardiac condition. It illustrates the importance of routine pericardial fluid analysis for triglycerides, as this led to her correct diagnosis of chylopericardium. The use of percutaneous thoracic duct embolization has only recently been reported as a novel approach for treatment of chylous leak, and may emerge as a useful alternative to surgery for recurrent chylopericardium.

Educational Exhibit Abstract No. 477 - An overview of ultrasound-guided transnodal lymphangiography with percutaneous thoracic duct embolization

Educational Exhibit Abstract No. 477 - An overview of ultrasound-guided transnodal lymphangiography with percutaneous thoracic duct embolization

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.

Treatment options in patients with chylothorax.

Chylothorax arises when lymphatic fluid (chyle) accumulates in the pleural cavity because of leakage from lymphatic vessels. It is most commonly seen after thoracic surgery (in 0.5% to 1% of cases) and in association with tumors. No prospective or randomized trials have yet been performed to evaluate the available treatment options. This review is based on a selective search of the PubMed database for pertinent publications from the years 1995 to 2013. Emphasis was laid on articles that enabled a comparative assessment of treatment options. Initial conservative treatment (e.g., parenteral nutrition or a special diet) succeeds in 20% to 80% of cases. When such treatment fails, the standard approach up to the present has been to treat surgically, e.g., with ligation of the thoracic duct, pleurodesis, or a pleuroperitoneal shunt. The success rates of such procedures have ranged from 25% to 95%. Most of the patients undergoing such procedures are severely ill; complication rates as high as 38% have been reported, with mortality as high as 25%. In more recent publications, however, morbidity and mortality were lower. Interventional radiological treatments, such as percutaneous thoracic duct embolization or the percutaneous destruction of lymphatic vessels, succeed in about 70% of cases and lead to healing in up to 80% of cases, even after unsuccessful surgery. The complication rate of percutaneous methods is roughly 3%. Interventional radiological procedures have now taken their place alongside conservative treatment and surgery in the management of chylothorax, although they are currently available in only a small number of centers.

Ultrasound‐guided intranodal lymphangiography followed by thoracic duct embolization for treatment of postoperative bilateral chylothorax

Percutaneous thoracic duct embolization (TDE) is a safe, effective, and minimally invasive option for treating chylothorax. A recent report demonstrated the feasibility of ultrasound-guided intranodal lymphangiography as an alternative to pedal lymphangiography for visualization of the thoracic duct, promising relative technical ease and decreased procedure time for TDE. We report a case of postoperative bilateral chylothorax treated with ultrasound-guided intranodal lymphangiography followed by TDE. Intranodal lymphangiography resulted in rapid opacification of the abdominal lymphatics, permitting technically successful primary and secondary embolization procedures. Deployment of metallic coils and liquid embolic agents within the thoracic duct produced rapid clinical and radiographic improvement. Intranodal lymphangiography is a reliable, reproducible, and less technically challenging alternative to pedal lymphangiography.

Bilateral Chylothorax After Severe Vomiting in a Child

In the etiology of chylothorax, traumas and malignancies are the first two leading causes. Today in pediatric patients, the most common cause of chylothorax includes the complications secondary to cardiothoracic operations. Bilateral chylothorax is rarely observed after severe vomiting leading to increase in intrathoracic pressure. In idiopathic chylothorax, bilateral localization is dominant. A 9-year-old girl who presented to our emergency department with the complaints of dyspnea and back pain following severe vomiting received a diagnosis of bilateral chylothorax. The patient was treated with the insertion of a bilateral chest tube, and pleurodesis was performed in left hemithorax. Examination did not reveal a pathology to this condition, except the vomiting observed 2 days previously after the meal.

Percutaneous Thoracic Duct Embolization as a Treatment for Intrathoracic Chyle Leaks in Infants

Chylothorax is an uncommon complication of cardiothoracic surgery in children that is traditionally treated with either conservative (diet modification, octreotide administration, and percutaneous drainage) or surgical (thoracic duct ligation, pleurodesis, and pleuroperitoneal shunt) approaches. We report here the cases of 2 children (a 6-month-old and a 1-month-old) with postoperative chylous leaks who were treated successfully by percutaneous thoracic duct embolization.

Bilateral traumatic chylothorax treated by thoracic duct embolization: A rare treatment for an uncommon problem

Prolonged chylothorax is a rare, life-threatening, pleural effusion that may be encountered in the setting of trauma. Conservative treatment may be successful and is the traditional approach in cases of limited chyle output. Early surgical intervention is required in cases with large refractory chyle output, but may be associated with substantial morbidity and mortality. Percutaneous thoracic duct embolization is an uncommon, minimally invasive, safe and effective treatment alternative. We report a case of successful thoracic duct embolization to treat large-volume chylothorax due to blunt trauma.

Recurrent chylothorax after neck surgery: Percutaneous thoracic duct embolization as primary treatment

Recurrent chylothorax after neck surgery: Percutaneous thoracic duct embolization as primary treatment