Thoracic Duct Embolization for Chylous Leaks

 

 Buy Article Permissions and Reprints

ABSTRACT

Chylous leaks, such as chylothorax and chylopericardium, are uncommon effusions resulting from the leakage of intestinal lymphatic fluid from the thoracic duct (TD) and its tributaries, or intestinal lymphatic ducts. The cause can be either traumatic (thoracic surgery) or nontraumatic (idiopathic, malignancy). Treatment has traditionally consisted of dietary modification (nonfat diet) and/or surgery (TD ligation, pleurodesis). Thoracic duct embolization (TDE) has become a viable treatment alternative due to it high success rate and minimal complications. In this article, the authors describe the etiologies of chylothorax, patient population, outcomes, and long-term follow-up of TDE patients. Relevant lymphatic anatomy and physiology are reviewed, with special attention paid to the formation of the duct by tributaries at the cisterna chyli (CC). The technique of TDE is outlined, including bilateral pedal lymphangiography, TD cannulation, and embolic agents used for the procedure.

REFERENCES

• 1 Dunn R P. Primary chylopericardium: a review of the literature and an illustrated case.  Am Heart J. 1975;  89 (3) 369-377
  CrossrefPubMedGoogle Scholar
• 2 Itkin M, Swe N M, Shapiro S E, Shrager J B. Spontaneous chylopericardium: delineation of the underlying anatomic pathology by CT lymphangiography.  Ann Thorac Surg. 2009;  87 (5) 1595-1597
  CrossrefPubMedGoogle Scholar
• 3 Doerr C H, Allen M S, Nichols III F C, Ryu J H. Etiology of chylothorax in 203 patients.  Mayo Clin Proc. 2005;  80 (7) 867-870
  CrossrefPubMedGoogle Scholar
• 4 Cerfolio R J, Allen M S, Deschamps C, Trastek V F, Pairolero P C. Postoperative chylothorax.  J Thorac Cardiovasc Surg. 1996;  112 (5) 1361-1365 discussion 1365-1366
  CrossrefPubMedGoogle Scholar
• 5 Dougenis D, Walker W S, Cameron E W, Walbaum P R. Management of chylothorax complicating extensive esophageal resection.  Surg Gynecol Obstet. 1992;  174 (6) 501-506
  PubMedGoogle Scholar
• 6 Romero S. Nontraumatic chylothorax.  Curr Opin Pulm Med. 2000;  6 (4) 287-291
  CrossrefPubMedGoogle Scholar
• 7 Itkin M, Kucharczuk J C. Thoracic duct embolization (TDE) for non-traumatic chylous effusion: Experience in 31 patients.  Chest. 2010;  138 (4, Suppl) 654A
  CrossrefPubMedGoogle Scholar
• 8 Marts B C, Naunheim K S, Fiore A C, Pennington D G. Conservative versus surgical management of chylothorax.  Am J Surg. 1992;  164 (5) 532-534 discussion 534-535
  CrossrefPubMedGoogle Scholar
• 9 Christodoulou M, Ris H B, Pezzetta E. Video-assisted right supradiaphragmatic thoracic duct ligation for non-traumatic recurrent chylothorax.  Eur J Cardiothorac Surg. 2006;  29 (5) 810-814
  CrossrefPubMedGoogle Scholar
• 10 Thompson K J, Kernstine K H, Grannis Jr F W, Mojica P, Falabella A. Treatment of chylothorax by robotic thoracic duct ligation.  Ann Thorac Surg. 2008;  85 (1) 334-336
  CrossrefPubMedGoogle Scholar
• 11 Bolger C, Walsh T N, Tanner W A, Keeling P, Hennessy T P. Chylothorax after oesophagectomy.  Br J Surg. 1991;  78 (5) 587-588
  CrossrefPubMedGoogle Scholar
• 12 Orringer M B, Bluett M, Deeb G M. Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy.  Surgery. 1988;  104 (4) 720-726
  PubMedGoogle Scholar
• 13 Cope C, Kaiser L R. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients.  J Vasc Interv Radiol. 2002;  13 (11) 1139-1148
  CrossrefPubMedGoogle Scholar
• 14 Itkin M, Kucharczuk J C, Kwak A, Trerotola S O, Kaiser L R. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients.  J Thorac Cardiovasc Surg. 2010;  139 (3) 584-589 discussion 589-590
  CrossrefPubMedGoogle Scholar
• 15 Cope C. Percutaneous thoracic duct cannulation: feasibility study in swine.  J Vasc Interv Radiol. 1995;  6 (4) 559-564
  CrossrefPubMedGoogle Scholar
• 16 Cope C. Percutaneous transabdominal embolization of thoracic duct lacerations in animals.  J Vasc Interv Radiol. 1996;  7 (5) 725-731
  CrossrefPubMedGoogle Scholar
• 17 Cope C. Diagnosis and treatment of postoperative chyle leakage via percutaneous transabdominal catheterization of the cisterna chyli: a preliminary study.  J Vasc Interv Radiol. 1998;  9 (5) 727-734
  CrossrefPubMedGoogle Scholar
• 18 Cope C, Salem R, Kaiser L R. Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial.  J Vasc Interv Radiol. 1999;  10 (9) 1248-1254
  CrossrefPubMedGoogle Scholar
• 19 Bonn J, Sperling D, Walinsky P, Mannion J. Percutaneous embolization of thoracic duct injury.  Circulation. 2000;  102 (2) 268-269
  PubMedGoogle Scholar
• 20 Schild H, Hirner A. Percutaneous translymphatic thoracic duct embolization for treatment of chylothorax.  Rofo. 2001;  173 (7) 580-582
  Article in Thieme ConnectPubMedGoogle Scholar
• 21 Choo J C, Foley P T, Lyon S M. Percutaneous management of high-output chylothorax: case reviews.  Cardiovasc Intervent Radiol. 2009;  32 (4) 828-832
  CrossrefPubMedGoogle Scholar
• 22 Bierman H R, Byron Jr R L, Kelly K H et al.. The characteristics of thoracic duct lymph in man.  J Clin Invest. 1953;  32 (7) 637-649
  CrossrefPubMedGoogle Scholar
• 23 Dumont A E, Mulholland J H. Flow rate and composition of thoracic-duct lymph in patients with cirrhosis.  N Engl J Med. 1960;  263 471-474
  CrossrefPubMedGoogle Scholar
• 24 Ludwig J, Linhart P, Baggenstoss A H. Hepatic lymph drainage in cirrhosis and congestive heart failure. A postmortem lymphangiographic study.  Arch Pathol. 1968;  86 (5) 551-562
  PubMedGoogle Scholar
• 25 Verma S K, Mitchell D G, Bergin D et al.. Dilated cisternae chyli: a sign of uncompensated cirrhosis at MR imaging.  Abdom Imaging. 2009;  34 (2) 211-216
  CrossrefPubMedGoogle Scholar
• 26 Agur AMR, Dalley A F, Grant JCB. Grant's Atlas of Anatomy. 11th ed. Philadelphia: Lippincott Williams & Wilkins; 2005
  Google Scholar
• 27 Skandalakis J E, Skandalakis L J, Skandalakis P N. Anatomy of the lymphatics.  Surg Oncol Clin N Am. 2007;  16 (1) 1-16
  CrossrefPubMedGoogle Scholar
• 28 Adachi B. Der Ductus Thoracicus der Japane. In Das Lymphgefässsystem der Japaner. Tokyo: Kenkyusha; 1953
  Google Scholar
• 29 Okuda I, Udagawa H, Takahashi J, Yamase H, Kohno T, Nakajima Y. Magnetic resonance-thoracic ductography: imaging aid for thoracic surgery and thoracic duct depiction based on embryological considerations.  Gen Thorac Cardiovasc Surg. 2009;  57 (12) 640-646
  CrossrefPubMedGoogle Scholar
• 30 Kausel H W, Reeve T S, Stein A A, Alley R D, Stranahan A. Anatomic and pathologic studies of the thoracic duct.  J Thorac Surg. 1957;  34 (5) 631-641
  PubMedGoogle Scholar
• 31 Browse N L, Burnand K G, Mortimer P. Diseases of the Lymphatics. London/New York: Arnold/Oxford University Press; 2003
  Google Scholar
• 32 Kurosaki Y, Fujikawa A. Left-sided cisterna chyli.  AJR Am J Roentgenol. 2000;  175 (5) 1462
  PubMedGoogle Scholar
• 33 Pomerantz M, Herdt J R, Rockoff S D, Ketcham A S. Evaluation of the functional anatomy of the thoracic duct by lymphangiography.  J Thorac Cardiovasc Surg. 1963;  46 568-575
  PubMedGoogle Scholar
• 34 Rosenberger A, Adler O, Abrams H L. The thoracic duct: structural, functional, and radiologic aspects.  CRC Crit Rev Radiol Sci. 1972;  3 (4) 523-541
  PubMedGoogle Scholar
• 35 Erden A, Fitoz S, Yagmurlu B, Erden I. Abdominal confluence of lymph trunks: detectability and morphology on heavily T2-weighted images. Abstracts of the 105th Annual Meeting of the American Roentgen Ray Society. May 15-20, 2005, New Orleans, Louisiana, USA.  AJR Am J Roentgenol. 2005;  184 (4, Suppl) 1
  PubMedGoogle Scholar
• 36 Loukas M, Wartmann C T, Louis Jr R G et al.. Cisterna chyli: a detailed anatomic investigation.  Clin Anat. 2007;  20 (6) 683-688
  CrossrefPubMedGoogle Scholar
• 37 Plotnik A N, Foley P T, Koukounaras J, Lyon S M. How I do it: Lymphangiography.  J Med Imaging Radiat Oncol. 2010;  54 (1) 43-46
  CrossrefPubMedGoogle Scholar
• 38 Guermazi A, Brice P, Hennequin C, Sarfati E. Lymphography: an old technique retains its usefulness.  Radiographics. 2003;  23 (6) 1541-1558 discussion 1559-1560
  CrossrefPubMedGoogle Scholar
• 39 Binkert C A, Yucel E K, Davison B D, Sugarbaker D J, Baum R A. Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique.  J Vasc Interv Radiol. 2005;  16 (9) 1257-1262
  CrossrefPubMedGoogle Scholar
• 40 Matsumoto T, Yamagami T, Kato T et al.. The effectiveness of lymphangiography as a treatment method for various chyle leakages.  Br J Radiol. 2009;  82 (976) 286-290
  CrossrefPubMedGoogle Scholar
• 41 Maldonado F, Cartin-Ceba R, Hawkins F J, Ryu J H. Medical and surgical management of chylothorax and associated outcomes.  Am J Med Sci. 2010;  339 (4) 314-318
  CrossrefPubMedGoogle Scholar
• 42 Abbes M, Juillard G. Study of 27 lymphovenous communications observed by lymphography in man.  Ann Radiol (Paris). 1969;  12 (1) 107-115
  PubMedGoogle Scholar
• 43 Edwards J M, Kinmonth J B. Lymphovenous shunts in man.  BMJ. 1969;  4 (5683) 579-581
  CrossrefPubMedGoogle Scholar
• 44 Laslett D, Itkin M. Delayed complications following technically successful thoracic duct embolization (TDE). Paper presented at: Society of Interventional Radiology. 2011. Chicago. 
  PubMedGoogle Scholar

Maxim Itkin M.D. 

Division of Interventional Radiology, Hospital of the University of Pennsylvania

3400 Spruce Street, Philadelphia, PA 19004

Email: itkinmax@uphs.upenn.edu