Thoracic Duct Embolization for Chylous Leaks

Chen, Eric; Itkin, Maxim

doi:10.1055/s-0031-1273941

Cited by 178 publications

(127 citation statements)

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“…6) Matsumoto et al stated that 89% of patients with postoperative chylothorax avoid surgical intervention after lymphography. 7) As an other percutaneous intervention, thoracic duct embolization was reported by Chen et al 8) A microcatheter is inserted into the thoracic duct and embolization of thoracic duct was achieved with microcoils and Truefill glue. We performed lipiodol lymphography in our patient and successfully treated his chylothorax, which was intractable for several already known conservative treatments.…”

Section: Discussionmentioning

confidence: 99%

Management of Aortic Replacement-Induced Chylothorax by Lipiodol Lymphography

Kuwabara

Yoshitake

Hachiya

et al. 2015

Annals of Vascular Diseases

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A 39-year-old man was admitted to our hospital for aortic surgery for a remaining descending aortic dissected aneurysm. He previously underwent emergency total arch replacement for the treatment of ascending aortic dissection Stanford type A 5 years ago. Physical examination and laboratory data revealed no remarkable findings. Computed tomography (CT) detected a 70-mm-diameter descending aortic aneurysm. Descending aortic replacement was performed following posterolateral thoracotomy. Venoarterial bypass was established by femoral venous and arterial cannulation. Intraoperatively, the adhesion around the lung and aneurysm was not dense. The descending aortic replacement was carried out using a 28-mm-diameter woven graft. Surgery was completed uneventfully with no significant bleeding. One day postoperatively, hoarseness developed. A nasogastric tube was then inserted and enteral nutrition was initiated. Non-fat diet was given because the amount of pleural drainage was higher than the usual 300 mL/day, with a suspicion of chylothorax. Subsequently, the pleural drainage started to decrease. Thereafter, a fat-included diet was started on postoperative day 6, changing the pleural effusion to chyle. Chylothorax was confirmed by chemical analysis indicating triglyceride in the pleural drainage (1325 mg/dL) and blood (295 mg/dL). Oral intake cessation and total parenteral nutrition through a central venous catheter were started. As the factor XIII activity was 46%, factor XIII products were administered at 20 mL/day for 5 days. However, pleural effusion remained after these treatments. To specifically identify the location of and reduce the chyle leakage, lipiodol lymphography was attempted in the supine position through bilateral inguinal lymph nodes. A 23-G needle was inserted to the inguinal lymph nodes, followed by the injection of 7 mL of lipiodol in the right lymph node and 8 mL in the left lymph node (Fig. 1). Thirty minutes later, CT scan detected the location of the chyle leakage in the pleural cavity near the distal anastomosis (Fig. 2). Two days after this procedure, the amount of pleural effusion decreased. Following chest Chylothorax is a rare but serious complication of thoracic aortic surgery, leading to malnutrition, respiratory insufficiency, and prolonged hospital stay. In this article, we describe the successful treatment of a case of intractable chylothorax by lipiodol lymphography. The patient was a 39-year-old man who underwent descending aortic replacement for a remaining dissected aneurysm after total arch replacement. Chylothorax developed postoperatively. After complete oral intake cessation, total parenteral nutrition, and plasmatic factor XIII administration, lipiodol lymphography detected the chyle leakage location and subsequently decreased pleural effusion. The patient recovered uneventfully and was discharged on postoperative day 30 without any complications.

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Section: Discussionmentioning

confidence: 99%

Management of Aortic Replacement-Induced Chylothorax by Lipiodol Lymphography

Kuwabara

Yoshitake

Hachiya

et al. 2015

Annals of Vascular Diseases

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“…A kórkép megjelenése általában jobb oldali [8]. Éhomi állapotban az óránkénti nyirokvezetés körülbelül 15 ml-es, amely érték postprandialisan 100 ml-re növekedik [9,10]. A ductus thoracicus sérülése tehát gyorsan vezethet nagy volumenű folyadékgyülem képződéséhez.…”

Section: Kórélettanunclassified

“…A cysterna chyli és a ductus thoracicus megfestése rendszerint a láb nyirokútjai felől történik, de a lipiodol injekció beadható egy inguinalis nyirokcsomóba is [9,53,59,60,63]. A cysterna chyli megfestése után a cysterna percutan kanülálása egy vékony tűvel történik, majd egy mikrokatéteren keresztül elvégezhető a sérülés helyén a coiling.…”

Section: Intervenciós Kezelésunclassified

“…Ha a kanülálás nem kivitelezhető, megkísérelhető a lymphographiával már azonosított nyirokutak "megkarcolása" ("tűs megszakítás", interruptio) és ezáltal a nyirokáramlás csökkentése [9,59,65]. Az így kezelt betegek körülbelül egyharmadánál ez a szivárgás megszűnéséhez vezet [59,64], az esetleges abdominalis chylus pedig felszívódik.…”

Section: Intervenciós Kezelésunclassified

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A chylothorax modern kezelésének bizonyítékalapú áttekintése

2016

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A chylothorax napjainkban rendszerint műtéti vagy baleseti szövődmény, ritkábban daganat következménye. Prospektív vagy randomizált vizsgálatok hiányában a bizonyítékalapú kezelés személyes tapasztalaton, ideálisan a retrospektív elemzések ismeretében történik. A szerzők célja a chylothorax modern kezelésének áttekintése. A PubMed adatbázist "chylothorax" kulcsszóra szűrték az elmúlt tíz év közleményei között, kiemelve az összehasonlító értéke-léseket. A módszerek és ajánlások kritikai elemzésekor a szerzők együttes 39 éves klinikai tapasztalatukra támaszkod-tak. A konzervatív kezelés sikere az etiológiától függően nagy szórást mutat (3-90%). A non-és szemi-invazív intervenciós eljárások sikerrátája 50-100% közötti. Eredménytelen konzervatív kezeléskor a sebészi kezelés, elsősorban a ductus thoracicus lekötése jelenti a standard terápiát. Ezen beavatkozások sikerességi aránya 64-100% közötti, a morbiditási/mortalitási mutató elérheti a 25%-ot. A kezelést konzervatívan kell megkezdeni, majd egy lépcsőzetes agresszivitású terápia ajánlott, amelyben a beteg állapota és a drénvolumen irányítják a döntéshozatalt. Az intervenciós radiológiai eljárások biztonságosak, sikeresek és helyet kaptak a konzervatív és műtéti megoldások mellett. Orv. Hetil., 2016, 157(2), 43-51. Kulcsszavak: chylothorax, szövődmény, mellkassebészet Review of evidence-based modern treatment for chylothoraxChylothorax is a multi-factorial complication, frequently of an operation or an accident, but rarely of a tumour. In the absence of prospective or randomised studies evidence-based treatment is normally based on personal experience, ideally in the possession of retrospective analyses using the "best practice" method. The aim of the authors was the review the up-to-date chylothorax treatments. They performed the PubMed database's "chylothorax" keyword search of the publications reported in the last ten years. They put emphasis on articles that included a comparative analysis of the various treatment options. During the critical analysis of the methods and recommendations, the authors relied on their own joint experience amounting to 39 years. The results showed that the success of the initial conservative treatment indicates a signifi cant deviation depending on the etiology (3-90%). The success rate of noninvasive or semi-invasive interventions is between 50-100%, again depending on the etiology. The standard surgical treatment following an unsuccessful conservative treatment of an operable patient includes the fi tting of a (thoracoscopic) knot to the ductus thoracicus, pleurodesis, insertion of a permanent chest drain or a pleuroperitoneal shunt. The success rate of these interventions is between 64-100%, with a morbidity index and mortality index exceeding 25%. Conservative treatment should be the fi rst step, which should then be followed by a gradually increased aggressive therapy, during which the decisions should be made according to the patient's condition and the drain volume. Interventional radiology procedures are safe, successful an...

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“…It is believed that after the TD is occluded, new lymphovenous communications develop and "dormant" anastomoses reopen. 20 Thus, TDEs performed at higher levels allow a greater number of lymphovenous communications and better collateral circulation. In our patient, the site of the lymphatic leak was low, and every attempt was made to selectively embolize only the leaking branch.…”

Section: Figurementioning

confidence: 99%

Minimal Lymphatic Leakage in an Infant With Chylothorax Detected by Lymphoscintigraphy SPECT/CT

2014

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A 7-month-old girl with history of persistent left chylous pleural effusion was referred for lymphoscintigraphy. A previous chest computed tomography (CT) scan demonstrated a small to moderate-sized left pleural effusion but could not identify the lymphatic leakage site. Lymphoscintigraphy using filtered 99m Tc sulfur colloid showed minimal focal activity in the lower chest. A correlative single-photon emission computed tomography (SPECT)/CT localized this activity to distal paraesophageal region, being highly suggestive of the site of lymphatic leakage. Subsequent lymphangiography confirmed these findings, revealing an abnormal lymphatic branch at the level of T10 and T11 vertebrae with retrocrural extravasation toward the left hemithorax. Thoracic duct embolization was accomplished at and proximal to the site of chyle leak using a platinum coil and n-Butyl cyanoacrylate glue. The patient was followed up for .24 months and demonstrated no recurrence of pleural effusion. No ascites or other complications related to the procedure were noted. The case demonstrates that 99m Tc sulfur colloid lymphoscintigraphy SPECT/CT can be a useful modality for detecting the chyle leakage site in children with chylothorax even when the amount of leakage is minimal.

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Thoracic Duct Embolization for Chylous Leaks

Cited by 178 publications

References 36 publications

Management of Aortic Replacement-Induced Chylothorax by Lipiodol Lymphography

Management of Aortic Replacement-Induced Chylothorax by Lipiodol Lymphography

A chylothorax modern kezelésének bizonyítékalapú áttekintése

Minimal Lymphatic Leakage in an Infant With Chylothorax Detected by Lymphoscintigraphy SPECT/CT

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