Use of Contrast-Enhanced Ultrasound to Determine Thoracic Duct Patency

Mejia, Erika; Otero, Hansel J.; Smith, Christopher L.; Shipman, Molly; Liu, Mandi; Pinto, Erin; DeWitt, Aaron; Rome, Jonathan J.; Dori, Yoav; Biko, David M.

doi:10.1016/j.jvir.2020.05.022

Cited by 26 publications

(13 citation statements)

References 14 publications

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“…In all 12 patients, the thoracic duct was confirmed patent either by direct lymphangiography, lymphatic contrast ultrasound examination, or both. 17 In one patient, there were bilateral TD outlets. Ten patients underwent lymphatic embolization procedures as listed in Table 2 a median of 27.5 (range: 7–325) days before the TDD procedure.…”

Section: Resultsmentioning

confidence: 96%

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Transcatheter Thoracic Duct Decompression for Multicompartment Lymphatic Failure After Fontan Palliation

Smith

Dori

O’Byrne

et al. 2022

Circ: Cardiovascular Interventions

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Background: Lymphatic embolization therapy has proven effective for Fontan failure from plastic bronchitis or protein-losing enteropathy but not when multiple lymphatic compartments are involved; furthermore, embolization does not alter the underlying pathophysiology of lymphatic dysfunction. A technique for transcatheter thoracic duct decompression (TDD), rerouting the thoracic duct to the pulmonary venous atrium to treat multicompartment lymphatic failure is described and early outcomes presented. Methods: Initially covered stents were used to channel the innominate vein flow inside of the cavopulmonary pathway into the pulmonary venous atrium. A modified approach was developed where covered stents redirected innominate vein directly to the left atrium via an extravascular course. Baseline and follow-up data on all patients undergoing TDD were reviewed. Results: Twelve patients underwent TDD between March 2018 and February 2021 at a median age of 12 (range: 2–22) years. Lymphatic failure occurred in median of 3 compartments per patient (protein-losing enteropathy, ascites, pleural effusions, plastic bronchitis); 10 patients had lymphatic embolizations before TDD. TDD method was intra-Fontan tunnel in 4, direct approach in 7, and other in 1. There were no major procedural complications; 6 patients underwent subsequent procedures, most commonly to treat endoleaks. Lymphatic failure resolved in 6 patients, improved in 2, and was unchanged in 4 at 6 (range: 1–20) months follow-up. One patient died after TDD from Fontan failure. Conclusions: TDD is a promising new treatment for the failing Fontan physiology from multicompartment lymphatic failure. Additional work is needed to refine the technique and define optimal candidates.

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Section: Resultsmentioning

confidence: 96%

“…In other cases, intranodal Lumason (Bracco Diagnostics, Princeton, NJ) injections were performed with high resolution ultrasound of the venous angle to identify patency. 17 Tomographic imaging with 3-dimensional reconstruction of the cardiovascular structures was deemed particularly useful for procedural planning.…”

Section: Procedural Planning and Techniquementioning

confidence: 99%

Transcatheter Thoracic Duct Decompression for Multicompartment Lymphatic Failure After Fontan Palliation

Smith

Dori

O’Byrne

et al. 2022

Circ: Cardiovascular Interventions

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“…In addition, the cervical part of the thoracic duct, including the thoracic duct outlet and the lympho-venous valve can be imaged with gray scale high resolution ultrasound. It allows the assessment of local anatomy, imaging of valvular function and even detection of chyle flow in the terminal part (53,54). The use of microbubble ultrasound contrast agents has recently expanded the diagnostic potential of ultrasound in lymphatic disease.…”

Section: Ultrasoundmentioning

confidence: 99%

Current diagnostic and therapeutic strategies for the management of lymphatic insufficiency in patients with hypoplastic left heart syndrome

Bauer

Dori²,

Scala³

et al. 2023

Front. Pediatr.

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Children with hypoplastic left heart syndrome share unique hemodynamic features that alter lymphatic integrity at all stages of palliation. Lymphatic congestion is almost universal in this patient group to some extent. It may lead to reversal of lymphatic flow, the development of abnormal lymphatic channels and ultimately decompression and loss of protein rich lymphatic fluid into extra lymphatic compartments in prone individuals. Some of the most devastating complications that are associated with single ventricle physiology, notably plastic bronchitis and protein losing enteropathy, have now been proven to be lymphatic in origin. Based on the new pathophysiologic concept new diagnostic and therapeutic strategies have recently been developed. Dynamic contrast magnetic resonance lymphangiography is now mainstay in diagnosis of lymphatic insufficiency and allows a thorough assessment of anatomy and function of the main lymphatic compartments through intranodal, intrahepatic and intramesenteric lymphatic imaging. Contrast enhanced ultrasound can evaluate thoracic duct patency and conventional fluoroscopic lymphangiography has been refined for evaluation of patients where magnetic resonance imaging cannot be performed. Novel lymphatic interventional techniques, such as thoracic duct embolization, selective lymphatic duct embolization and liver lymphatic embolization allow to seal abnormal lymphatic networks minimally invasive and have shown to resolve symptoms. Innominate vein turn-down procedures, whether surgical or interventional, have been designed to reduce lymphatic afterload and increase systemic preload effectively in the failing Fontan circulation. Outflow obstruction can now be managed with new microsurgical techniques that create lympho-venous anastomosis. Short term results for all of these new approaches are overall promising but evidence is sparse and long-term outcome still has to be defined. This review article aims to summarize current concepts of lymphatic flow disorders in single ventricle patients, discuss new emerging diagnostic and therapeutic strategies and point out lacks in evidence and needs for further research on this rapidly growing topic.

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“…Ultrasound contrast lymphangiography is another technique that was recently published (19). This technique is good for assessing thoracic duct outlet patency which needs to be confirmed in all patients undergoing a thoracic duct decompression (TDD) procedure.…”

Section: Lymphatic Imagingmentioning

confidence: 99%

Lymphatic Disorders in Patients With Single Ventricle Heart Disease

Dori

Smith

2022

Front. Pediatr.

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Lymphatic abnormalities in patients with single ventricle physiology can lead to early Fontan failure and severe Fontan complications, such as protein-losing enteropathy (PLE), plastic bronchitis (PB), chylothorax, and edema. Recent developments in lymphatic imaging and interventions have shed new light on the lymphatic dysfunction in this patient population and the role of the lymphatic circulation in PLE, PB, and chylothorax. In this study, we reviewed some of the latest developments in this field and discuss new treatment options for these patients.

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Use of Contrast-Enhanced Ultrasound to Determine Thoracic Duct Patency

Cited by 26 publications

References 14 publications

Transcatheter Thoracic Duct Decompression for Multicompartment Lymphatic Failure After Fontan Palliation

Transcatheter Thoracic Duct Decompression for Multicompartment Lymphatic Failure After Fontan Palliation

Current diagnostic and therapeutic strategies for the management of lymphatic insufficiency in patients with hypoplastic left heart syndrome

Lymphatic Disorders in Patients With Single Ventricle Heart Disease

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