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• W2080861888 abstract "Persistent high-output chylothorax can result in life-threatening malnutrition and metabolic deterioration. A minimally invasive approach is desirable for patients, many of whom are already medically fragile as a result of the underlying disease. In recent years, percutaneous transabdominal thoracic duct procedures, such as embolization or needle disruption, have been reported with good clinical outcomes (1Binkert C.A. Yucel E.K. Davison B.D. et al.Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique.J Vasc Interv Radiol. 2005; 16: 1257-1262Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 2Cope 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: 1139-1148Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 3Hoffer E.K. Bloch R.D. Mulligan M.S. et al.Treatment of chylothorax: percutaneous catheterization and embolization of the thoracic duct.AJR Am J Roentgenol. 2001; 174: 1040-1042Crossref Scopus (57) Google Scholar, 4Mittleider D. Dykes T.A. Cicuto K.P. et al.Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites.J Vasc Interv Radiol. 2008; 19: 285-290Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar). These procedures are feasible and less invasive than surgical thoracic duct ligation; however, they are difficult in patients who do not have a distinct cisterna chyli. Additionally, patients with a coagulation abnormality have a risk of hemorrhage with a transhepatic or transintestinal approach. We describe two patients with persistent chylothorax in whom embolization of the thoracic duct was successfully performed via a transvenous retrograde approach. Our institution did not require institutional review board approval for this retrospective technical report. Written informed consent was obtained from the patients before the procedure. The first patient, a man in his 60s, had undergone a graft replacement of the descending aorta for a saccular aneurysm 4 days earlier. The patient experienced progressive output from the surgical drain (158 mL/d). Analysis of fluid from the drain revealed triglyceride levels of 427 mg/dL, which was consistent with postsurgical thoracic duct injury. After 2 weeks of failed conservative treatment measures, we were consulted for percutaneous treatment. Because of the patient’s tendency to bleed, we were unwilling to access the site by transabdominal puncture. We attempted embolization of the thoracic duct by a percutaneous transvenous retrograde approach. The second patient, a woman in her 50s, had undergone surgery for spinal arteriovenous malformation and paraplegia when she was 19 years old. The patient had edema of the right lower extremity and dyspnea. Computed tomography revealed a left pleural effusion, and analysis of the fluid from the drain revealed triglyceride levels of 1,343 mg/dL. High-output chylothorax (984 mL/d) was also diagnosed. After 4 weeks of conservative treatment measures failed, we were consulted for percutaneous treatment. Because of the absence of a suitable access target by lymphography, we attempted embolization of the thoracic duct via a percutaneous transvenous retrograde approach. We attempted to access the thoracic duct at its confluence with the left subclavian vein, as previously reported (4Mittleider D. Dykes T.A. Cicuto K.P. et al.Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites.J Vasc Interv Radiol. 2008; 19: 285-290Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar). After administration of local anesthesia, the procedure was performed under fluoroscopic guidance via the left brachial vein approach. A 5-F RIM catheter (Cook, Inc, Bloomington, Indiana) was used to seek and cannulate the thoracic duct (Fig 1). Retrograde cannulation of the thoracic duct was successful in both patients. After retrograde cannulation was confirmed by the injection of contrast material (Fig 2), a microcatheter (Renegade; Boston Scientific, Natick, Massachusetts, in patient 1; PROWLER PLUS; Codman, Raynham, Massachusetts, in patient 2) and a 0.014-inch or 0.016-inch wire (Transend; Boston Scientific, in patient 1; AQUA V-III; Cordis Corportion, Miami Lakes, Florida, in patient 2) were coaxially introduced and advanced into the lower thoracic duct. A clear yellow fluid was aspirated through the catheter. Selective lymphangiography revealed a thoracic duct with active extravasation that corresponded to chyle leakage (Fig 3). We crossed the source of the leakage with a wire and catheter to perform embolization of the region proximal to the leakage. A 33% mixture of N-butyl cyanoacrylate (NBCA; B. Braun, Melsaungen, Germany) and iodized oil (Lipiodol Ultra-fluide; Terumo, Tokyo, Japan) was used. The volume of the glue was 0.4 mL in patient 1 and 0.2 mL in patient 2. The fluoroscopic time was 79 minutes in patient 1 and 126 minutes in patient 2.Figure 2Selective lymphangiography. After patiently seeking the ostium of the thoracic duct (arrow), retrograde cannulation was confirmed by injection of contrast material (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Selective lymphangiography through the microcatheter (white arrowheads) revealed the thoracic duct (black arrowheads) with active extravasation (black arrow). The tip of the microcatheter (white arrow) was placed proximal to the source of chyle leakage.View Large Image Figure ViewerDownload Hi-res image Download (PPT) After the procedure, three-dimensional soft tissue imaging with a C-arm angiographic computed tomography system (XperCT; Philips Medical Systems, Best, Netherlands) showed that an accumulation of the mixture of NBCA and Lipiodol within the thoracic duct covered the site of leakage (Fig 4). In patient 1, the chest tubes were removed 4 days after the procedure, which corresponded to a “cure,” similar to the previous report (3Hoffer E.K. Bloch R.D. Mulligan M.S. et al.Treatment of chylothorax: percutaneous catheterization and embolization of the thoracic duct.AJR Am J Roentgenol. 2001; 174: 1040-1042Crossref Scopus (57) Google Scholar). In patient 2, although chyle output promptly decreased after the procedure (<10 mL/day), the chylothorax relapsed after resuming a normal diet (150 mL/d), which corresponded to a “partial response.” Malnutrition with low total protein and albumin improved after the procedure (total protein improved from 4.7 mg/dL to 6.7 mg/dL and albumin improved from 1.5 mg/dL to 2.2 mg/dL). Patient 2 underwent an omentopexy in a tolerable condition. There were no significant or minor procedure-related complications. The percutaneous transvenous retrograde approach of the thoracic duct, adapted in the present study, was first described in a previous report (4Mittleider D. Dykes T.A. Cicuto K.P. et al.Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites.J Vasc Interv Radiol. 2008; 19: 285-290Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar) for the treatment of chylous ascites. This approach can be adapted for the treatment of chylothorax. Although the thoracic duct was not visualized by subclavian venography, retrograde cannulation was successfully performed by patiently searching the region. The process of advancing the wire and the catheter in the duct is extensive, especially because of the difficulty in traversing the terminal valves. Eventually, embolization of the thoracic duct was achieved with clinical improvement. As an embolic agent, a combination of coils and glue seemed to work well in several previous studies (1Binkert C.A. Yucel E.K. Davison B.D. et al.Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique.J Vasc Interv Radiol. 2005; 16: 1257-1262Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 2Cope 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: 1139-1148Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar, 3Hoffer E.K. Bloch R.D. Mulligan M.S. et al.Treatment of chylothorax: percutaneous catheterization and embolization of the thoracic duct.AJR Am J Roentgenol. 2001; 174: 1040-1042Crossref Scopus (57) Google Scholar). Some reports stated that coils alone or glue alone was insufficient because of the decreased volume of coagulation factors or unknown properties of NBCA in the lymphatic environment (1Binkert C.A. Yucel E.K. Davison B.D. et al.Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique.J Vasc Interv Radiol. 2005; 16: 1257-1262Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 3Hoffer E.K. Bloch R.D. Mulligan M.S. et al.Treatment of chylothorax: percutaneous catheterization and embolization of the thoracic duct.AJR Am J Roentgenol. 2001; 174: 1040-1042Crossref Scopus (57) Google Scholar). However, it is not easy to cross proximal to the leakage with the wire and with the catheter as planned. We chose a mixture of NBCA and Lipiodol alone, which resulted in a successful embolization. An additional point to consider when using a mixture of NBCA and Lipiodol only is the potential for reflux when injecting against the flow. Limitations for the transvenous retrograde approach include variation of the thoracic duct and postsurgical ligation. If cannulation of the thoracic duct is difficult, traditional lymphangiography and magnetic resonance lymphangiography may be useful to visualize the anatomic location of the thoracic duct. In the case of complete transection, it would be impossible to cross the source of leakage to perform embolization of it. Additionally, retrograde lymphangiography is limited by the upstream flow and valves, which may result in an incomplete treatment. Nevertheless, this approach is based on venous puncture and catheter manipulation in the vessels, which is readily accessible to vascular interventional radiologists. It should be considered as a treatment for persistent chyle leakage. In summary, percutaneous transvenous retrograde thoracic duct embolization may be a potential alternative approach in the percutaneous treatment of patients with persistent chylothorax." @default.
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• W2080861888 title "Percutaneous Transvenous Embolization of the Thoracic Duct in the Treatment of Chylothorax in Two Patients" @default.
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