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• W3207935863 abstract "TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: Chylothorax is a well described complication after thoracic interventions. It can occur in a wide variety of procedures such as brachiocephalic manipulation or lymph node dissection. Often, there can be disruption of the lymphatic drainage resulting in chlye draining into the pleural space. We discuss a case where a patient was found to have chylothorax after intervention was performed to his brachiocephalic fistula previously placed for hemodialysis access. While under fluoroscopy in the operating room, the effusion was mischaracterized as a hypoplastic lung which prompted a pulmonary consultation. Drainage of the pleural cavity, by bedside ultrasound guided thoracentesis, showed elevated triglycerides. CASE PRESENTATION: The patient is a 53-year-old physically active, non-smoking, gentleman with a history of end-stage renal disease secondary to unknown cause, renal transplant rejection, and hypertension. He was initially on peritoneal dialysis but was converted to hemodialysis after brachiocephalic AV creation performed one year ago. However, this was complicated by venous stenosis requiring multiple dilation procedures. He also developed left neck and arm swelling since insertion of the fistula which has not properly matured. Due to worsening arm swelling and dyspnea, he presented for a repeat fistulogram. Under fluoroscopy, there was concern for a hypoplastic left lung (IMAGE 1). Chest radiography post-procedure showed a left pleural effusion (FIGURE 2), confirmed by ultrasound. Bedside thoracentesis yielded 1.5 liters of milky, layering, blood tinged free flowing fluid. Pleural fluid analysis revealed 211 mg/dL triglycerides. During a 2 week follow up visit, he noted recurrent shortness of breath. Chest ultrasound showed recurrent left pleural fluid, prompting a second thoracentesis which recovered 2 liters of straw-colored fluid. Repeat pleural fluid triglyceride level was 30 mg/dL DISCUSSION: Occlusion of the thoracic duct can lead to chylous extravasation and pleural fluid accumulation. Our patient developed pleural effusion four times, the first being chylothorax, the second not. His suspected superior vena cava syndrome was from webbing stenosis in his brachiocephalic region that required balloon angioplasty and numerous fistulograms and eventually was tied off at patient request. He was instructed to decrease his dietary free fatty acid intake. If conservative measures do not improve the condition and if vascular intervention cannot alleviate his stenosis, pleurodesis will need to be considered to prevent reaccumulation. CONCLUSIONS: While ESRD patients may have pleural effusions due to nephrosis, we present a case where a possible SVC syndrome provoked by AVF stenosis leading to obstruction of the thoracic duct caused a chylothorax. Further management in this situation is to address the underlying stenosis near the fistula to prevent recurrence. REFERENCE #1: Bryant, Ayesha S. et a. The Incidence and Management of Postoperative Chylothorax After Pulmonary Resection and Thoracic Mediastinal Lymph Node Dissection. The Annals of Thoracic Surgery, Volume 98, Issue 1, 232 - 237. 2014. DISCLOSURES: no disclosure on file for Ronald Evans; No relevant relationships by Salman Khan, source=Web Response No relevant relationships by Sudheer Penupolu, source=Web Response" @default.
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• W3207935863 date "2021-10-01" @default.
• W3207935863 modified "2023-09-25" @default.
• W3207935863 title "A CASE OF A HYPOPLASTIC LUNG FOUND TO BE INCIDENTALLY A CHYLOTHORAX" @default.
• W3207935863 doi "https://doi.org/10.1016/j.chest.2021.07.1745" @default.
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