Original post, lightly edited for flow:
Does anyone have a suggestion for performing a lymphangiogram/thoracic duct embolization when there are no (or just tiny 2–3 mm) lymph nodes present in the pelvis and upper legs? I am working with a young patient who has already had thoracic duct clipping and continues to have a high output chylous pleural effusion but has no lymph nodes to access for performing a lymphangiogram.
Author name and contact information
Joseph McBride, MD, FRCPC
jmcbride@unmc.edu
Omaha, NE
Author background and current practice preferences for lymphangiograms and thoracic duct embolization:
I was in private practice for one year and have been involved in academics most of my career. I am now based in Nebraska where we cover a wide breadth of procedures.
When I was training, a few institutions were performing thoracic duct embolization. At that time, I had some experience with diagnostic lymphangiogram and began getting more referrals in this area about 12 years ago. Cardiothoracic and head and neck surgeons are our biggest referrals, usually for chylous leaks. We started performing more lymphangiograms, and typically we percutaneously accessed a uni- or bilateral inguinal nodes or the cisterna chyli directly depending on the indication.
Please elaborate on the specific patient background and presentation in this case.
The patient in this case was a younger patient with a history of chylous pleural effusion. Cardiothoracic surgery had explored and put clips into a potential leak. When the effusion recurred, we were asked to see the patient in consultation for a lymphangiogram and potential thoracic duct embolization. We did a pelvis CT where we were able to see tiny lymph nodes in the pelvis. One of these nodes was accessible under ultrasound, but when lymphangiogram was attempted we did not get a typical appearance and the other lymph nodes were not easily accessible. This prompted me to ask for advice on SIR Connect.
How was lymphangiogram performed in this case?
After gathering advice from SIR Connect and performing a literature search on the topic, I decided accessing the left arm might be our best bet for performing a lymphangiogram. We ended up accessing the arm like a PICC but using a bigger sheath, reverse curve catheter through the subclavian vein, and catheterizing the thoracic duct as it comes into the vein in that region. We used a 2.4 Fr microcatheter via retrograde access to get into the duct. Getting deep into the chest was a bit more challenging due to small duct size in this patient. We were able to identify what appeared to be a small leak and injected some ethiodol. This slowed down the patient’s pleural effusion for 3–4 days, after which the patient was placed on a full fat diet and the effusion reaccumulated. A few weeks later after dietary restriction, the pleural effusion improved.
Which specific methods, techniques or considerations do you find useful in performing a lymphangiogram?
I will consider using the subclavian approach in the future as a good first step after the shorter amount of time it took to get in and obtain access. It is important to consider general anesthesia given it can be painful to access the cisterna chyli, especially for a younger patient population. Deep venous thrombosis compression devices also play an important role periprocedurally and can make all the difference in the world in helping to see the cisterna chyli. Additionally, the risk of deep venous thrombosis is not small in these patients especially if they are on the table for several hours. Depending on the case, we tend to keep these devices on.
Does embolic choice for thoracic duct embolization matter?
The biggest consideration for embolic agents involves the route of access. Using glue when accessing from below is okay because trying to reroute lymphatics, and you are essentially internally ligating below the leak. The risk of this includes leg swelling and lymphedema, but this is easier to deal with than a chest tube in place 24/7. Coming from the arm, injecting something like glue, unless you get it right down where it needs to go, could cause major problems, like ligating duct at its insertion.
I have used coils before, but usually in conjunction with glue to serve as a matrix. Glue by itself does not set up in the lymphatic system as it does in blood.
What post or posts were most valuable to you and why?
Posts outlining a subclavian approach were the most valuable for me in this case. The posts on SIR Connect helped me formulate a plan, and in the future I will be using a more systemic approach when I gauge access from above or below the leak for chylous pleural effusion versus ascites.
Will you, or have you changed your practice patterns based off responses on SIR Connect? Please describe any changes you are considering.
Yes, in the future I will consider taking a subclavian approach in a lot more patients.
An additional technique I also considered in a case like this would be approaching infectious disease to see if the patient had vaccines that were due, and if administering these would result in adenopathy amenable to percutaneous access.
Additional commentary
Chylous effusion is defined as a leakage of lymph fluid from the intestinal lymphatics system1 into the thoracic (chylothorax) or peritoneal cavity (chyloperitoneum). Chylous leaks can occur iatrogenically from cardiac or head and neck surgery, trauma, malignancy, lymphatic vessel disease and infection.1,2 The pathophysiology is attributed to disruption of the thoracic duct resulting in loss of protein, vitamins and immunoglobulins.3 Chylothorax is typically treated with dietary modification (medium chain fatty acid diet, total parenteral nutrition), surgical management (pleurodesis, thoracic duct ligation) for persistent chylous leaks that fail initial treatment,3,4 and thoracic duct embolization (TDE).4
TDE is a percutaneous, minimally invasive treatment that is traditionally performed by lymphangiogram followed by embolization with a combination of coils and glue proximal to the leak.1,4,5 A meta-analysis conducted by Pyeong et al reviewed lymphatic interventions for chylothorax and found a pooled technical and clinical success rate of TDE between 63% and 79%, respectively.6 In a cohort of 34 patients with non-traumatic chylous effusion, intention-to-treat success rate was reported as 52%.4 Identification of the leak location and presence of a normal thoracic duct with lymphangiography, traumatic versus non-traumatic etiology, technical success in catheterizing the thoracic duct and lower postprocedural effusion volumes have all been shown to impact success rates.1,2,4,6
The traditional pedal lymphangiogram has historically been described as technically challenging and tedious in comparison to newer methods such as intranodal access.1,2,7 This technique includes a right-sided dorsal foot cutdown and cannulation of a pedal lymphatic vessel using a 30-guage needle.2 Ethiodol is administered and contrast is serially monitored under fluoroscopy until progression to the cisterna chyli, which is then accessed in standard fashion.2 As discussed in this case, many additional potential approaches to performing a lymphangiogram have been previously described,3 including intranodal, percutaneous transabdominal, direct and percutaneous transcervical access, and percutaneous transvenous retrograde techniques.3 The percutaneous approach involves access into bilateral inguinal nodes under ultrasound guidance using a 25-gauge needle.1,7 After lymphatic anatomy is delineated with ethiodol contrast, a Chiba needle and microwire system are fluoroscopically advanced into the thoracic duct. If a thoracic duct leak or injury is identified, an attempt is made to advance a microcatheter as close as possible to an injury.7 The thoracic duct or leak source are then embolized upstream with coils, which provide a scaffolding for glue.1,7 The retrograde transvenous approach has been recently described and involves left brachial or basilic vein access with identification of the thoracic duct ostium via a subclavian venogram. This technique can be technically challenging and is used in circumstances where the cisterna chyli is inadequately seen on lymphangiogram.3,8,9 Research comparing efficacy and outcomes of retrograde transvenous versus traditional percutaneous approaches would be of benefit when considering an approach.
References:
- Higgins CSSM, Itkin M. Thoracic duct embolization for chylothorax. Handbook of Interventional Radiologic Procedures. Krishna Kandarpa et al., Lippincott Williams & Wilkins. 2016:453–
- Pamarthi V, Stecker MS, Schenker MP, Baum RA, Killoran TP, Han AS, O’Horo SK, Rabkin DJ, Fan C. Thoracic duct embolization and disruption for treatment of chylous effusions: experience with 105 patients. 2014;25(9):1398–1404.
- Toliyat M, Singh K, Sibley RC, Chamarthy M, Kalva SP, Pillai AK. Interventional radiology in the management of thoracic duct injuries: anatomy, techniques and results. Clin Imaging. 2017;43:183–92.
- Nadolski GJ, Itkin M. Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization. 2012;23 (5):613–16.
- Nadolski GJ, Itkin M. Thoracic duct embolization for nontraumatic chylous effusion: Experience in 34 patients.” 2013;143(1):158–63.
- Kim PH, Tsauo J, Shin JH. Lymphatic interventions for chylothorax: A systematic review and meta-analysis. 2018;29(2):194-202.e4.
- Gilyard SN, Khaja MS, Goswami AK, Kokabi N, Saad WE, Majdalany BS. Traumatic chylothorax: Approach and outcomes. Semin Intervent Radiol. 2020;37(3):263–68.
- Mittleider D, Dykes TA, Cicuto KP, Amberson SM, Leusner CR. Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites. 2008;19(2):285–90.
- Yuya K, Nishimura J, Hirai C, Moriya N, Katsumata Y. Percutaneous transvenous embolization of the thoracic duct in the treatment of chylothorax in two patients. JVIR. 2013;24(1):135–37.
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