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Thoracic Duct Embolization
Nikhil Bhagat, MD; Suvranu Ganguli, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Outcomes

          TERMINOLOGY

          • Definitions

            • Thoracic duct embolization
              • 2-phase procedure
                • Conventional pedal lymphography or intranodal lymphography
                  • Visualize cisterna chyli or dominant upper lumbar lymphatics
                • Cannulation, embolization of thoracic duct
                  • Percutaneous anterior abdominal approach
              • 2 types of treatment described
                • Type 1 thoracic duct embolization
                  • Direct thoracic duct cannulation, embolization
                • Type 2 thoracic duct embolization
                  • Cisterna chyli maceration
                  • Disruption of duct
                  • Diverts chyle flow into retroperitoneum
                  • Promotes healing of breach
              • Relatively underutilized procedure
                • Lack of physician awareness
                • Lack of technical familiarity with procedure
                • Low morbidity, mortality
                • Recommended 1st-line therapy for persistent postoperative chylothorax
                  • Surgery has higher primary success rate but higher mortality
            • Cisterna chyli: Dilated lower end of thoracic duct
              • Formed by confluence of intestinal trunk/lumbar lymphatic trunks
                • Receives fatty chyle from intestines
                • Acts as conduit for lipid digestive products
              • Located between L2 and T12 levels
            • Thoracic duct
              • Largest lymphatic vessel in body
                • Typically 38-45 cm in length, 5 mm in diameter
                • Extends to base of neck
                • Arises from cephalad end of cisterna chyli
                  • Ascends posterior mediastinum between descending aorta/azygos vein
                  • Posterior to esophagus; slightly right of midline
                  • Crosses to left of midline at T5-T6
                • Terminates at left subclavian/internal jugular vein confluence where it empties into venous system
              • Transports up to 4 L of lymph/day
                • Valves prevent retrograde lymph flow
                • Valves at duct junction with left subclavian vein
                  • Prevents venous blood flow into thoracic duct
              • 10% incidence of duplicated (bilateral) thoracic duct
              • Causes of thoracic duct injury
                • Surgery: Pulmonary or esophageal
                • Trauma: Penetrating thoracic
                • Malignancy: Lymphoma, lymphadenopathy/metastasis
            • Chylous effusion (chylothorax)
              • Complication of thoracic/cardiac/neck surgery
                • Rare complication; significant morbidity/mortality
                  • Thoracic surgery procedures: 0.4-2.0% incidence
                  • Post esophagectomy: Up to 3.9%
                • Milky appearance; chylomicrons
                  • Triglyceride level above 110 mg/dL
              • Low-output chylothorax (< 1,000 mL/day) treated conservatively
                • Total parental nutrition
                • Medium-chain fatty acid diet
              • High-output chylothorax (> 1,000 mL/day) mandates intervention; has high mortality rate
                • 50% mortality with conservative treatment
                • May have ≥ 10-15% mortality with surgical repair in high-risk patients
                • Chyle rich in nutrients/T cells/electrolytes
                  • Consists mainly of lymph/fat digestion products
                  • Prolonged leakage worsens patient condition

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        OUTCOMES

                        • Problems

                          • Complications

                            • Expected Outcomes

                              Selected References

                              1. Nadolski G: Nontraumatic chylothorax: diagnostic algorithm and treatment options. Tech Vasc Interv Radiol. 19(4):286-290, 2016
                              2. Gaba RC et al: Chylous ascites: a rare complication of thoracic duct embolization for chylothorax. Cardiovasc Intervent Radiol. 34 Suppl 2:S245-9, 2011
                              3. Itkin M et al: Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg. 139(3):584-89; discussion 589-90, 2010
                              4. Repko BM et al: Recurrent chylothorax after neck surgery: percutaneous thoracic duct embolization as primary treatment. Otolaryngol Head Neck Surg. 141(3):426-7, 2009
                              5. Mittleider D et al: Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites. J Vasc Interv Radiol. 19(2 Pt 1):285-90, 2008
                              6. Scorza LB et al: Modern management of chylous leak following head and neck surgery: a discussion of percutaneous lymphangiography-guided cannulation and embolization of the thoracic duct. Otolaryngol Clin North Am. 41(6):1231-40, xi, 2008
                              7. van Goor AT et al: Introduction of lymphangiography and percutaneous embolization of the thoracic duct in a stepwise approach to the management of chylous fistulas. Head Neck. 29(11):1017-23, 2007
                              8. Binkert CA et al: Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique. J Vasc Interv Radiol. 16(9):1257-62, 2005
                              9. Cope C et al: Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol. 13(11):1139-48, 2002
                              10. Ngan H et al: The role of lymphography in chylothorax following thoracic surgery. Br J Radiol. 61(731):1032-6, 1988
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    • Outcomes

                                      TERMINOLOGY

                                      • Definitions

                                        • Thoracic duct embolization
                                          • 2-phase procedure
                                            • Conventional pedal lymphography or intranodal lymphography
                                              • Visualize cisterna chyli or dominant upper lumbar lymphatics
                                            • Cannulation, embolization of thoracic duct
                                              • Percutaneous anterior abdominal approach
                                          • 2 types of treatment described
                                            • Type 1 thoracic duct embolization
                                              • Direct thoracic duct cannulation, embolization
                                            • Type 2 thoracic duct embolization
                                              • Cisterna chyli maceration
                                              • Disruption of duct
                                              • Diverts chyle flow into retroperitoneum
                                              • Promotes healing of breach
                                          • Relatively underutilized procedure
                                            • Lack of physician awareness
                                            • Lack of technical familiarity with procedure
                                            • Low morbidity, mortality
                                            • Recommended 1st-line therapy for persistent postoperative chylothorax
                                              • Surgery has higher primary success rate but higher mortality
                                        • Cisterna chyli: Dilated lower end of thoracic duct
                                          • Formed by confluence of intestinal trunk/lumbar lymphatic trunks
                                            • Receives fatty chyle from intestines
                                            • Acts as conduit for lipid digestive products
                                          • Located between L2 and T12 levels
                                        • Thoracic duct
                                          • Largest lymphatic vessel in body
                                            • Typically 38-45 cm in length, 5 mm in diameter
                                            • Extends to base of neck
                                            • Arises from cephalad end of cisterna chyli
                                              • Ascends posterior mediastinum between descending aorta/azygos vein
                                              • Posterior to esophagus; slightly right of midline
                                              • Crosses to left of midline at T5-T6
                                            • Terminates at left subclavian/internal jugular vein confluence where it empties into venous system
                                          • Transports up to 4 L of lymph/day
                                            • Valves prevent retrograde lymph flow
                                            • Valves at duct junction with left subclavian vein
                                              • Prevents venous blood flow into thoracic duct
                                          • 10% incidence of duplicated (bilateral) thoracic duct
                                          • Causes of thoracic duct injury
                                            • Surgery: Pulmonary or esophageal
                                            • Trauma: Penetrating thoracic
                                            • Malignancy: Lymphoma, lymphadenopathy/metastasis
                                        • Chylous effusion (chylothorax)
                                          • Complication of thoracic/cardiac/neck surgery
                                            • Rare complication; significant morbidity/mortality
                                              • Thoracic surgery procedures: 0.4-2.0% incidence
                                              • Post esophagectomy: Up to 3.9%
                                            • Milky appearance; chylomicrons
                                              • Triglyceride level above 110 mg/dL
                                          • Low-output chylothorax (< 1,000 mL/day) treated conservatively
                                            • Total parental nutrition
                                            • Medium-chain fatty acid diet
                                          • High-output chylothorax (> 1,000 mL/day) mandates intervention; has high mortality rate
                                            • 50% mortality with conservative treatment
                                            • May have ≥ 10-15% mortality with surgical repair in high-risk patients
                                            • Chyle rich in nutrients/T cells/electrolytes
                                              • Consists mainly of lymph/fat digestion products
                                              • Prolonged leakage worsens patient condition

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Preprocedure Imaging

                                            • Getting Started

                                              PROCEDURE

                                              • Procedure Steps

                                                • Alternative Procedures/Therapies

                                                  POST PROCEDURE

                                                  • Things to Do

                                                    OUTCOMES

                                                    • Problems

                                                      • Complications

                                                        • Expected Outcomes

                                                          Selected References

                                                          1. Nadolski G: Nontraumatic chylothorax: diagnostic algorithm and treatment options. Tech Vasc Interv Radiol. 19(4):286-290, 2016
                                                          2. Gaba RC et al: Chylous ascites: a rare complication of thoracic duct embolization for chylothorax. Cardiovasc Intervent Radiol. 34 Suppl 2:S245-9, 2011
                                                          3. Itkin M et al: Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg. 139(3):584-89; discussion 589-90, 2010
                                                          4. Repko BM et al: Recurrent chylothorax after neck surgery: percutaneous thoracic duct embolization as primary treatment. Otolaryngol Head Neck Surg. 141(3):426-7, 2009
                                                          5. Mittleider D et al: Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites. J Vasc Interv Radiol. 19(2 Pt 1):285-90, 2008
                                                          6. Scorza LB et al: Modern management of chylous leak following head and neck surgery: a discussion of percutaneous lymphangiography-guided cannulation and embolization of the thoracic duct. Otolaryngol Clin North Am. 41(6):1231-40, xi, 2008
                                                          7. van Goor AT et al: Introduction of lymphangiography and percutaneous embolization of the thoracic duct in a stepwise approach to the management of chylous fistulas. Head Neck. 29(11):1017-23, 2007
                                                          8. Binkert CA et al: Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique. J Vasc Interv Radiol. 16(9):1257-62, 2005
                                                          9. Cope C et al: Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol. 13(11):1139-48, 2002
                                                          10. Ngan H et al: The role of lymphography in chylothorax following thoracic surgery. Br J Radiol. 61(731):1032-6, 1988