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
Sommer CM et al: Radiological management of postoperative lymphorrhea. Langenbecks Arch Surg. 406(4):945-69, 2021
Moussa AM et al: Thoracic duct embolization in post-neck dissection chylous leakage: a case series of six patients and review of the literature. Cardiovasc Intervent Radiol. 43(6):931-7, 2020
Kim PH et al: Lymphatic interventions for chylothorax: a systematic review and meta-analysis. J Vasc Interv Radiol. 29(2):194-202.e4, 2018
Gaba RC et al: Chylous ascites: a rare complication of thoracic duct embolization for chylothorax. Cardiovasc Intervent Radiol. 34 Suppl 2:S245-9, 2011
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
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
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
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
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
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
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
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
Relatively underutilized procedure
Lack of physician awareness
Lack of technical familiarity with procedure
Time required for procedure
Recommended 1st-line therapy for persistent postoperative chylothorax
Surgery has higher primary success rate but higher mortality
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
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
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
Sommer CM et al: Radiological management of postoperative lymphorrhea. Langenbecks Arch Surg. 406(4):945-69, 2021
Moussa AM et al: Thoracic duct embolization in post-neck dissection chylous leakage: a case series of six patients and review of the literature. Cardiovasc Intervent Radiol. 43(6):931-7, 2020
Kim PH et al: Lymphatic interventions for chylothorax: a systematic review and meta-analysis. J Vasc Interv Radiol. 29(2):194-202.e4, 2018
Gaba RC et al: Chylous ascites: a rare complication of thoracic duct embolization for chylothorax. Cardiovasc Intervent Radiol. 34 Suppl 2:S245-9, 2011
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
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
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
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
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
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
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
Ngan H et al: The role of lymphography in chylothorax following thoracic surgery. Br J Radiol. 61(731):1032-6, 1988
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