Nikhil Bhagat, MD; Suvranu Ganguli, MD

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
  - 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

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
Nadolski G: Nontraumatic chylothorax: diagnostic algorithm and treatment options. Tech Vasc Interv Radiol. 19(4):286-90, 2016
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

Related Differential Diagnoses

References

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
  - 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

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
Nadolski G: Nontraumatic chylothorax: diagnostic algorithm and treatment options. Tech Vasc Interv Radiol. 19(4):286-90, 2016
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

KEY FACTS

Terminology

Preprocedure

Procedure

Outcomes

TERMINOLOGY

Definitions

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

Tables

KEY FACTS

Terminology

Preprocedure

Procedure

Outcomes

TERMINOLOGY

Definitions

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