Thoracic duct embolization

Case contributed by Dr Tom Pearson

Presentation

This patient was admitted for an elective bilateral neck dissection for recurrent papillary thyroid cancer. His post-operative course was complication by a high output chylothorax (1.4L/day).

Patient Data

Age: 35 years
Gender: Male
DSA (angiography)

Procedure performed under general anesthesia. Ultrasound and fluoroscopic guidance. Right inguinal node accessed with 25 G spinal needle. Lipiodol injected at 1 ml q3-5mins for a total of 5-6 ml. Satisfactory opacification of cisterna chylae. Left neck chyle leak shown.

Cisterna chylae accessed via an anterior abdominal approach using fluoroscopic guidance and a 22g X 20 needle. V18 micro wire navigated up to thoracic inlet. Rebar 18 micro catheter placed. Satisfactory catheter position.  The thoracic duct was occluded in the mid thoracic region with IDC detectable coils followed by by 30% strength glue (Histoacryl). Satisfactory occlusion.

Images

  • Image 1: Cannulated inguinal lymph node (bottom left). Opacified efferent lyphatic duct leading on to the more dense lateral pelvic nodes
  • Image 2: Abdominal lymphatics converging on the cisterna chylii, with contrast flowing up into the thoracic duct
  • Image 3: Successful cannulation and advancement of a wire into the thoracic duct
  • Image 4: Lymphatic leak shown (top right) and placement of 4 coils
  • Image 5: post glue appearance

Case Discussion

Due to the high volume of chylothorax, thoracic duct embolization was utilized as a first line procedure in combination with conservative management strategies.

This was a technically successful thoracic duct embolization. Within 48hrs, both drains had reduced to <10ml/h and been removed. The patient was sent home on D3 post procedure with no immediate complications noted.

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