When, Why, and How of Thoracic Duct Embolization Poster No.:

C-1449

Congress:

ECR 2015

Type:

Educational Exhibit

Authors:

J. F. B. Chick, N. Chauhan, A. Suzuki Han; Boston, MA/US

Keywords:

Trauma, Treatment effects, Sclerosis, Embolisation, MR, Lymphography, Fluoroscopy, Lymph nodes, Interventional vascular, Interventional non-vascular

DOI:

10.1594/ecr2015/C-1449

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Learning objectives 1. 2. 3. 4.

5.

Review the typical anatomy of the thoracic duct. Outline the causes of thoracic duct injury and the indications for thoracic duct embolization. Review thoracic duct embolization pre-procedural imaging such as magnetic resonance ductography and lymphangiography. Describe thoracic duct embolization intra-procedural techniques including: cut-down, lymphatic duct isolation, and pedal lymphangiography, lower extremity lymphangiography, cisterna chyli access and cannulization, thoracic duct lymphangiography, and thoracic duct embolization. Discuss thoracic duct embolization procedural success and complications.

Background The thoracic duct is the largest lymphatic conduit, draining upwards of seventy-five percent of lymphatic fluid, and extending from the cisterna chyli to the left jugulovenous angle. The lengthy course of the thoracic duct predisposes it to injury from a variety of iatrogenic causes including: thoracic, cardiac, and head and neck surgeries as well as spontaneous benign or malignant lymphatic obstructions. Disruption of the thoracic duct frequently results in chylothoraces that subsequently cause an immunocompromised state, result in nutritional depletion, and impair respiratory function, but disruption may also result in chylopericardium and persistent postoperative chylous wound drainage. Although conservative dietary treatments exist, the majority of thoracic duct injuries require thoracic duct embolization and ligation techniques. Such procedures have been found to be upwards of seventy-four percent successful with few complications.

Findings and procedure details Anatomy of the Thoracic Duct: •

•

•

Tubular structure extending from cisterna chyli at the the second lumbar vertebral body to the junction of the left subclavian and left interval jugular veins [1,2]. Originates at the abdominal cisterna chyli, extends along the posterior aspect of the aorta and right diaphragmatic crus, and enters the thorax between the aorta and azygos vein. Courses through the posterior mediastinum deep to the esophagus and pericardium.

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• • • • • • • •

Enters the superior mediastinum at the fifth thoracic vertebral body and extends posterior to the aortic arch and left subclavian artery. Crosses anterior to the subclavian and vertebral veins, thyrocervical trunk, and anterior scalene muscle in the neck. Drains into the junction of the left subclavian and left internal jugular veins. 2-5 mm in diameter [1]. 38-45 cm in length [1]. Carries 1-2 L of lymphatic fluid/day [1]. 80% of lymphatic fluid is from intestinal and hepatic lymphatic ducts [1]. See our exhibit entitled Illustration of Variable Thoracic Duct Anatomy for Thoracic Duct Embolization Pre-Procedure Planning for additional anatomic description.

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Fig. 1: Schematic diagram demonstrating the normal course of the thoracic duct (solid green outline). Adapted from: Allaham AH, Estrera AL, Miller CC, Achouh P, Safi HJ. Chylothorax complicating repairs of the descending and thoracoabdominal aorta. Chest. 2006;130(4):1138-42. References: Radiology, Harvard Medical School, Brigham and Women's Hospital / Harvard Medical School - Boston/US Causes of Chylous Leaks and Indications for Thoracic Duct Embolization: •

• • • •

• • • • •

Two mechanisms of chylous extravasation: (1) direct trauma to the lymphatic vessels and (2) occlusion of the thoracic duct with concurrent delicate collateral duct formation [3,4]. Traumatic injury is the most common cause of chylous extravasation typically from thoracic, cardiac, or head and neck surgeries [5]. 0.42% injury from general thoracic surgery [6]. 3.9% injury from esophagectomy [7]. Nontraumatic occlusion of the thoracic duct is less common, but may arise from maligancies (lymphoma, esophageal adenocarcinoma, primary lung malignancies, and mesothelioma), systemic diseases and infections (sarcoidosis, tuberculosis, and Behcet's disease), lymphatic vessel diseases (lymphangiomatosis and Gorham's disease), congenital malformations, and idiopathic cases [8]. 42% nontraumatic obstruction from idiopathic causes [9]. 27% nontraumatic obstruction from malignancies such as lymphoma [9]. Low-output chylous leakage (1000 mL/day) treated with thoracic duct embolization or surgical ligation [11]. Indications for thoracic duct embolization include: chylothorax, chylopericardium, and postoperative chylous wound leakage (less likely chylous ascites, chyloptysis, and chyluria).

Thoracic Duct Embolization Pre-Procedural Imaging: • •

Magnetic resonance ductography including heavily T2-weighted axial and coronal images of the thoracoabdominal region. Lymphangiography.

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Fig. 2: Coronal T2-weighted magnetic resonance images (A and C) and corresponding lymphangiogram images (B and D) demonstrating dilated lymphatic channels in the retrocrural spaces and retroperitoneum (solid white arrows). References: Radiology, Harvard Medical School, Brigham and Women's Hospital / Harvard Medical School - Boston/US Thoracic Duct Intra-Procedural Techniques: Cut-down, Lymphatic Duct Isolation, and Pedal Lymphangiography: • • •

• • •

Intravenous moderate procedural sedation is administered. Prophylactic administration of 1-2 g cefazolin is given for skin flora. 0.5-1 mL of methylene blue dye (American Regent, Shirley, New York) is injected intradermally into the first and second and third and forth web spaces of the toes to facilitate visualization of lymphatic vessels. Local anesthesia with 2% lidocaine is provided and a 2 cm incision is made along the dorsum of the foot. A lymphatic duct is identified, tied with silk, and cannulated with a 30-gauge lymphangiography needle (Cook, Bloomington, Indiana). Ethiodized oil (Ethiodol; Savage Laboratories, Melville, New York or Lipiodol UltraFluide, Guerbet, Roissy, France) is infused at a rate of 8-10 mL/hour with a power injector into the lymphangiography needle.

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Fig. 3: Multiple images demonstrating the injection of methylene blue dye (A), creation of a longitudinal incision along the dorsum of the foot (B), and isolation of a lymphatic duct (C and D). References: Radiology, Harvard Medical School, Brigham and Women's Hospital / Harvard Medical School - Boston/US Lower Extremity Lymphangiography: •

Spot radiographs of the lower extremity are obtained every 15 minutes to monitor the progression of the ethiodized oil throughout the lower extremity. Page 7 of 22

• •

Evaluation is terminated when the ethiodized oil opacifies the cisterna chyli. Prophylactic administration of 500 mg levofloxacin is given for gastrointestinal flora.

Fig. 4: Multiple images demonstrating the injection of ethiodized oil into the lymphatic system (A) and evaluation of its progression through the lower extremity (B) and pelvis (C) (solid white arrows). References: Radiology, Harvard Medical School, Brigham and Women's Hospital / Harvard Medical School - Boston/US Cisterna Chyli Access and Cannulization: •

• •

Under fluoroscopic guidance, the opacified cisterna chyli, or prominent retroperitoneal duct, is accessed using a 21-gauge 15 cm needle with an inner stylet using a right transabdominal approach. Access is confirmed by injection of 1 mL of iodinated contrast material. Once targeted, the inner stylet is removed and an 0.018-inch guidewire (Boston Scientific, Natick, Massachusetts) is advanced through the thoracic duct and into the thorax.

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Fig. 5: Multiple images demonstrating the initial transabdominal access (A), continuous fluoroscopic monitoring to access the cisterna chyli (B), and guidewire placement into the thoracic duct (C). References: Radiology, Harvard Medical School, Brigham and Women's Hospital / Harvard Medical School - Boston/US Thoracic Duct Lymphangiography: • •

A 3 F straight Slip-Cath microcatheter (Cook, Bloomington, Indiana) is advanced over the guidewire into the thoracic duct. The wire is removed and iodinated contrast is injected to evaluate the type of thoracic duct and the level and degree of contrast extravasation.

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Fig. 6: Multiple lymphangiogram images demonstrating a normal appearing thoracic duct (A) (solid white arrows) and an abrupt cut off (B) with massive contrast extravasation (C) (solid white arrows) consistent with thoracic duct injury and leakage. References: Radiology, Harvard Medical School, Brigham and Women's Hospital / Harvard Medical School - Boston/US Thoracic Duct Embolization: • •

Embolization coils are deployed proximally along the entire course of the thoracic duct. A 2:1 ethiodized oil and N-butyl cyanoacrylate glue (Codman and Shurtleff, Raynham, Massachusetts) mixture with tantalum powder is used to complete the embolization of the distal thoracic duct and cisterna chyli.

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Fig. 7: Multiple images demonstrating the placement of embolization coils proximally (A) (solid white arrows) and N-butyl cyanoacrylate glue distally (B) (solid white arrows). References: Radiology, Harvard Medical School, Brigham and Women's Hospital / Harvard Medical School - Boston/US Thoracic Duct Embolization Success Rates: • • • • •

Overall technical success rate of 79% [12]. Overall clinical success rate of 55-73.8% [13,14]. Traumatic chylous leakage clinical success rate: 62% [12]. Nontraumatic chylous leakage clinical success rate: 13% [12]. Complication rates of 0-3% [13,14].

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Images for this section:

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Fig. 1: Schematic diagram demonstrating the normal course of the thoracic duct (solid green outline). Adapted from: Allaham AH, Estrera AL, Miller CC, Achouh P, Safi HJ. Chylothorax complicating repairs of the descending and thoracoabdominal aorta. Chest. 2006;130(4):1138-42.

Fig. 2: Coronal T2-weighted magnetic resonance images (A and C) and corresponding lymphangiogram images (B and D) demonstrating dilated lymphatic channels in the retrocrural spaces and retroperitoneum (solid white arrows).

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Fig. 3: Multiple images demonstrating the injection of methylene blue dye (A), creation of a longitudinal incision along the dorsum of the foot (B), and isolation of a lymphatic duct (C and D).

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Fig. 4: Multiple images demonstrating the injection of ethiodized oil into the lymphatic system (A) and evaluation of its progression through the lower extremity (B) and pelvis (C) (solid white arrows).

Fig. 5: Multiple images demonstrating the initial transabdominal access (A), continuous fluoroscopic monitoring to access the cisterna chyli (B), and guidewire placement into the thoracic duct (C).

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Fig. 6: Multiple lymphangiogram images demonstrating a normal appearing thoracic duct (A) (solid white arrows) and an abrupt cut off (B) with massive contrast extravasation (C) (solid white arrows) consistent with thoracic duct injury and leakage.

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Fig. 7: Multiple images demonstrating the placement of embolization coils proximally (A) (solid white arrows) and N-butyl cyanoacrylate glue distally (B) (solid white arrows).

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Conclusion The thoracic duct may be injured in a variety of surgical procedures as well as obstructing processes, predisposing individuals to chylothoraces, chylopericardium, and postoperative chylous wound leakages, leading to nutritional depletion and impaired respiratory function. Knowledge of thoracic duct anatomy coupled with awareness of appropriate thoracic duct embolization techniques allows highly successful treatment with minimal morbidity or mortality.

Personal information Jeffrey Forris Beecham Chick, MD, MPH PGY V Department of Radiology Brigham and Women's Hospital Harvard Medical School [email protected] Nikunj Rashmikant Chauhan, MD PGY V Department of Radiology Brigham and Women's Hospital Harvard Medical School [email protected] Alisa Siziki Han, MD Instructor of Radiology Brigham and Women's Hospital Harvard Medical School [email protected]

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Fig. 8 References: Radiology, Harvard Medical School, Brigham and Women's Hospital / Harvard Medical School - Boston/US Images for this section:

Fig. 8

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References [1] Skandalakis JE, Skandalakis LJ, Skandalakis PN. Anatomy of the lymphatics. Surg Oncol Clin N Am. 2007;16(1):1-16. [2] Agur AMR, Dalley AF, Grant JCB. Grant's Atlas of Anatomy. 11th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. [3] Dunn RP. Primary chylopericardium: a review of the literature and an illustrated case. Am Heart J. 1975;89(3):369-377. [4] Itkin M, Swe NM, Shapiro SE, Shrager JB. Spontaneous chylopericardium: delineation of the underlying anatomic pathology by CT lymphangiography. Ann Thorac Surg. 2009;87(5):1595-1597. [5] Doerr CH, Allen MS, Nichols FC, III, Ryu JH. Etiology of chylothorax in 203 patients. Mayo Clin Proc. 2005;80(7):867-870. [6] Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC. Postoperative chylothorax. J Thorac Cardiovasc Surg. 1996;112(5):1361-1365. [7] Dougenis D, Walker WS, Cameron EW, Walbaum PR. Management of chylothorax complicating extensive esophageal resection. Surg Gynecol Obstet. 1992;174(6):501-506. [8] Romero S. Nontraumatic chylothorax. Curr Opin Pulm Med. 2000;6(4):287-291. [9] Itkin M, Kucharczuk JC. Thoracic duct embolization (TDE) for non-traumatic chylous effusion: Experience in 31 patients. Chest. 2010;138(4, Suppl):654A. [10] Marts BC, Naunheim KS, Fiore AC, Pennington DG. Conservative versus surgical management of chylothorax. Am J Surg. 1992;164(5):532-534. [11] Thompson KJ, Kernstine KH, Grannis FW, Jr, Mojica P, Falabella A. Treatment of chylothorax by robotic thoracic duct ligation. Ann Thorac Surg. 2008;85(1):334-336.

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[12] Pamarthi V, Stecker MS, Schenker MP, Baum RA, Killoran TP, Suzuki Han A, O'Horo SK, Rabkin DJ, Fan CM. Thoracic duct embolization and disruption for treatment of chylous effusions: experience with 105 patients. J Vasc Interv Radiol. 2014 Sep;25(9):1398-404. [13] Cope C, Kaiser LR. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol. 2002;13(11):1139-1148. [14] Itkin M, Kucharczuk JC, Kwak A, Trerotola SO, Kaiser LR. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg.2010;139(3):584-589.

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