Solved on SIR Connect


By Joseph McBride, MD, Jackson Bennett, MD, Mithil B. Pandhi, DO, and Sudhen B. Desai, MD, FSIR


Feedback on lymphangiogram and thoracic duct embolization


Original post, lightly edited for flow bit.ly/3KNUDyF


Does anyone have a suggestion for performing a lymphangiogram/ thoracic duct embolization when there are no (or just tiny 2–3 mm) lymph nodes present in the pelvis and upper legs? I am working with a young patient who has already had thoracic duct clipping and continues to have a high output chylous pleural effusion but has no lymph nodes to access for performing a lymphangiogram.


Author background and current practice preferences for lymphangiograms and thoracic duct embolization:


Author name and contact information


Joseph McBride, MD, FRCPC jmcbride@unmc.edu Omaha, NE


I was in private practice for one year and have been involved in academics most of my career. I am now based in Nebraska where we cover a wide breadth of procedures.


When I was training, a few institutions were performing thoracic duct embolization. At that time, I had some experience with diagnostic lymphangiogram and began getting more referrals in this area about 12 years ago. Cardiothoracic and head and neck surgeons are our biggest referrals,


34 IRQ | SPRING 2022


usually for chylous leaks. We started performing more lymphangiograms, and typically we percutaneously accessed a uni- or bilateral inguinal nodes or the cisterna chyli directly depending on the indication.


Please elaborate on the specific patient background and presentation in this case. The patient in this case was a younger patient with a history of chylous pleural effusion. Cardiothoracic surgery had explored and put clips into a potential leak. When the effusion recurred, we were asked to see the patient in consultation for a lymphangiogram and potential thoracic duct embolization. We did a pelvis CT where we were able to see tiny lymph nodes in the pelvis. One of these nodes was accessible under ultrasound, but when lymphangiogram was attempted we did not get a typical appearance and the other lymph nodes were not easily accessible. This prompted me to ask for advice on SIR Connect.


How was lymphangiogram performed in this case? After gathering advice from SIR Connect and performing a literature search on the topic, I decided accessing the left arm might be our best bet for performing a lymphangiogram. We ended up accessing the arm like a PICC but using a bigger sheath, reverse curve catheter through the subclavian vein, and catheterizing the thoracic duct as it comes into the vein in that region. We used a 2.4 Fr microcatheter via retrograde access to get into the duct. Getting deep into the chest was a bit more challenging due to small duct size in this patient. We were able to


identify what appeared to be a small leak and injected some ethiodol. This slowed down the patient’s pleural effusion for 3–4 days, after which the patient was placed on a full fat diet and the effusion reaccumulated. A few weeks later after dietary restriction, the pleural effusion improved.


Which specific methods, techniques or considerations do you find useful in performing a lymphangiogram? I will consider using the subclavian approach in the future as a good first step after the shorter amount of time it took to get in and obtain access. It is important to consider general anesthesia given it can be painful to access the cisterna chyli, especially for a younger patient population. Deep venous thrombosis compression devices also play an important role periprocedurally and can make all the difference in the world in helping to see the cisterna chyli. Additionally, the risk of deep venous thrombosis is not small in these patients especially if they are on the table for several hours. Depending on the case, we tend to keep these devices on.


Does embolic choice for thoracic duct embolization matter? The biggest consideration for embolic agents involves the route of access. Using glue when accessing from below is okay because trying to reroute lymphatics, and you are essentially internally ligating below the leak. The risk of this includes leg swelling and lymphedema, but this is easier to deal with than a chest tube in place 24/7. Coming from the arm, injecting something like glue, unless you get it right down where it needs to go, could


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