cause major problems, like ligating duct at its insertion.


I have used coils before, but usually in conjunction with glue to serve as a matrix. Glue by itself does not set up in the lymphatic system as it does in blood.


What post or posts were most valuable to you and why? Posts outlining a subclavian approach were the most valuable for me in this case. The posts on SIR Connect helped me formulate a plan, and in the future I will be using a more systemic approach when I gauge access from above or below the leak for chylous pleural effusion versus ascites.


Will you, or have you changed your practice patterns based off responses on SIR Connect? Please describe any changes you are considering. Yes, in the future I will consider taking a subclavian approach in a lot more patients.


An additional technique I also considered in a case like this would be approaching infectious disease to see if the patient had vaccines that were due, and if administering these would result in adenopathy amenable to percutaneous access.


Additional commentary: Chylous effusion is defined as a leakage of lymph fluid from the intestinal lymphatics system1


into the thoracic


(chylothorax) or peritoneal cavity (chyloperitoneum). Chylous leaks can occur iatrogenically from cardiac or head and neck surgery, trauma, malignancy, lymphatic vessel disease and infection.1,2


by embolization with a combination of coils and glue proximal to the leak.1,4,5 A meta-analysis conducted by Kim et al reviewed lymphatic interventions for chylothorax and found a pooled technical and clinical success rate of TDE between 63% and 79%, respectively.6 In a cohort of 34 patients with non- traumatic chylous effusion, intention- to-treat success rate was reported as 52%.4


Identification of the leak location


and presence of a normal thoracic duct with lymphangiography, traumatic versus non-traumatic etiology, technical success in catheterizing the thoracic duct and lower postprocedural effusion volumes have all been shown to impact success rates.1,2,4,6


The traditional pedal lymphangiogram has historically been described as technically challenging and tedious in comparison to newer methods such as intranodal access.1,2,7


This technique


includes a right-sided dorsal foot cutdown and cannulation of a pedal lymphatic vessel using a 30-guage needle.2


Ethiodol is administered


and contrast is serially monitored under fluoroscopy until progression to the cisterna chyli, which is then accessed in standard fashion.2


As


discussed in this case, many additional potential approaches to performing a lymphangiogram have been previously described,3


including intranodal,


percutaneous transabdominal, direct and percutaneous transcervical access, and percutaneous transvenous retrograde techniques.3


The


percutaneous approach involves access into bilateral inguinal nodes under ultrasound guidance using a 25-gauge needle.1,7


After lymphatic anatomy is The pathophysiology is


attributed to disruption of the thoracic duct resulting in loss of protein, vitamins and immunoglobulins.3 Chylothorax is typically treated with dietary modification (medium chain fatty acid diet, total parenteral nutrition), surgical management (pleurodesis, thoracic duct ligation) for persistent chylous leaks that fail initial treatment,3,4 embolization (TDE).4


and thoracic duct


TDE is a percutaneous, minimally invasive treatment that is traditionally performed by lymphangiogram followed


delineated with ethiodol contrast, a Chiba needle and microwire system are fluoroscopically advanced into the thoracic duct. If a thoracic duct leak or injury is identified, an attempt is made to advance a microcatheter as close as possible to an injury.7


The


thoracic duct or leak source are then embolized upstream with coils, which provide a scaffolding for glue.1,7


The


retrograde transvenous approach has been recently described and involves left brachial or basilic vein access with identification of the thoracic duct ostium via a subclavian venogram. This technique can be technically challenging


and is used in circumstances where the cisterna chyli is inadequately seen on lymphangiogram.3,8,9


Research


comparing efficacy and outcomes of retrograde transvenous versus traditional percutaneous approaches would be of benefit when considering an approach.


References


1. Higgins CSSM, Itkin M. Thoracic duct embolization for chylothorax. Handbook of Interventional Radiologic Procedures. Krishna Kandarpa et al., Lippincott Williams & Wilkins. 2016:453–459.


2. Pamarthi V, Stecker MS, Schenker MP, Baum RA, Killoran TP, Han AS, O’Horo SK, Rabkin DJ, Fan C. Thoracic duct embolization and disruption for treatment of chylous effusions: experience with 105 patients. JVIR. 2014;25(9):1398–1404.


3. Toliyat M, Singh K, Sibley RC, Chamarthy M, Kalva SP, Pillai AK. Interventional radiology in the management of thoracic duct injuries: anatomy, techniques and results. Clin Imaging. 2017;43:183–92.


4. Nadolski GJ, Itkin M. Feasibility of ultrasound- guided intranodal lymphangiogram for thoracic duct embolization. JVIR. 2012;23 (5):613–16.


5. Nadolski GJ, Itkin M. Thoracic duct embolization for nontraumatic chylous effusion: Experience in 34 patients.” Chest. 2013;143(1):158–63.


6. Kim PH, Tsauo J, Shin JH. Lymphatic interventions for chylothorax: A systematic review and meta-analysis. JVIR. 2018;29(2):194-202.e4.


7. Gilyard SN, Khaja MS, Goswami AK, Kokabi N, Saad WE, Majdalany BS. Traumatic chylothorax: Approach and outcomes. Semin Intervent Radiol. 2020;37(3):263–68.


8. Mittleider D, Dykes TA, Cicuto KP, Amberson SM, Leusner CR. Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites. JVIR. 2008;19(2):285–90.


9. Yuya K, Nishimura J, Hirai C, Moriya N, Katsumata Y. Percutaneous transvenous embolization of the thoracic duct in the treatment of chylothorax in two patients. JVIR. 2013;24(1):135–37.


Disclaimer: This column represents the work and opinions of the contributing authors and do not necessarily reflect the views or policies of SIR. SIR assumes no liability, legal, financial or otherwise, for the accuracy of information in this article or the manner in which it is used. The statements made in the column are not intended to set a standard of care and should not be treated as medical advice nor as a substitute for independent, professional judgment.


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