Management of Unremitting Chylothorax by Percutaneous Embolization and Blockage of Retroperitoneal Lymphatic Vessels in 42 Patients

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PURPOSE

To demonstrate the applicability, technique, and efficacy of percutaneous transabdominal catheter embolization or needle disruption of retroperitoneal lymphatic vessels in the treatment of high-output or unremitting chylothorax.

MATERIALS AND METHODS

Forty-two patients (21 men, 21 women; mean age, 56 y; range, 19–80 y) who had chylothorax with various etiologies were referred from the thoracic surgery department for treatment as soon as chylothorax was documented. The thoracic duct was punctured and catheterized via a peritoneal cannula to facilitate embolization with use of microcoils, particles, or glue; if there were no lymph trunks that could be catheterized, attempts were made to disrupt lymph collaterals with use of needles.

RESULTS

The thoracic duct was catheterized in 29 patients and embolized in 26 patients. In patients with lymph trunks that could be catheterized, treatment resulted in cure within 7 days in 16 patients and partial response with cure within 3 weeks in six patients. In the patients with lymph trunks that could not be catheterized (n = 16), disruption with use of needles resulted in cure in five patients and partial response in two patients. Cure and partial response rates after thoracic duct embolization and needle disruption were 73.8%, with no morbidity. Surgical thoracic duct ligation was performed in seven patients. The nonprocedural mortality rate was 19%. Follow-up was 3 months or longer.

CONCLUSIONS

Effective percutaneous treatment of high-output or medically uncontrollable chylothorax was performed promptly and safely in more than 70% of referred cases. This procedure should be attempted, especially if patients are very ill, before riskier surgical thoracic duct ligation is considered.

Section snippets

Study Group

Forty-two patients were treated during a period of 4 years for the management of symptomatic chylothorax (Table 1). All patients were referred from our institution's cardio-thoracic department because of high-output chylothorax or from outside institutions because of recurrent bouts of chylous pleural effusions, which could not be cured by diet, repeated thoracentesis, pleurodesis, or surgical TD ligation. These interventional procedures were performed immediately after the chylous effusion was

RESULTS

The ability to catheterize the TD after lymphography was completely dependent on the availability of suitably sized cisternae chyle or retroperitoneal lymphatic trunks; it was possible to successfully catheterize all uninterrupted lymphatic channels that were more than 2 mm in diameter. In 26 patients, the TD was catheterized via recognizable cisterna chyli in 22 procedures and retroperitoneal lymphatic trunks in seven procedures (Table 2).

In the 16 patients in whom lymphatic trunks could not

DISCUSSION

The TD is a 2–4-mm-wide duct with multiple valves, which arises from the cisterna chyli in the upper abdomen to empty either directly or through multiple branches into the left jugular or subclavian veins. The flow of chyle in the TD varies from 2 to 4 L/d. In the presence of an untreated chylothorax, the major loss of chyle, which contains 2%– 6% protein and 80% T-cells and electrolytes, can lead patients to experience life-threatening weakness, dehydration, edema, emaciation, and hemodynamic

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From the 2002 SCVIR Annual Meeting. Neither of the authors has identified a conflict of interest.

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