PERCUTANEOUS THORACIC DUCT EMBOLIZATION
HOW I DO IT

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PERCUTANEOUS MANAGEMENT OF CHYLOUS LEAKS

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THORACIC DUCT EMBOLIZATION

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CONFLICT OF INTEREST

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Introduction

 

- Approximately 2-3 l of chyle is transported thought the lymphatic system every day. 80% of this fluid comes from the intestinal and hepatic lymphatic ducts.

 

- Damage or rupture of the thoracic duct can give rise to a rapid accumulation of fluid in the pleural space, condition known as chylothorax.

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TORACIC DUCT: ANATOMY

Introduction

 

- Approximately 2-3 l of chyle is transported thought the lymphatic system every day. 80% of this fluid comes from the intestinal and hepatic lymphatic ducts.

 

- Damage or rupture of the thoracic duct can give rise to a rapid accumulation of fluid in the pleural space, condition known as chylothorax.

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TORACIC DUCT: ANATOMY

 

- The thoracic duct (TD) is the largest lymphatic duct in the body, measuring up to 45 cm in length and 2-5 mm in diameter.

- TD drains lymph and chyle from the entire body except the right hemi-thorax, right head and neck and right arm.

- TD originates in the upper abdomen at the cisterna Chyli (CC) and enters in the thoracic cavity at the aortic hiatus (aorta on its left and azygos vein on its right)

- TD ascents along the anterior surface of the vertebrae and drains into the confluence of the great veins of the left neck.

 

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TORACIC DUCT: ANATOMY

- The Cisterna Chyli (CC) is a triangular or oblong sac measuring 3-5 cm in length. On lympho, its dimensions are smaller (1 cm wide and 2 cm long)

- CC typically located at the L1-L2  level, just right to the aorta. 

- CC not always visualized, present in 30% to 53% of the lymphangiographic studies and from 76% to 96% on MR ductography.

- CC receives the R and L lumbar trunks, the intestinal trunk, the lowest intercostal trunk and the hepatic lymphatic ducts.

 

 

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TORACIC DUCT: ANATOMY

- The course of the TD can be predominantly left-sided, right-sided or bilateral if it is duplicated.

- The typical pathway occurs in only 65% of the population due to embryological variations

 

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TORACIC DUCT: ANATOMY

Gen Thorac Cardiovasc Surg 2009;57(12):640

J thorac Surg 1957;34(5):631

- Traumatic

 

Iatrogenic

Non-iatrogenic (20% of traumatic cases)

 

- Non traumatic

 

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CHYLOTHORAX

Respiratory Medicine 2010; 104:1-8

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CHYLOTHORAX

Respiratory Medicine 2010; 104:1-8

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CHYLOTHORAX

Respiratory Medicine 2010; 104:1-8

Clinical symptoms

 

- Chyle loss: Hypovolemia and respiratory difficulty

 

- Protein loss: Malnutrition

 

- Electrolyte loss: Hyponatremia and hypocalcemia

 

- Immunoglobulin and T lymphocytes loss: Immunosupression  


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CHYLOTHORAX

Respiratory Medicine 2010; 104:1-8

Diagnosis

 

- Milky appearance

 

- Presence of chylomicrons in the pleural fluid.

 

- Pleural fluid triglyceride > 110 mg/dl: 1% chance of being 

non-chylous

 

- Pleural fluid triglyceride < 50 mg/dl: 5% chance of being chylous


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CHYLOTHORAX

Respiratory Medicine 2010; 104:1-8

Treatment

 

- Conservative treatment

NPO, chylothorax drain, low fat medium chain tryglicerides, TPN, Somatostatin/octreotide.

- Treatment of underlying condition

Sarcoid/steroids, CHF/diuretics, Chemo/RDT

- Surgical management

Pleurodesis. Thoracic duct ligation. Success: 67%

- Percutaneous management


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CHYLOTHORAX


 

- INTRANODAL LYMPHANGIOGRAM

 

 

- THORACIC DUCT EMBOLIZATION (TDE)

 

 

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

INTRANODAL LYMPHANGIOGRAM

 

- Inguinal lymph nodes are typically targeted for cannulation to perform a lymphangiogram.  The inguinal lymph nodes are divided into superficial and deep nodal groups; the superficial lymph nodes are of interest for lymphangiography.  These nodes lie in the femoral triangle of Scarpa ( Bullfighter Triangle). 

 

 

 

 

 

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

INTRANODAL LYMPHANGIOGRAM

 

 

 

 

 

 

CD pass 1.jpg

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

INTRANODAL LYMPHANGIOGRAM

 

 

 

 

 

 

Intranodal lymphangiography.jpgCD pass 3.jpgCD pass 2.jpg2014-02-10 10.22.57.jpg

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

INTRANODAL LYMPHANGIOGRAM

 

 

 

 

 

 

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

INTRANODAL LYMPHANGIOGRAM

 

 

 

 

 

 

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

INTRANODAL LYMPHANGIOGRAM

 

 

 

 

 

 

CD pass 5.jpgDinesh patel Presby 2.jpgDR CHP 5.jpg

Lipiodol injection: Rate 1 ml/4 minutes

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

INTRANODAL LYMPHANGIOGRAM

 

 

 

 

 

 

DR CHP 7.jpgDR CHP 8.jpgDR CHP 9.jpgDR CHP 10.jpg

11 yo male with Hx of possible nontraumatic chylothorax

* If the TD is normal, with no leak, TDE should not be performed 

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

TDE

 

 

 

 

 

 

Material: 

 

- 21-22 gauge needle, 15-20 cm Chiba needle. 


- Stiff 0.018-inch guidewire (V18 Control, BS)


- Microcatheter, Rapid Transit (Johnson&Johnson), 65 cm.

 

- Coils


- Glue (Truefill Cordis, Histoacryl)


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TORACIC DUCT EMBOLIZATION: TECHNIQUE

TDE

 

 

 

 

 

 

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

TDE

 

 

 

 

 

 

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

TDE

 

 

 

 

 

 

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

TDE

 

 

 

 

 

 

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C:\Documents and Settings\santose\Desktop\Lymphangiography\Therapeutic Lymphangiography\DP CASE 22 2jpg.jpgC:\Documents and Settings\santose\Desktop\Lymphangiography\Therapeutic Lymphangiography\DP C 22 5.jpg

TORACIC DUCT EMBOLIZATION: TECHNIQUE

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C:\Documents and Settings\santose\Desktop\Lymphangiography\Therapeutic Lymphangiography\DP CASE 22 6.jpg

TORACIC DUCT EMBOLIZATION: TECHNIQUE

Dinesh patel Presby 7.jpg
  • Advancement of the 0.018 guidewire in the thoracic duct.

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

Dinesh patel Presby 9.jpgDinesh patel Presby 10.jpg

- Removal of 22 G needle and advancement of the microcatheter. Contrast injection to confirm the level of the leak.

Dinesh patel Presby 11.jpg

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

Dinesh patel Presby 14.jpg

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

Sam Be Presby 4.jpgSam Be Presby 5.jpgSam Be Presby 6.jpgSam Be Presby 7.jpgSam Be Presby9.jpg

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

LAM Yola Mar Presby 1.jpgLAM Yola Mar Presby 2.jpgLAM Yola Mar Presby 5.jpg

28 yo female with LAM. Chylothorax after lung transplant. No filling of the cisterna chyli and TD

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

CD pass 7.jpgCD pass 8.jpgCD pass 9.jpg

76 yo male with esophageal ca and minimally invasive esophagectomy with gastric pull through

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TORACIC DUCT EMBOLIZATION: TECHNIQUE

76 yo male with esophageal ca and minimally invasive esophagectomy with gastric pull through

CD pass 10.jpgCD pass 11.jpgCD pass 12.jpgCD pass 13.jpgCD pass 14.jpgCD pass 17.jpgCD pass 18.jpg

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dd 15 4.jpgdd 15 2.jpg

Mesenteric ischemia. SMA occlusion. Aortomesenteric by-pass. Chylous ascites and chylothorax. Output: 2000 cc per day.

 

dd 15 3.jpg

TORACIC DUCT EMBOLIZATION: TECHNIQUE

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dd 15 5.jpgdd 15 6.jpg

Mesenteric ischemia. SMA occlusion. Aortomesenteric by-pass. Chylous ascites and chylothorax. Output: 2000 cc per day.

 

dd 15 12.jpgdd 15 13.jpgdd 15 16.jpgdd 15 15.jpg

TORACIC DUCT EMBOLIZATION: TECHNIQUE

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61 yo patient with AO mesenteric, renal and hepatic by-passes and AO bifem by-pass. Chylous ascites and chylothorax. Output: 1300 cc per day.

 

TORACIC DUCT EMBOLIZATION: TECHNIQUE

D Allen Shy 10.jpgD Allen Shy 11.jpg

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61 yo patient with AO mesenteric, renal and hepatic by-passes and AO bifem by-pass. Chylous ascites and chylothorax. Output: 1300 cc per day.

 

TORACIC DUCT EMBOLIZATION: TECHNIQUE

D Allen Shy 1.jpgD Allen Shy 2.jpg

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61 yo patient with AO mesenteric, renal and hepatic by-passes and AO bifem by-pass. Chylous ascites and chylothorax. Output: 1300 cc per day.

 

TORACIC DUCT EMBOLIZATION: TECHNIQUE

D Allen Shy 6.jpgD Allen Shy 7.jpgD Allen Shy 9.jpgD Allen Shy 5.jpg

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TORACIC DUCT EMBOLIZATION: OUTCOMES

Cope published the first large series of 42 patients: 

 

Success rate following TDE and TD disruption was reported to be 73.8%.

 

This study included patients with both traumatic and non-traumatic causes of chylothorax.


Cope C, Kaiser LR. Management of chylothorax by percutaneous catheterization and embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol 2002; 13:1139-1148 

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TORACIC DUCT EMBOLIZATION: OUTCOMES

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; 139:584-589.

TDE in traumatic chylothorax

 

 

 

 

 

 

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TORACIC DUCT EMBOLIZATION: OUTCOMES

Nadolski GJ, Itkin M. Thoracic duct embolization (TDE) for nontraumatic chylous effusion: experience in 34 patients. Chest 2013; 143:158-163.

TDE in nontraumatic chylothorax

 

 

 

 

 

 

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TORACIC DUCT EMBOLIZATION: FUTURE

- Hybrid technology will increase the success rate during the catheterization of the TD

 

- CT/MRI + Fluoroscopy

 

- When TD embolization is not possible or in cases with chylous leaks in abdomen and pelvis, ancillary US/CT/MRI guided interventions can help to seal the chylous leaks off. 

Praveen A, Sreekumar KP. Technical note: thoracic duct embolization for treatment of chylothorax: a novel guidance technique for puncture using combined MRI and fluoroscopy. Indian J Radiol Imaging 2012; 64:5-11

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TORACIC DUCT EMBOLIZATION: FUTURE

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Cerdan Santacruz, C, Ildefonso Martin JA, Santos E. Percutaneous embolization of cervical thoracic duct leak.  Cir Esp 2011, 89:325