SIR 2024
Embolization
Nathaniel Mizraki, MD
Radiology Resident
Cedars-Sinai Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Gabriel Lipshutz, MD
Disclosure information not submitted.
The thoracic duct is the major lymphatic channel of the body, originating from the cisterna chyli at the level of the T12 vertebral body and draining into the confluence of the left subclavian and internal jugular veins. Injury to the thoracic duct is a known complication of thoracic surgery, occurring in approximately 1% of cases {1}. Thoracic duct injury can result in chylothorax, with symptoms including respiratory difficulty and malnutrition. Chylothorax is initially managed with conservative therapy which typically consists of octreotide, a low-fat diet, and thoracenteses. However, conservative therapy is often unsuccessful and surgical management is thus required for definitive treatment. Thoracic duct embolization has emerged as a potential option for treatment of chylothorax refractory to conservative management, with success rates reported at 71% {2}.
Clinical Findings/Procedure Details:
In this educational exhibit, we will describe several advanced techniques of thoracic duct cannulation for subsequent embolization through a series of case examples. The classic technique is via direct transabdominal access to the cisterna chyli after lymphangiography using a 21- or 22-gauge needle. The successes of this method are well documented, although it can be challenging in patients with atypical anatomy. In patients who lack a cisterna chyli whether due to variant anatomy or prior surgical resection, retrograde access to the thoracic duct via the left subclavian vein can be performed using an 0.018-inch wire and microcatheter system. Alternatively, direct retrograde access to the thoracic duct can also be attained percutaneously in the left neck with a 22-gauge needle. With the utilization of advanced techniques, cannulation of the thoracic duct can be achieved in a greater population of patients, resulting in improved success rates for thoracic duct embolization.
Conclusion and/or Teaching Points:
Chylothorax is a major source of morbidity in patients with iatrogenic thoracic duct injury, and thoracic duct embolization is a safe and effective option for patients in whom conservative management is unsuccessful. Cannulation of the thoracic duct for embolization can pose a procedural challenge, particularly in patients with variant anatomy, and advanced techniques can be employed to optimize outcomes.