Thoracic Duct Interventions: A Comparison of Outcomes Across a Variety of Approaches

Treatment options available for management of iatrogenic or idiopathic chylothorax has significantly grown in the last decade.  Thoracic duct embolization (TDE), cryoablation, maceration, stenting, and lipiodol lymphangiography (LL) alone have been shown to provide variable degrees of success.  This study aims to compare the outcomes of these variable approaches performed at a single institution. 

Materials and Methods:

Single-center retrospective study reviews the images and records of patients who underwent lipiodol lymphangiography, TDE, thoracic duct ablation, thoracic duct needle maceration, and thoracic duct stenting.  Demographic data, cause of chylous effusion, thoracic duct anatomy, and procedure-specific factors, such as type of embolic used, etc., are evaluated. Outcomes were reviewed, including need for additional intervention or surgery, changes in chylous effusion drainage catheter output, changes in radiographic appearance of effusion on follow up chest x rays, and time to discharge following intervention.

Results:

This study includes 41 unique patients, and a total of 66 separate thoracic duct interventions.  24 of these patients had a single intervention, 6 of these patients had two interventions, and the remaining patients had more than three interventions, with one of these having ten interventions for thoracic duct stenting.  Of the patients who had a single intervention, technical success—as defined by diminished chest tube output and improved chest x rays following intervention—was achieved 74 percent of the time within 72 hours.  Thoracic duct cannulation and embolization provided the best immediate outcome in patients with traumatic or iatrogenic injury, though it did not provide significant improvement in patients with malignant chylothorax when compared with maceration or LL alone.  Single intervention with maceration or LL alone showed improvement within 6 days typically. On the three patients who underwent thoracic duct cryoablation, technical success was achieved in each of them, however each of these patients had undergone LL prior to ablation. 

Conclusion:

A variety of techniques for management of symptomatic chylous effusion exist.  While TDE remains the most effective treatment strategy, technical success is highly dependent on etiology of chylothorax and operator experience.  LL and thoracic duct maceration shows comparable albeit limited impact on malignant chylothorax.  Cryoablation shows promise as well, especially when combined with LL, highlighting a need to explore this option further.