748 - Access of the Cisterna Chyli Through Axillary Intranodal Fluoroscopic Lymphangiography and Retrograde Thoracic Duct Approach

Learning Objectives: Review relevant lymphatic anatomy and current approaches to lymphangiography

Demonstrate an alternative approach to lymphangiography

Background: The cisterna chyli and thoracic duct serve as the body’s main lymphatic channel, ultimately draining a majority of lymphatic fluid into the junction of the left subclavian and jugular veins. Pedal and inguinal intranodal lymphangiography are well-documented techniques for visualizing and facilitating accessing the cisterna chyli, although it is limited if lymphatic channels in the groin are fibrotic or inaccessible. Patients with significant and unresolved chyle leaks following lymphangiogram may pose a challenge for interventional radiologists, due to the propensity of the lymphatic channels to sclerose after injection of Lipiodol, further limiting feasibility for repeat intervention. We present a successful case of axillary intranodal access used for visualization of the thoracic duct and retrograde access of the cisterna chyli.

Clinical Findings/Procedure Details: This exhibit presents a case of a 22-year-old heart and bilateral lung transplant patient presenting with persistent chylous ascites following unsuccessful left inguinal intranodal lymphangiogram 27 days prior.

Sonographic assessment did not identify a viable target in the groin, and attention was turned to the left axilla. Using a 25-gauge spinal needle, 2 mL of Lipiodol was hand-injected over 30 minutes under intermittent fluoroscopy. Contrast opacified the lymphatic chain and the thoracic duct.

The left brachial vein was initially accessed, which revealed complete collateralization of the left axillary vein. Venous access was then obtained through the right brachial vein and, using a 5 Fr Kumpe catheter, we successfully reached the thoracic duct in a retrograde fashion. Using a 2 Fr microcatheter and Fathom guidewire, we achieved thoracic duct access. Utilizing injection of contrast under fluoroscopic guidance, the microcatheter system was carefully advanced in a retrograde manner until reaching the cisterna chyli. A chyle leak was not visualized on lymphangiogram, and embolization was deferred. Following the procedure, the chylous component of ascites resolved within 1 month.

Conclusion and/or Teaching Points: Intranodal axillary access is a potential alternative approach for lymphangiography. Left axillary access may provide opacification of the thoracic duct to allow for retrograde access of the cisterna chyli, particularly in clinical scenarios where inguinal or pedal access is not feasible.