Procedure Guides
Fluid Management

Lymphangiography and Thoracic Duct Embolization

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Procedure Guide

  • Persistent, high volume (>1000 mL/d) chylothorax or low volume chylothorax that has failed 1-2 weeks of conservative management

    • Traumatic chylothorax (80%): thoracic surgeries, blunt/penetrating trauma

    • Non-traumatic chylothorax (20%): idiopathic, lymphoma > SLE, Behcet's, TB, congenital anomalies (e.g. Gorham’s dx, lymphangiomatosis), plastic bronchitis

    • Chylothorax risks: hypovolemia, malnutrition, and infection

  • Other chylous syndromes, e.g., chylous ascites, chyluria, lymphatic leaks

  • Obstruction and Collateral Flow, e.g., lymphocele

  • No safe access

  • Active right to left shunt for oil-based contrast

  • INR >1.7, Plts <50K, or uncorrected coagulopathy

  • Conservative management (low-fat diet or TPN and octreotide) often not successful but tried first (~28% efficacy).

  • Embolization: 70-80% efficacious without complications. Failures are often secondary to congenital lack of cisterna chyli or comparable target for canalization.

  • Surgical thoracic duct ligation is highly successful but has 35% morbidity and 2.1% mortality.

  • Obtain labs (PT/INR, CBC, CMP, GFR)

  • Consider dynamic contrast enhanced MR lymphangiography (DCMRL) to characterize anatomy.

  • Hold antiplatelet agents 5d pre-op if possible.

  • Some give prophylactic antibiotics.

  • Perform diagnostic lymphangiogram to ideally opacify the cisterna chyli for access and identify leak

    • Nodal approach is preferred due to efficiency

      • Access hila of bilateral inguinal lymph nodes with a 25G spinal needle attached to K50 tubing with lipidol syringe via a long lateral subcutaneous course for stability

      • Test injection of lipiodol to confirm access

      • Some will use Dermabond to further secure needle positioning

      • Slowly inject lipidol at 0.1-0.2 mL/min intermittently checking progress with fluoro (often takes a LONG time). Max dose of 6-8 mL unilateral, 12-16 mL bilateral.

      • Placing SCDs prior to the procedure can help make it more efficient.

    • Alternative is traditional pedal access

      • Inject methylene blue between toes just beneath the epidermis to identify lymphatic vessels on the dorsal aspect of the foot

      • Make an incision and carefully exposure the lymphatic vessel

      • Cannulate vessel with a 25G or smaller butterfly needle

      • Slowly inject lipidol as above

  • Percutaneously access the cisterna chyli or prominent retroperitoneal lymphatic duct with a 15 or 20 cm 22G chiba or 21G trochar needle under fluoroscopic guidance.

    • Classic teaching was to try to avoid traversing colon but later studies suggests it doesn’t matter.

  • Advance 0.018” wire (e.g. V-18) into the thoracic duct followed by a 2.4 Fr microcatheter over the wire

    • If unsuccessful, an alternative is thoracic duct disruption with the needle

  • Inject contrast to confirm positioning and perform diagnostic angiogram.

  • Embolize the thoracic duct - lots of variation, but often people use glue or coils and glue.

Alternative access techniques

  • Transvenous retrograde  - can obtain left cephalic or basilic access and try to access whether the thoracic duct traditionally drains into the confluence of the left IJ and subclavian, 4F or 5F RIM is a good catheter for this but challenging to select and lots of variable anatomy.

  • Direct retrograde - sometimes the termination of the thoracic duct can be visualized with ultrasound and directly accessed with a micropuncture set.

Diarrhea and LE swelling > infection, bleeding, injury to the aorta, IVC, intestine, or liver

Daily chest radiograph with chest tube in place until output <200 mL/d.