Interventional procedure overview of percutaneous thoracic duct embolisation for persistent chyle leak

Alejandre-Lafont E, Krompiec C, Rau WS et al. (2011) Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol; 52: 305–311.

Case series

N=34 patients with lymphatic leaks (due to traumatic/malignant issues)

Lymphangiography was technically successful in 88% (30/34) and clinical success in 55% (16/29).

Included in systematic review added to the summary of evidence.

Bazancir LA, Jensen RJ, Frevert SC et al (2021) Embolization of the thoracic duct in patients with iatrogenic chylothorax. Diseases of the Esophagus, 34,1–8

Retrospective case series

N=patients with iatrogenic chylothorax treated with TDE.

.Lymphography was done in all and visualization of cisterna chyli was achieved in 83% (14/17) patients. Of the 17 patients included, 15 patients were successfully embolized and cured of chylothorax (88.2%). Median discharge time 7 days. Most patients reported post-procedural pain, which was treated with medications.

Larger studies included in the overview summary.

Boffa DJ, Sands MJ, Rice TW, et al. (2008) A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery. Eur J Cardiothorac Surg; 33:435–439.

N=37 patients with thoracic duct injuries had TDE (in 25) and TDD (9).

Lymphangiography was successful in 97%. In patients who had TDE, technical success was 48% (12/25) and clinical success was 100%. In those who had TDD, clinical success was 56% (5/9). The median time to discharge was 8 days with TDE and 19 days with TDD.

Included in systematic review added to the summary of evidence.

Bundy JJ, Chick JFB, Cline JMR et al. (2019) Percutaneous fluroscopically guided trans cervical retrograde access facilitates successful thoracic duct embolisation after failed antegrade transabdominal access. Lymphology (52), 52-60.

Case series

N=5 patients had TDE after failed transabdominal cisterna chyli cannulation for chylothorax.

Median follow-up 372 days.

Transcervical retrograde thoracic duct access and treatment was technically successful in all. No major or minor adverse events occurred. Clinical success was achieved in all.

Larger studies included in the overview summary.

Chen E, Itkin M. (2011) Thoracic duct embolization for chylous leaks. Semin Intervent Radiol;28:63–74.

Review describes the aetiologies of chylothorax, patient population, outcomes, and long-term follow-up of TDE patients.

Lymphatic anatomy physiology, and the formation of the duct by tributaries at the cisterna chyli are reviewed. The technique of TDE, including bilateral pedal lymphangiography, TD cannulation, and embolic agents used are outlined.

Review

Chen CS, Kim JW, Shin JH et al. (2020) Lymphatic imaging and intervention for chylothorax following thoracic aortic surgery. Medicine;99:34(e21725).

Case series

N=9 patients who had chylothorax interventions after thoracic aortic surgery.

The technical success rate of lymphangiography was 89% (8/9).The technical success rates of antegrade and retrograde TDE were 75% (6/8) and 100% (3/3). Clinical outcomes after embolisation were similar between low and high output chylothorax patients. The drainage amount decreased significantly. Clinical success rate of TDE was 88% (7/8).

Larger studies included in the overview summary.

Cope C, Salem R, Kaiser LR. (1999) Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: Prospective trial. J Vasc Interv Radiol; 10:1248–1254. 32.

Case series

N=11 patients with high output chylothoracic effusions had lymphangiography and TDE with platinum coils.

The thoracic duct was successfully catheterized in 5 patients who had major retroperitoneal lymphatic trunks, (45% technical success rate), embolisation was done in 4 patients and curative in 2. Previous abdominal surgery, aortic dissection, and lymph-angioleiomyomatosis can lead to silent occlusion of retroperitoneal lymphatic trunks.

Data included in Itkin 2011 and Nadolski 2013 added to systematic review.

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

Case series

N=42 patients who had chylothorax with various aetiologies and TDE with micro-coils particles or glue.

Follow up 3 months

The thoracic duct was catheterized in 29 patients and embolized in 26 patients. 16 patients were cured within 7 days and partial response was seen within 3 weeks in 6 patients. In the patients who could not be catheterized (n= 16), TDD resulted in cure in 5 patients and partial response in 2 patients. TDL was performed in 7 patients. The nonprocedural mortality rate was 19%.

Data included in Itkin 2011 and Nadolski 2013 added to systematic review.

Guevara CJ, Rialon KL, Ramaswamy RS et al. (2016) US-guided, direct puncture retrograde thoracic duct access, lymphangiography, and embolization: feasibility and efficacy. J Vasc Interv Radiol; 27:1890–1896.

Case series

N=10 patients with thoracic duct leaks had thoracic duct embolisation (TDE) via US-guided retrograde TD access.

Mean follow-up 5.4 months (range, 3-10 months).

All attempts at TD access via the neck were successful. Technical and clinical success of TDE was 60%. There were no complications. Mean TD access time was 17 minutes and mean total procedure time was 49 minutes.

Larger studies included in table 2.

Itkin M, Kucharczuk JC, Kwak A et al. (2010) Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg; 139:584–590

Case series

N=109 patients

106 with traumatic thoracic duct leak had INL,

TDE (with coils or embolic agent) or TDD

Lymphangiography was technically successful in 99%, and TDE in 66% (69/105). Clinical success was achieved in 87% (57/66) in those who had TDE and 71% (12/17) who had TDD.

Included in systematic review added to the summary of evidence.

Itkin M, Chen EH (2011) Thoracic duct embolization. How I do it. Semin Intervent Radiol;28:261–266.

Description of technique.

No extractable data.

Jayasinghe SA, Srinivasa RN, Hage AN et al. (2018) Thoracic duct embolization: analysis of practice patterns. Ann Vasc Surg; 52: 168–175

Survey of practice patterns of TDE

N=47 interventional radiologists.

TDE is performed by practitioners in both academic and private practice settings. Treatment techniques were similar for a majority of operators. Technical success rates were higher in private practice. Most referrals were from thoracic surgery.

Survey

Jeon YJ, Cho JH, Hyun D et al. (2021)Management of chyle leakage after general thoracic surgery: Impact of thoracic duct embolization. Thorac Cancer;12:1382–1386.

Retrospective case series

N=105 patients who developed chyle leakage after surgery

(49 due to lung surgery, 30 due to pulmonary resection, 8 after esophagectomy)

Only 10 had TDE procedures and 9 patients underwent TDL.

.

5 patients (16.7%) received TDE after lung surgery and 5 patients (27.7%) after esophageal surgery. Also, the hospital stay of patients who underwent pulmonary resection was shorter than patients who had lung surgery (12.6 days versus. 16.3 days; p = 0.026).

More comprehensive studies added to the overview summary.

Kim SK, Thompson RE, Guevara CJ et al. (2020) Intranodal Lymphangiography with Thoracic Duct Embolization for Treatment of Chyle Leak after Thoracic Outlet Decompression Surgery. Journal of vascular and interventional radiology, 31 (5), 795-800.

Case series

N= 9 patients had ultrasound-guided intranodal lymphangiography for chyle leak following thoracic outlet decompression surgery.

Mean follow-up 304 days

The technical success rate of TDE was 67% (6/9), fluoroscopic transabdominal antegrade access (n =4) and ultrasound-guided retrograde access (n = 2). Clinical success was achieved in 89% patients (8/9). The mean interval from lymphangiography to drain removal was 6.6 days (range, 4–18 d). No patients had a chyle leak recurrence.

Larger studies included in the overview summary.

Pamarthi V, Stecker MS, Schenker MP et al. (2014) Thoracic duct embolization and disruption for treatment of chylous effusions: experience with 105 patients. J Vasc Interv Radiol; 25:1398–1404.

N=105 patients with chylous effusions (traumatic in 97, malignancy in 4 and other reasons in 4) had TDE/TDD.

INL technical success 89.5% (94/105), TDE technical success in 57% (53/94), clinical success 72% (38/53). TDD clinical success in 62% (23/37).

Included in systematic review added to the summary of evidence.

Nadolski DJ, Itkin M. (2013) Thoracic duct embolization for nontraumatic chylous effusion experience in 34 patients. original Research Disorders of the Pleura. 143 (1),158-163.

Retrospective case series

N=34 patients with nontraumatic chylous effusions underwent TDE (n=31).

TDE was successful in 50% cases of thoracic duct occlusion and extravasation. Lymphangiography is important for identifying the cause of chylous effusions and selecting patients who benefit most from TDE. Complication was reported in 1 patient.

Included in systematic review added to the overview.

Nadolski G, Itkin M. (2012) Feasibility of ultrasound guided intranodal lymphangiogram for thoracic duct embolization. J Vasc Interv Radiol; 23: S103–S104

Case series

N=6 patients had Intranodal lymphangiography and TDE for chylothorax.

Opacification, catheterization, and embolisation of the thoracic duct was successful in all cases. Using IL, the thoracic duct may be more quickly visualized and catheterized for TDE than with PL.

Larger studies included in the overview summary.

Marthaller KJ, Johnson SP, Pride RM et al. (2015) Percutaneous embolization of thoracic duct injury post-esophagectomy should be considered initial treatment for chylothorax before proceeding with open re-exploration. The American Journal of Surgery. 209, 235-239

Case series

N=5 patients with refractory chylous fistula post-esophagectomy were treated with percutaneous embolisation.

Successful ablation of the chylous fistula was achieved in 80% (4/5) patients. Pre-treatment chylous output averaged 1,756 mL/day. A modified technique is detailed, which utilizes direct puncture of groin lymph nodes to facilitate opacification of the thoracic duct.

Larger studies included in the overview.

Majdalany BS, Saad WA, Beecham chick JF et al. (2018) Pediatric lymphangiography, thoracic duct embolization and thoracic duct disruption: a single-institution experience in 11 children with chylothorax. Pediatr Radiol. 48:235–240

Case series

N=11 paediatric patients who underwent lymphangiography and thoracic duct embolisation.

Lymphangiography was technically successful in all patients. In 37% (3/8) procedures, disruption was performed when the central lymphatics could not be accessed. Clinical success was achieved in 7/11 (64%) children. 3 minor complications were reported.

Paediatric study.

Moussa AM, Maybody M, Gonzalez Aguirre AJ et al. (2020) Thoracic duct embolization in post-neck dissection chylous leakage: A case series of 6 patients and review of the literature. Cardiovasc Intervent Radiol; 43(6): 931–937.

Case series

N=6 patients with chylous leaks following neck dissection who have failed conservative management.

Clinical success was achieved in all patients, with one patient requiring repeat TDE. No minor or major complications were reported.

Larger studies included in the overview.

Reisenauer J S, Puig C A, Reisenauer C J et al. (2018) Treatment of postsurgical chylothorax. Ann Thorac Surg; 105: 254–62.

N=48 patients with 1.1 litre daily output.

Surgical TDL (in 8), TDE (in 40)

TDE was technically successful in 48% patients. Clinical success in 85% patients who had TDL and 38% in patients who had TDE. 8% mortality was reported in patients with TDE.

Included in systematic review added to the overview.

Ruan Z, Zhou Y, Wang S et al. (2011) Clinical use of lymphangiography for intractable spontaneous chylothorax. Thorac Cardiovasc Surg; 59:430–435.

Case series

N=15 patients with chylothorax had lymphangiography alone.

80% technical success

58% clinical success.

Included in systematic review added to the overview.

Nadolski G J, Itkin M. (2018) Lymphangiography and thoracic duct embolization following unsuccessful thoracic duct ligation: imaging findings and outcomes. J Thorac Cardiovasc Surg; 156: 838–43.

N=50 patients with failed TDL/referrals had TDE (n=49) /TDD (n=1)

Technical and clinical success was 98% in patients with TDE and 100% in the 1 patient who had TDD.

Included in systematic review added to the overview.

Schild HH, Naehle CP, Wilhelm KE, et al. (2015) Lymphatic interventions for treatment of chylothorax. Rofo; 187:584–588.

Case series

N= 21 patients with therapy resistant chylothorax a lymphatic had TDE in 17 (3 with prior failed TDL) and percutaneous destructions of lymphatic vessels in 2, CT-guided injection of ethanol next to a duplicated thoracic duct in 1.

82% (14/17) successful embolisations were clinically successful including ethanol injection. Complications were a bile peritonitis requiring operation, and one clinical deterioration of unknown cause.

Included in systematic review added to the overview.

Stecker MS, Pamarthi V, Steigner ML et al. (2020). Utility of planning MRI in percutaneous thoracic duct embolization for chylothorax. Clinical Imaging; 64: 43-49.

Retrospective case series

N=96 MRI and conventional lymphangiograms reviewed.

Identification of a cisterna chyli and/or 4 mm or greater target on pre-procedural MRI indicated higher likelihood of technically successful TDE. MRI did not help predict unsuccessful TDE procedures. Better target level concordance was not associated with improved technical outcomes.

More comprehensive studies included.

Ushinsky A, Guevara CJ, Kim SK. (2021) Intranodal lymphangiography with thoracic duct embolization for the treatment of chyle leaks after head and neck cancer surgery. Head & Neck; 43:1823–1829.

Retrospective case series

N=12 patients had lymphangiography and 11 TDE for a chyle leak after head and neck surgery

3 patients had repeat TDE. Technical success of TDE was 86% (12/14). Clinical success of TDE was 90% (9/10). Median time until drain removal was 2.1 days in 9 patients. Two had chylothorax after initial TDE, requiring additional TDE and one needed surgical TD ligation.

Larger studies added to the overview summary.

Yannes M, Shin D, McCluskey K et al. (2017) Comparative analysis of intranodal lymphangiography with percutaneous intervention for postsurgical chylous effusions. J Vasc Interv Radiol; 28:704–711.

Retrospective comparative case series

N=46/57 patients with chyle leaks postoperatively and failed medical conservative treatment had intranodal lymphangiography (INL) alone (n=12), INL +TDE (n=22). and INL+TDD (n=12).

In patients who had TDE, clinical success was 91% (21/22) and median time to response was 3 days. In those who had TDD, clinical success was 50% (6/12) and median time to response was 7 days. In 7 patients who had INL alone, clinical success was 58% (7/12) and median time to response was 14 days. 1 patient died in INL+CTE group died.

Included in systematic review added to the overview.