Percutaneous thoracic duct embolisation for persistent chyle leak

2.1 Chyle leak or discharge can occur as a result of thoracic duct injury (injury to the structure that returns lymph and chyle from the lower half of the body). Injury can happen during surgery, from trauma or from disease such as cancer. Chyle leak can cause delayed wound healing, dehydration, malnutrition, electrolyte imbalance, breathing problems and immunosuppression.

2.2 Small chyle leaks are usually treated with medicines and by managing nutrition (including by modifying diet or with total parenteral nutrition) to reduce chyle secretion and relieve symptoms. Persistent high-volume leaks may need drainage or percutaneous or open surgical repair (such as thoracic duct ligation).

2.3 Thoracic duct embolisation is a percutaneous image-guided closure of the thoracic duct and is done under general or local anaesthesia. It is a 3‑step process consisting of intranodal inguinal lymphangiography followed by percutaneous transabdominal catheterisation of the thoracic duct or cisterna chyli and then embolisation of the thoracic duct.

2.4 Under fluoroscopic or ultrasound guidance, an oil-based contrast medium is injected into inguinal lymph nodes. This progresses slowly through the network of pelvic and retroperitoneal lymphatic vessels and allows the thoracic duct and cisterna chyli to be visualised. Then, through transabdominal access under imaging guidance, the target thoracic duct or cisterna chyli is accessed with a guidewire using a needle. A microcatheter is advanced over the guidewire into the thoracic duct, then the guidewire is removed. Contrast medium is injected through the catheter to define the source of the leak and the thoracic duct anatomy. The target thoracic duct and its branches are embolised proximally to the leak with a combination of microcoils and cyanoacrylate glue.