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Technical Innovation |
1
Department of Radiology, Section of Vascular and Interventional Radiology,
University of Washington Medical Center, 1949 Pacific Ave. N.E., Box 357115,
Seattle, WA 98195.
2
Present address: Department of Radiology, Box 359728, Harborview Medical
Center, 325 9th Ave., Seattle, WA 98104.
3
Department of Surgery, Division Cardiothoracic Surgery, University of
Washington Medical Center, Seattle, WA 98195.
Received August 23, 2000;
accepted after revision October 3, 2000.
Address correspondence to E. K. Hoffer.
Introduction
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The chest was entered above the sixth rib through a posterolateral thoracotomy. The right lung was deflated, and a right upper lobe adhesion to the chest wall was released. The azygos vein was transected to gain exposure to the diverticulum, which was associated with inflammation and adhesions in the posterior mediastinum. The diverticulum was resected and the esophagus repaired.
Because of persistent chylous leakage from the chest tubes, the patient was returned to the operating room 5 days later. Through the previous incision, the chest was opened and a leaking thoracic duct at the T2 level was identified. The duct was ligated, with additional ligatures placed on the duct at the T8 level. These areas were then covered with fibrin glue (Tisseel VH kit; Baxter Healthcare, Deerfield, IL) to ensure chylous stasis. There was no evidence of leak at the end of the procedure. However, within 4 days, the chest tube resumed its output of 2 L per day of chylous fluid. After discussing the options with the patient and his family, the decision to perform percutaneous repair was made. In the angiographic suite, bipedal lymphangiography was performed. Cutdown was performed on a lymphatic duct on the dorsum of each foot. Access was obtained with 28-gauge needles (Lymphangiography Set; Cook, Bloomington, IN), and 6 mL of iodinated oily contrast medium (Ethiodol; Savage Laboratory, Melville, NY) was injected on each side. An hour later, the cisterna chyli and thoracic duct were opacified.
Sonography was used to evaluate the tract from the skin to the cisterna chyli, and a 45° course through the left lobe of the liver was chosen. After administration of local anesthesia and conscious sedation, a 21-gauge needle was advanced through the anterior abdominal wall to puncture the cisterna chyli (Figs. 1A and 1B). On the third attempt, an 0.018-inch nitinol guidewire (Hytek; Microvena, White Bear Lake, MN) was passed into the thoracic duct. A 4-French catheter on a metal cannula (inner portion of the Accustick; Boston Scientific, Natick, MA) was advanced over the guidewire to the cisterna, and the catheter was then passed over the guidewire, which was supported by the cannula, into the duct. Aqueous contrast medium injection revealed a 3-mm duct with active extravasation at the T6-T7 level (Fig. 1C). Through the 4-French catheter, three 4-mm-diameter spiral coils (Vortex-18; Boston Scientific/Medi-Tech, Natick, MA) were deployed, which did not completely obstruct the flow of contrast medium. Moistened absorbable gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, MI) cut into 1 x 2 mm pledgets was then injected and trapped by two additional coils in the more caudal thoracic duct, which proved to be occlusive (Fig. 1D). Because of the presence of fewer thrombotic components in chyle compared with blood, the coils probably did not immediately occlude the duct. The coils did confine the gelatin pledgets, and together proved to be occlusive.
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The next day chest tube output dropped to 120 mL of chyle. After 3 days, there was no further output and the chest tube was removed. The patient was transferred from the intensive care unit and was sent home 7 days after embolization.
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TopIntroductionSubject and MethodsDiscussionReferences |
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Of the 11 patients involved in the clinical prospective trial of the technique, the thoracic duct or cisterna chyli was identified in only five patients [5]. Catheterization of the thoracic duct was possible in all patients in whom it could be identified. Either the cisterna chyli or a major retroperitoneal lymphatic vessel larger than 1 mm in diameter with a direct course to the thoracic duct was required for successful catheterization [5, 8]. Of the five thoracic ducts catheterized, four were embolized, two of which had leakage totally controlled within a few days. In five of the six patients who could not be catheterized, chylous extravasation was identified from a small thoracic duct collateral or from a reconstituted duct [5]. Although the technical success rate was only 45%, the procedure produced no additional morbidity.
The procedure described by Cope [8] used an 8-French guiding cannula to prevent the small catheters and guidewires from buckling in the peritoneal cavity. We found, however, that the inner metal cannula provided adequate support and allowed the procedure to be performed through a 4-French access.
Chylothorax that persists beyond 5-7 days of conservative medical treatment should be treated promptly to avoid complications of nutritional and immunologic depletion [1,2,3,4]. Because of the low risks of the percutaneous procedure, it should be considered before open repair. The availability of nontraumatic yet firm guidewires and microcatheters make this approach a possible solution for an often difficult problem. Anatomic constraints, which prevent opacification of the cisterna chyli or retroperitoneal lymphatic supply to the thoracic duct, are the major obstacles to successful percutaneous repair.
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