Thoracic duct leakage in a patient with Type B-Non-Hodgkin lymphoma treated with transvenous retrograde access embolization: a case report

Marcello Petrini; Davide Colombi; Flavio Cesare Bodini; Nicola Morelli; Corrado Ciatti; Fabrizio Quattrini; Pietro Maniscalco; Emanuele Michieletti

doi:10.23750/abm.v94iS1.12732

Thoracic duct leakage in a patient with Type B-Non-Hodgkin lymphoma treated with transvenous retrograde access embolization: a case report

Authors

Marcello Petrini 1Guglielmo da Saliceto Hospital, Department of Radiology, Via Taverna 49, 29121, Piacenza, Italy
Davide Colombi 1Guglielmo da Saliceto Hospital, Department of Radiology, Via Taverna 49, 29121, Piacenza, Italy
Flavio Cesare Bodini 1Guglielmo da Saliceto Hospital, Department of Radiology, Via Taverna 49, 29121, Piacenza, Italy
Nicola Morelli 1Guglielmo da Saliceto Hospital, Department of Radiology, Via Taverna 49, 29121, Piacenza, Italy
Corrado Ciatti Guglielmo da Saliceto Hospital, Department of Orthopaedics and Traumatology, Via Taverna 49, 29121, Piacenza, Italy https://orcid.org/0000-0002-7094-4344
Fabrizio Quattrini Guglielmo da Saliceto Hospital, Department of Orthopaedics and Traumatology, Via Taverna 49, 29121, Piacenza, Italy
Pietro Maniscalco Orthopedics and Traumatology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
Emanuele Michieletti 1Guglielmo da Saliceto Hospital, Department of Radiology, Via Taverna 49, 29121, Piacenza, Italy

Keywords:

Lymphangiography, radiology, interventional, embolization, chylothorax, thoracic duct

Abstract

Thoracic duct (TD) is the largest lymphatic vessel in the body and drains the lymph at the junction between the left subclavian and jugular veins. Chylothorax (CTX) represents an accumulation of lymphatic fluid in the pleural space. We present a case of a 65 years-old man with an histologically diagnosed mediastinal type B non-Hodgkin Lymphoma, treated with chemo-immunotherapy. CT scan during follow up showed significant left side pleural effusion, amounting to 2.8 litres after drainage. Conservative treatment with low fat parenteral nutrition was started without reduction of drainage output, then lymphangiography (LP) with Lipiodol was performed demonstrating a leak in the distal TD. CTX increased in the following days, and a further LP was performed. Using transvenous retrograde access we catheterized TD at the left subclavian jugular veins using a microcatheter. The leak was treated with multiple conventional and controlled delivery microcroils and cyanoacrylate, obtaining complete embolization without residual leak.

References

Riley LE, Ataya A. Clinical approach and review of causes of a chylothorax. Respir Med. 2019;157:7–13.

Doerr CH, Allen MS, Nichols FC, Ryu JH. Etiology of Chylothorax in 203 Patients. Mayo Clin Proc. 2005;55905(July):867–70.

Chalret Du Rieu M, Baulieux J, Rode A, Mabrut JY. Management of postoperative chylothorax. J Chir Viscerale. 2011;148(5):392–9.

Lee EW, Shin JH, Ko HK, Park J, Kim SH, Sung KB. Lymphangiography to treat postoperative lymphatic leakage: A technical review. Korean J Radiol. 2014;15(6):724–32.

Kim PH, Tsauo J, Shin JH. Lymphatic Interventions for Chylothorax: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol [Internet]. 2018;29(2):194-202.e4.

Bender B, Murthy V, Chamberlain RS. The changing management of chylothorax in the modern era. Eur J Cardio-thoracic Surg. 2016;49(1):18–24.

Dugue L, Sauvanet A, Farges O, Goharin A, Le Mee J, Belghiti J. Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy. Br J Surg [Internet]. 1998;85(8):1147–9.

Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC, Christakis GT, et al. Postoperative chylothorax. J Thorac Cardiovasc Surg [Internet]. 1996;112(5):1361–6.

Paul S, Altorkl NK, Port JL, Stiles BM, Lee PC. Surgical management of chylothorax. Thorac Cardiovasc Surg [Internet]. 2009;57(4):226–8.

Pieper CC, Hur S, Sommer CM, Nadolski G, Maleux G, Kim J, et al. Back to the Future: Lipiodol in Lymphography - From Diagnostics to Theranostics. Invest Radiol. 2019;54(9):600–15.

Gruber-Rouh T, Naguib NNN, Lehnert T, Harth M, Thalhammer A, Beeres M, et al. Direct lymphangiography as treatment option of lymphatic leakage: Indications, outcomes and role in patient’s management. Eur J Radiol [Internet]. 2014;83(12):2167–71.

Itkin M, Kucharczuk JC, Kwak A, Trerotola SO, Kaiser LR. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: Experience in 109 patients. J Thorac Cardiovasc Surg [Internet]. 2010;139(3):584–90.

Rott G, Boecker F. High-output chyloperitoneum following laparoscopic Nissen fundoplication treated with retrograde transvenous thoracic duct embolization. CVIR Endovasc [Internet]. 2020 Dec;3(1).

Morikawa K, Takenaga S, Hasumi J, Kano A, Tatsuno S, Michimoto K, et al. Retrograde transvenous lymphatic embolization for postoperative chylous ascites: A report of three cases and literature review. Radiol Case Reports [Internet]. 2020 Sep 1;15(9):1623–8.

Koike Y, Nishimura JI, Hirai C, Moriya N, Katsumata Y. Percutaneous transvenous embolization of the thoracic duct in the treatment of chylothorax in two patients. J Vasc Interv Radiol [Internet]. 2013;24(1):135–7.

Kariya S, Nakatani M, Ueno Y, Yoshida A, Ono Y, Maruyama T, et al. Transvenous Retrograde Thoracic Ductography: Initial Experience with 13 Consecutive Cases. Cardiovasc Intervent Radiol. 2018;41(3):406–14.