Management of chylothorax by percutaneous catheterization and embolizationof the thoracic duct: Prospective trial

PURPOSE: To prospectively assess the efficacy of percutaneous transabdomina l thoracic duct catheterization and embolization in the management of patie nts with high-output chylothoracic effusions. MATERIALS AND METHODS: Eleven consecutive patients (four women and seven me n; mean age, 53 years) were referred with chylothorax secondary to esophage ctomy (n = 4), lobectomy (n = 1), lung transplant (n = 1), coronary artery bypass (n = 1), aortic graft (n = 2), lymphangioleiomyomatosis (n = 1), and gunshot wound (n = 1). Two patients were brought by ambulance and referred back to their hospital on the same day. Pedal lymphography was used to opa cify the cisterna chyli or major retroperitoneal lymphatic trunks. When pat ent, these were punctured under local anesthesia with a fine needle and the thoracic duct was catheterized over a microguide wire with use of a 3-F ca theter; the duct was embolized with platinum coils. Patients were followed up for decrease in thoracic drainage output and morbidity. RESULTS: There were no retroperitoneal ducts suitable for catheterization i n six patients because of previous abdominal surgery, trauma, or lymphansol eiomyomatosis; the thoracic duct was successfully catheterized in five pati ents, a 45% technical success rate. Thoracic duct embolization was pel form ed in four patients, with cure of effusion in two. In the other two patient s, one with lymphangioleiomyomatosis and the other with nonchylous pleural fluid, continued effusion was successfully treated by means of pleurodesis. Of two patients with previous thoracic duct ligation, one was found to hav e the duct incompletely tied. The authors were surprised to find that previ ous major abdominal surgery, chronic aortic dissection, and lymphansoleiomy omatosis could obliterate major retroperitoneal lymphatic ducts and the cis terna chyli. Percutaneous study of the thoracic duct with aqueous contrast medium was more sensitive than lymphography with iodinated oil. There was n o morbidity. CONCLUSIONS: Catheterization of the thoracic duct was possible in all patie nts who had patent major retroperitoneal lymphatic trunks. Thoracic duct em bolization was curative in patients with demonstrable duct leakage. Previou s abdominal surgery, aortic dissection, and lymphansoleiomyomatosis can lea d to silent occlusion of retroperitoneal lymphatic trunks. Percutaneous tho racic duct catheterization and embolization is safe and can replace surgica l ligation in some patients.