Superior Vena Cava Reconstruction for Treatment of Chylothorax Resulting From Thrombosis of Superior Vena Cava in Young Infants

Post-operative Chylothorax in Patients with Repaired Transposition of the Great Arteries

Patients with dextro-transposition of the great arteries (d-TGA) require surgical repair as neonates. These patients are at risk for post-operative chylothorax. We sought to describe the presentation, imaging, and outcomes after intervention for patients with d-TGA with post-operative chylothorax. A retrospective chart review was performed in patients with repaired d-TGA who were referred from 1/1/2013 to 4/1/2020 for evaluation of chylothorax. Patient history, lymphatic imaging, and interventional data were collected. Impact of intervention on lymphatic drainage was evaluated with a student's t-test. Eight patients met inclusion criteria for this study. Five patients had a history of central venous thrombus leading to thoracic duct outlet occlusion. Five patients underwent intervention, two were managed conservatively, and one was not a candidate for intervention. Chylothorax resolved in six patients. There was a significant difference in output from 7 days prior to first intervention (114 mL/kg/day) compared to 28 days following final intervention (27 mL/kg/day, p = 0.034). There were no procedural complications. Chylothorax in patients with repaired transposition of the great arteries is often amenable to intervention. Early surveillance and management of central venous thrombosis may reduce the burden of lymphatic disease in these patients.

Vena Cava Thrombosis after Congenital Diaphragmatic Hernia Repair: Multivariate Analysis of Potential Risk Factors

INTRODUCTION

 The treatment of newborns with congenital diaphragmatic hernia (CDH) is associated with a significant complication rate. Information on major thrombotic complications and their incidence in newborns with CDH is lacking. The aims of our analysis were to evaluate the frequency of vena cava thrombosis and to determine its predictors within a consecutive series of patients with CDH.

MATERIALS AND METHODS

 We retrospectively analyzed charts of all neonates of our department that underwent CDH repair from 2007 to 2021, focusing on vena cava thrombosis. Vena cava thrombosis was diagnosed sonographically and classified as complete or partial venous occlusion. Complete occlusion was confirmed by cavography. Variables evaluated were CDH side, liver position, central vein line, surgical approach, and extracorporeal membrane oxygenation (ECMO). Univariate and multivariate tests were utilized.

RESULTS

 Among 57 neonates who underwent CDH repair, vena cava thrombosis was diagnosed in 14 (24.6%), seven of whom had complete occlusion of the vena cava. Factors associated with vena cava thrombosis were femoral or saphenous venous catheter (p = 0.044), right sided CDH (p = 0.027) and chylothorax (p < 0.0001). ECMO was not associated with vena cava thrombosis. Seven patients (50%) with vena cava thrombosis were treated interventionally with angioplasty and seven (50%) conservatively with anticoagulation only. Mortality was not higher in patients with compared with patients without vena cava thrombosis.

CONCLUSION

 The incidence of vena cava thrombosis in newborns with CDH in our series is high. Routine postoperative abdominal sonography focusing on vena cava thrombosis is mandatory in all patients with CDH. Patients who developed vena cava thrombosis were more likely to develop chylothorax after CDH repair. Considering the good outcome of medical therapy of partial vena cava thrombosis, it may be discussed whether low dose anticoagulation may be provided to all newborns with CDH.

Percutaneous Venous Reconstruction for Central Thrombosis-Associated Chylothorax: A Safe and Efficacious Option

Central thrombosis–associated chylothorax is underrecognized in children and frequently refractory to conservative management. Central venous catheterizations are the predominate cause. We present 3 cases highlighting endovascular techniques used to treat persistent chylous effusions. (Level of Difficulty: Advanced.)

Chylothorax in the neonate-A stepwise approach algorithm

BACKGROUND

Chylothorax in neonates results from leakage of lymph from thoracic lymphatic ducts and is mainly congenital or posttraumatic. The clinical course of the effusion is heterogeneous, and consensus on treatment, timing, and modalities of measures has not yet been established. This review aims to present, along with levels of evidence and recommendation grades, all current therapeutic possibilities for the treatment of chylothorax in neonates.

METHODS

An extensive search of publications between 1970 and 2020 was performed in the PubMed, Cochrane Database of Systematic Reviews, and UpToDate databases. A stepwise approach algorithm was proposed for both congenital and traumatic conditions to guide the clinician in a rational and systematic way for approaching the treatment of neonates with chylothorax.

DISCUSSION AND CONCLUSION

The treatment strategy for neonatal chylothorax generally involves supportive care and includes drainage and procedures to reduce chyle flow. A stepwise approach starting with the least invasive method is advocated. Progression in the invasiveness of treatment options is determined by the response to previous treatments. A practical stepwise approach algorithm is proposed for both, congenital and traumatic chylothoraces.

Superior vena caval thrombosis after a neonatal arterial switch procedure

Superior vena cava (SVC) and inferior vena cava obstructions were once well-documented complications from the Mustard repair for D-transposition of the great arteries (TGA), occurring in 10%–40% patients; however, they are rarely documented with the current, more common arterial switch operation (ASO). Similarly, SVC thrombosis is an uncommon, severe complication following neonatal cardiac surgery. We report a case of persistent SVC thrombosis, SVC syndrome, and chylothorax arising after ASO, refractory to thrombolysis and stent placement. A 6-day-old neonate with prenatally known TGA underwent an arterial switch procedure. Despite an initially unremarkable postoperative course, he developed respiratory difficulty after starting enteral feeding. Soft-tissue swelling was noted in the neck, chest, and upper face. An SVC thrombus was identified with cardiac catheterization. Multiple thrombolytic modalities were attempted. His postoperative course was further complicated by recurrent chylothoraces, respiratory failure, sepsis, anasarca, and renal failure. He was eventually transferred to a larger center for a special lymphatics evaluation, where two lymphovenous anastomoses were unsuccessful. He was sent to his home hospital, where he died from extended-spectrum beta-lactamase Klebsiella sepsis. Early diagnosis of SVC syndrome and prompt thrombolysis may prevent the complications encountered in this patient. More research is needed in neonatal thrombolysis and anticoagulation.

Surgical Reconstruction for High-Output Chylothorax Associated with Thrombo-Occlusion of Superior Vena Cava and Left Innominate vein in a Neonate

We report a case of high-output chylothorax associated with thrombo-occlusion of the superior vena cava (SVC) and left innominate vein (LIV) following an arterial switch operation in a neonate. The chylothorax was resolved by 3 weeks after surgical reconstruction of the SVC and LIV using fresh autologous pericardium. We confirmed the patency of the SVC and LIV with a 1-year follow-up computed tomographic scan at our outpatient clinic.

Chylothorax as a Risk Factor for Thrombosis in Adults: A Proof-of-Concept Study

BACKGROUND

Postoperative chylothorax in children is associated with an increased risk of vascular thrombosis, hypothesized to be from loss of antithrombin into chylous fluid resulting in a hypercoagulable state. In adults, an increased thrombotic risk with chylothorax has not been described. Adults undergoing Ivor-Lewis esophagogastrectomy have two strong thrombotic risk factors-active malignancy and postoperative state-allowing for relative homogeneity in baseline thrombotic risk; therefore, we studied the association of chylothorax with thrombosis in this population.

METHODS

We performed a single-center retrospective cohort study at a tertiary care academic center. Patients included adults undergoing Ivor-Lewis esophagogastrectomy between January 1, 2006, and December 31, 2012. We collected demographics, pleural fluid characteristics, and relevant imaging within 30 days after the operation. Using nominal logistic regression, we studied the effects of chylothorax, age, sex, body mass index, American Society of Anesthesiologists Physical Status Classification, operative duration, and hospital length of stay on the incidence of postoperative thrombosis.

RESULTS

We identified 608 patients who underwent Ivor-Lewis esophagogastrectomy. Of these, 524 (86.2%) had no pleural fluid analysis, 48 (7.9%) had nonchylous effusions, and 36 (5.9%) had chylothoraces, with incident acute vascular thrombosis within 30 days postoperatively occurring in 22 of 524 (4.2%), 2 of 48 (4.2%), and 8 of 36 (22.2%), respectively (p = 0.001). In multivariate analyses, after adjusting for the above factors, chylothorax was associated with significantly higher odds of any vascular thrombosis (odds ratio, 5.46; p = 0.0013) and deep venous thrombosis/pulmonary embolism (odds ratio, 6.76; p = 0.0016).

CONCLUSIONS

Chylothorax is associated with a significantly higher incidence of vascular thrombosis in adults undergoing Ivor-Lewis esophagogastrectomy. Vascular thrombosis was associated with a significantly higher 90-day mortality rate.

Diaphragmatic fenestration for refractory chylothorax after congenital cardiac surgery in infants

OBJECTIVE

Medically refractory chylous pleural effusion after congenital heart surgery is associated with significant morbidity and mortality, especially in infants. We reviewed our experience with diaphragmatic fenestration procedure in this group of patients.

METHODS

A retrospective chart review of all patients who had diaphragmatic fenestrations for chylous effusion at our institution over a 2-year period was performed.

RESULTS

A total of 9 diaphragmatic fenestration procedures were performed in 8 patients who had failed medical management of chylous pleural effusions. All procedures except 1 were performed on the right side. The median age at time of procedure was 4.6 months (range, 3 weeks to 14 months). The average time between primary congenital cardiac surgery and fenestration was 26 days (range, 4-53 days). Three patients had single ventricle repair. Average time of chest tube removal after procedure was 4 days. Average time to extubation was 3 days. All patients but 1 were able to advance to full feedings without reaccumulation of chylous effusion within 12 days. No complications developed in the patients. Recurrent effusion over a median follow-up period of 19 months did not develop in the patients.

CONCLUSIONS

Diaphragmatic fenestration is an effective and safe strategy for management of persistent chylous effusions after congenital cardiac surgery.

[Chylothorax in practice of thoracic and cardiovascular surgeon]

AIM

to improve the results and current pathogenetic treatment of chylorrhea.

MATERIAL AND METHODS

Thirty seven patients with chylothorax have been treated for the period 2004-2014. In 34 cases traumatic chylothorax developed after surgery and in 3 cases - after intensive care for therapeutic diseases and great veins catheterization. Chylothorax was predominantly diagnosed by X-ray method. Herewith, hydrothorax was established and its nature was defined using laboratory survey. Presence of neutral fat in pleural drainage is the sign of chylothorax. Pathogenetic treatment was often delayed (up to 4.5 months) due to poor awareness of physicians about this pathological process. 6 patients underwent thoracic duct ligation above diaphragm due to ineffective therapy.

RESULTS

Medical therapy had good clinical effect in 83.8% of cases. Postoperatively 1 patient died for single lung inflammation on background of postoperative chylothorax after right-sided pneumonectomy. In other cases chylothora was eliminated with no recurrence in remote postoperative period. It is difficult to recognize injury of thoracic duct or its great branches during surgery. In these cases prolonged thoracic duct ligation above diaphragm is indicated.