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Lu X, Wang M, Han L, Krieger J, Ivers J, Chambers S, Itkin M, Burkhoff D, Kassab GS. Changes of thoracic duct flow and morphology in an animal model of elevated central venous pressure. Front Physiol 2022; 13:798284. [PMID: 36003647 PMCID: PMC9393243 DOI: 10.3389/fphys.2022.798284] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: Investigation of lymph fluid dynamics in thoracic duct during central venous pressure elevation.Background: Lymphatic flow is affected by elevated central venous pressure (CVP) in congestive heart failure. The changes of thoracic duct (TD) lymph flow have not been studied chronically in the setting of elevated CVP. This study is to investigate fluid dynamics and remodeling of the TD in the elevated CVP animal model.Methods: A flow probe was implanted on the swine TD (n = 6) and tricuspid regurgitation (TR) was created by cutting tricuspid chordae percutaneously. Six swine were used as control group animals. The TD flow was measured for 2 weeks (baseline) before TR and 4 weeks postop-TR surgery. Arterial pressure and CVP were measured. The pressure and flow in the TD were measured percutaneously. Histological and morphological analyses were performed.Results: TR resulted in an increase in CVP from 4.2 ± 2.6 to 10.1 ± 4.3 mmHg (p < 0.05). The lymph flow in the TD increased from 0.78 ± 1.06 before TR to 8.8 ± 4.8 ml/min (p < 0.05) 2 days post-TR and remained plateau for 4 weeks, i.e., the TD flow remained approximately 8–11 fold its baseline. Compared to the 8.1 ± 3.2 mmHg control group, the TD average pressures at the lymphovenous junction increased to 14.6 ± 5.7 mmHg in the TR group (p < 0.05). The TD diameter and wall thickness increased from 3.35 ± 0.37 mm and 0.06 ± 0.01 mm in control to 4.32 ± 0.57 mm and 0.26 ± 0.02 mm (p < 0.05) in the TR group, respectively.Conclusion: The elevated CVP results in a significant increase in TD flow and pressure which causes the TD’s outward remodeling and thickening. Our study implicates that the outward remodeling may result in the TD valve incompetence due to failure coaptation of leaflets.
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Affiliation(s)
- Xiao Lu
- California Medical Innovations Institute, San Diego, CA, United States
| | | | - Ling Han
- California Medical Innovations Institute, San Diego, CA, United States
| | | | | | | | - Max Itkin
- Center for Lymphatic Imaging and Interventions, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York, NY, United States
| | - Ghassan S. Kassab
- California Medical Innovations Institute, San Diego, CA, United States
- *Correspondence: Ghassan S. Kassab,
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Higgins MC, Shi J, Bader M, Kohanteb PA, Brahmbhatt TS. Role of Interventional Radiology in the Management of Non-aortic Thoracic Trauma. Semin Intervent Radiol 2022; 39:312-328. [PMID: 36062226 PMCID: PMC9433159 DOI: 10.1055/s-0042-1753482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Trauma remains a leading cause of death for all age groups, and nearly two-thirds of these individuals suffer thoracic trauma. Due to the various types of injuries, including vascular and nonvascular, interventional radiology plays a major role in the acute and chronic management of the thoracic trauma patient. Interventional radiologists are critical members in the multidisciplinary team focusing on treatment of the patient with thoracic injury. Through case presentations, this article will review the role of interventional radiology in the management of trauma patients suffering thoracic injuries.
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Affiliation(s)
- Mikhail C.S.S. Higgins
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Jessica Shi
- Boston University School of Medicine, Boston, Massachusetts
| | - Mohammad Bader
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Paul A. Kohanteb
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Tejal S. Brahmbhatt
- Boston University School of Medicine, Boston, Massachusetts
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care; Boston Medical Center, Boston, Massachusetts
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3
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McGregor H, Weise L, Brunson C, Struycken L, Woodhead G, Celdran D. Percutaneous Radiofrequency Ablation to Occlude the Thoracic Duct: Preclinical Studies in Swine for a Potential Alternative to Embolization. J Vasc Interv Radiol 2022; 33:1192-1198. [PMID: 35595218 DOI: 10.1016/j.jvir.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 03/17/2022] [Accepted: 05/11/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To investigate the feasibility of percutaneous radiofrequency ablation (RFA) to occlude the thoracic duct (TD) in a swine model with imaging and histologic correlation. MATERIALS AND METHODS Six swine underwent TD RFA. Two terminal (4 hours; 1 open, 1 percutaneous) and four survival (30 days; all percutaneous) studies were performed. Two 20-gauge needles were placed adjacent to the TD under direct visualization after right thoracotomy or under fluoroscopic guidance using a percutaneous transabdominal approach after intranodal lymphangiography. Radiofrequency electrodes were advanced through the needles and ablation was performed at 90 degrees Celsius for 90 seconds. Lymphangiography was performed and the TD and adjacent structures were resected and examined microscopically at the end of each study period. RESULTS Four of six subjects survived the planned study period and underwent follow up lymphangiography. Two subjects in the survival group were euthanized early; 1 after developing an acute chylothorax and 1 due to gastric volvulus 14 days after ablation. Occlusion of the targeted TD segment was noted on lymphangiography in 3 of 4 remaining subjects (2 acute, 1 survival). Histology 4 hours after RFA demonstrated necrosis of the TD wall and hemorrhage within the lumen. Histology at 14 and 30 days revealed fibrosis with hemosiderin laden macrophages replacing the ablated TD. Collagen degeneration within the aortic wall involving a maximum of 60% thickness was noted in 5/6 subjects. CONCLUSION Percutaneous RFA can achieve short-segment TD occlusion. Further study is needed to improve safety and demonstrate clinical efficacy in treating TD leaks.
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Affiliation(s)
- Hugh McGregor
- Department of Radiology, University of Washington, 1959 NE Pacific St 2nd floor, Seattle, WA 98195
| | - Lorela Weise
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ 85724
| | - Christopher Brunson
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ 85724
| | - Lucas Struycken
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ 85724
| | - Gregory Woodhead
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ 85724
| | - Diego Celdran
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ 85724
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4
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Bazancir LA, Jensen RJ, Frevert SC, Ryom P, Achiam MP. Embolization of the thoracic duct in patients with iatrogenic chylothorax. Dis Esophagus 2021; 34:6129921. [PMID: 33550366 DOI: 10.1093/dote/doab001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/14/2020] [Accepted: 12/29/2020] [Indexed: 12/11/2022]
Abstract
Chylothorax is leakage of lymphatic fluid accumulating in the pleural cavity due to the thoracic duct's (TD) trauma or obstructions. It generally occurs as a traumatic complication after general thoracic surgery procedures (0.4%), especially after esophagectomy (4.7-8.6%). Traditionally, surgical intervention is performed if conservative management fails, but reports of high mortality (2.1%) and morbidity (38%) have led to the development of a minimally invasive percutaneous treatment method; TD embolization (TDE). The records of all patients treated for chylothorax with TDE from April 2015 to June 2019 were reviewed. Only patients with iatrogenic chylothorax were included. The outcomes measures are defined as a technical and a clinical success. A technical success, is defined as the ability to perform the embolization procedure, thereby injecting embolizing material Histoacryl with or without coils. A clinical success is defined as a complete cessation of lymphatic leakage into the pleural cavity without surgical intervention and, therefore, a cured patient. Lymphography was performed in all patients, and visualization of cisterna chyli was achieved in 14/17 patients (82.4%). Of the 17 patients included, 15 patients were successfully embolized and cured of chylothorax (88.2%). Successfully embolized patients had a median discharge time of 7 days. Most patients reported postprocedural pain, which was dealt with using conventional pain medication. TDE seems like a safe percutaneous treatment technique with a high clinical success rate in iatrogenic chylothorax patients which can be readily implemented if the clinical experience is available..
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Affiliation(s)
- Laser Arif Bazancir
- Department of Surgical Gastroenterology, Copenhagen University, Copenhagen, Denmark
| | - Ruben Juhl Jensen
- Department of Diagnostic Radiology, Copenhagen University, Copenhagen, Denmark
| | | | - Philip Ryom
- Department of Cardiothoracic Surgery, Copenhagen University, Copenhagen, Denmark
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5
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Itkin M, Rockson SG, Witte MH, Burkhoff D, Phillips A, Windsor JA, Kassab GS, Hur S, Nadolski G, Pabon-Ramos WM, Rabinowitz D, White SB. Research Priorities in Lymphatic Interventions: Recommendations from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol 2021; 32:762.e1-762.e7. [PMID: 33610432 DOI: 10.1016/j.jvir.2021.01.269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/06/2021] [Accepted: 01/16/2021] [Indexed: 11/26/2022] Open
Abstract
Recognizing the increasing importance of lymphatic interventions, the Society of Interventional Radiology Foundation brought together a multidisciplinary group of key opinion leaders in lymphatic medicine to define the priorities in lymphatic research. On February 21, 2020, SIRF convened a multidisciplinary Research Consensus Panel (RCP) of experts in the lymphatic field. During the meeting, the panel and audience discussed potential future research priorities. The panelists ranked the discussed research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were prioritized by RCP: lymphatic decompression in patients with congestive heart failure, detoxification of thoracic duct lymph in acute illness, development of newer agents for lymphatic imaging, characterization of organ-based lymph composition, and development of lymphatic interventions to treat ascites in liver cirrhosis. The RCP priorities underscored that the lymphatic system plays an important role not only in the intrinsic lymphatic diseases but in conditions that traditionally are not considered to be lymphatic such as congestive heart failure, liver cirrhosis, and critical illness. The advancement of the research in these areas will lead the field of lymphatic interventions to the next level.
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Affiliation(s)
- Maxim Itkin
- Penn Center for Lymphatic Disorders, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Stanley G Rockson
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Marlys H Witte
- University of Arizona College of Medicine Tucson Arizona, International Society of Lymphology, Tuscon, Arizona
| | | | - Anthony Phillips
- Applied Surgery and Metabolism Laboratory, Surgical and Translational Research Centre, School of Biological Sciences & Dept. of Surgery, Auckland University, Auckland, New Zealand
| | - John A Windsor
- Surgery and Director Surgical and Translational Research Centre, University of Auckland, New Zealand
| | | | - Saebeom Hur
- Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
| | - Gregory Nadolski
- Penn Center for Lymphatic Disorders, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Waleska M Pabon-Ramos
- Pediatric Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Debbie Rabinowitz
- Department of Medical Imaging, Division of Interventional Radiology, Nemours/duPont Hospital for Children, Radiology and Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, Delaware
| | - Sarah B White
- Clinical Research and Registries Division, SIR Foundation, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Gilyard SN, Khaja MS, Goswami AK, Kokabi N, Saad WE, Majdalany BS. Traumatic Chylothorax: Approach and Outcomes. Semin Intervent Radiol 2020; 37:263-268. [PMID: 32773951 DOI: 10.1055/s-0040-1713443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Traumatic chylothorax occurs more often now than in historic reports. In part, this is due to the increased ability to perform more advanced and aggressive thoracic resections and cardiovascular surgeries as well as the improved mortality of cancer patients. If untreated, chylothorax can result in significant morbidity and mortality, particularly in patients with underlying malignancy. Thoracic duct embolization for chylothorax was the first successful lymphatic intervention and has been performed for over 20 years. An overview of the clinical and technical approach to thoracic duct embolization for traumatic chylothorax is presented in addition to a review of outcomes.
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Affiliation(s)
- Shenise N Gilyard
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Minhaj S Khaja
- Division of Vascular and Interventional Radiology, Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia
| | - Abhishek K Goswami
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Nima Kokabi
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Wael E Saad
- Division of Vascular and Interventional Radiology, Department of Radiology, National Institutes of Health, Bethesda, Maryland
| | - Bill S Majdalany
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
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Abstract
Injury to the thoracic duct with resultant chylothorax can cause significant patient morbidity and mortality. Conservative treatment strategies often fail to address the problem. Open surgical and percutaneous approaches are often required to manage patients with refractory chylothorax. This review describes in detail the major role of minimally invasive interventional therapies for thoracic duct (TD) injury. The review emphasizes strategies for identifying the TD on preprocedural imaging and describes various techniques for percutaneous access to the TD. The advantages and disadvantages of several approaches for accessing the duct are discussed. The technique of duct embolization is highlighted. The role of the minimally invasive percutaneous approach over open surgical approaches is discussed with a review of clinical outcomes, as reported in the literature. This review will also briefly discuss the surgical approach to TD ligation.
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Matsumoto T, Tomita K, Maegawa S, Nakamura T, Suzuki T, Hasebe T. Lymphangiography and Post-lymphangiographic Multidetector CT for Preclinical Lymphatic Interventions in a Rabbit Model. Cardiovasc Intervent Radiol 2018; 42:448-454. [PMID: 30460384 DOI: 10.1007/s00270-018-2123-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/12/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe the feasibility of lymphangiography and the visibility of the lymphatic system using post-lymphangiographic multidetector CT (MDCT) for preclinical lymphatic interventions in a rabbit model. MATERIALS AND METHODS Lymphangiography via the popliteal lymph node or vessel after surgical exposure was performed, using six healthy female Japanese White rabbits. Lipiodol was manually injected for lymphangiography. Post-lymphangiographic MDCT examinations were performed in all rabbits. The dataset images were subjected to image processing analysis utilizing the three-dimensional maximum intensity projection technique. Three reviewers evaluated the degree of depiction of the lymphatic system using a four-point visual score (1, poor; 2, fair; 3, good; 4, excellent). The distance between the body surface and cisterna chyli was measured on post-lymphangiographic MDCT axial image. RESULTS Lymphangiography was successfully performed in all rabbits. The popliteal lymph node was detectable in 90%. The visualization of lymphatic system via the popliteal node was achieved in 89%. Mean visual scores of > 3.0 were realized by the right femoral lymphatic vessel, left femoral lymphatic vessel, left iliac lymphatic vessel, left lumbar lymphatic trunks and cisterna chyli, whereas mean visual scores of < 3.0 were yielded by the right iliac lymphatic vessel, right lumbar lymphatic trunks and thoracic duct. The distance between the body surface and cisterna chyli on post-lymphangiographic MDCT axial images was 4.33 ± 0.14 cm. CONCLUSION Lymphangiography is feasible, and the visibility of the lymphatic system on post-lymphangiographic MDCT in a rabbit model provides enough information for interventional radiologists to perform preclinical lymphatic interventions.
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Affiliation(s)
- Tomohiro Matsumoto
- Department of Radiology, Tokai University Hachioji Hospital, Tokai University School of Medicine, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
- Center for Science of Environment, Resources and Energy, Graduate School of Science and Technology, Keio University, 3-14-1 Hiyoshi, Kohoku-ku, Yokohama, Kanagawa, 223-8522, Japan
| | - Kosuke Tomita
- Department of Radiology, Tokai University Hachioji Hospital, Tokai University School of Medicine, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
| | - Shunto Maegawa
- Department of Radiology, Tokai University Hachioji Hospital, Tokai University School of Medicine, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan
- Center for Science of Environment, Resources and Energy, Graduate School of Science and Technology, Keio University, 3-14-1 Hiyoshi, Kohoku-ku, Yokohama, Kanagawa, 223-8522, Japan
| | - Takako Nakamura
- Advanced Coating Technology Research Center, National Institute of Advanced Industrial Science and Technology, Tsukuba, Ibaraki, 305-8565, Japan
| | - Tetsuya Suzuki
- Center for Science of Environment, Resources and Energy, Graduate School of Science and Technology, Keio University, 3-14-1 Hiyoshi, Kohoku-ku, Yokohama, Kanagawa, 223-8522, Japan
| | - Terumitsu Hasebe
- Department of Radiology, Tokai University Hachioji Hospital, Tokai University School of Medicine, 1838 Ishikawa-machi, Hachioji, Tokyo, 192-0032, Japan.
- Center for Science of Environment, Resources and Energy, Graduate School of Science and Technology, Keio University, 3-14-1 Hiyoshi, Kohoku-ku, Yokohama, Kanagawa, 223-8522, Japan.
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Nadolski GJ, Itkin M. Lymphangiography and thoracic duct embolization following unsuccessful thoracic duct ligation: Imaging findings and outcomes. J Thorac Cardiovasc Surg 2018; 156:838-843. [PMID: 29759734 DOI: 10.1016/j.jtcvs.2018.02.109] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 02/19/2018] [Accepted: 02/28/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To summarize the imaging findings and outcomes of thoracic duct (TD) embolization (TDE) performed in patients with chylous leaks persisting after TD ligation (TDL). MATERIALS AND METHODS In this review of 50 patients (30 males and 20 females; median age, 54 years) referred for TDE following unsuccessful surgical TDL, records were reviewed for lymphangiographic findings, technical success of TDE, and outcome of TDE. Comparisons between groups were performed using the Fisher exact test. RESULTS The causes of chylothorax were traumatic in 39 patients (78%) and nontraumatic in 11 (22%). Lymphangiography identified missed TDL in 30 patients (60%) and complete TDL in 15 patients (30%); however, in 12 of these 15 patients, collaterals around the ligation site supplying the leak could be identified. Incomplete ligation was observed in 4 patients (8%). In 1 patient (2%), a second TD was identified circumventing a complete ligation of the main TD. TDE was performed in 49 patients, and TD disruption was performed in 1 patient. Resolution of the chylous leak occurred in 45 patients (90%). There were 3 minor complications that resulted in no clinical sequela. CONCLUSIONS TDE produced cessation of chylous leak in the majority of the patients with persistent chylothorax after surgical TDL. Missed ligation is the most common finding on lymphangiography in patients with failed TDL. These findings support the use of image-guided closure of TD leaks.
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Affiliation(s)
- Gregory J Nadolski
- Division of Interventional Radiology, Department of Radiology, University of Pennsylvania, Philadelphia, Pa.
| | - Maxim Itkin
- Division of Interventional Radiology, Department of Radiology, University of Pennsylvania, Philadelphia, Pa
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Pamarthi V, Pabon-Ramos WM, Marnell V, Hurwitz LM. MRI of the Central Lymphatic System: Indications, Imaging Technique, and Pre-Procedural Planning. Top Magn Reson Imaging 2017; 26:175-180. [PMID: 28665889 PMCID: PMC5548502 DOI: 10.1097/rmr.0000000000000130] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Magnetic resonance imaging is increasingly being used to evaluate the lymphatic system. Advances in magnetic resonance (MR) software and hardware allow improved visualization of lymph nodes and lymphatic vessels. We describe how MR lymphangiography can be used to diagnose central lymphatic system anatomy and pathology, which can be used for diagnostic purposes or for pre-procedural planning.
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Yannes M, Shin D, McCluskey K, Varma R, Santos E. Comparative Analysis of Intranodal Lymphangiography with Percutaneous Intervention for Postsurgical Chylous Effusions. J Vasc Interv Radiol 2017; 28:704-711. [DOI: 10.1016/j.jvir.2016.12.1209] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 12/04/2016] [Accepted: 12/07/2016] [Indexed: 01/30/2023] Open
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12
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Interventional radiology in the management of thoracic duct injuries: Anatomy, techniques and results. Clin Imaging 2017; 42:183-192. [DOI: 10.1016/j.clinimag.2016.12.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 12/11/2016] [Accepted: 12/24/2016] [Indexed: 01/30/2023]
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Ierardi AM, Pappalardo V, Liu X, Wu CW, Anuwong A, Kim HY, Liu R, Lavazza M, Inversini D, Coppola A, Floridi C, Boni L, Carrafiello G, Dionigi G. Usefulness of CBCT and guidance software for percutaneous embolization of a lymphatic leakage after thyroidectomy for cancer. Gland Surg 2016; 5:633-638. [PMID: 28149811 DOI: 10.21037/gs.2016.12.13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Lymphatic leakage can develop as an iatrogenic complication of thoracic, cardiac, and neck surgery. The management of this complication may be challenging and involves more specialists. Percutaneous, image-guided techniques may offer two advantages: mini-invasivity and ability to image and identify the anatomy and the site of the leakage. We report a case of refractory cervical chylous leakage after thyroidectomy and lymphadenectomy for cancer that was successfully treated with an ultrasound-guided intranodal lymphangiography and a percutaneous puncture of the leak performed using CBCT as imaging guidance.
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Affiliation(s)
- Anna Maria Ierardi
- Insubria University, Interventional Radiology, Department of Radiology, Varese, Italy
| | - Vincenzo Pappalardo
- 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
| | - Xiaoli Liu
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun 130033, China
| | - Che-Wei Wu
- Department of Otolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Angkoon Anuwong
- Department of Surgery, Police General Hospital, Faculty of Medicine, Siam University, Pathumwan, Bangkok, Thailand
| | - Hoon Yub Kim
- KUMC Thyroid Center Korea University, Anam Hospital, Seoul, Korea
| | - Renbin Liu
- The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Matteo Lavazza
- 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
| | - Davide Inversini
- 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
| | - Andrea Coppola
- Insubria University, Interventional Radiology, Department of Radiology, Varese, Italy
| | - Chiara Floridi
- Insubria University, Interventional Radiology, Department of Radiology, Varese, Italy
| | - Luigi Boni
- 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Unit, Department of Health Sciences, University of Milan, Milan, Italy
| | - Gianlorenzo Dionigi
- 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
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14
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Itkin M. Introduction. Tech Vasc Interv Radiol 2016; 19:245-246. [DOI: 10.1053/j.tvir.2016.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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15
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Itkin M. Invited Commentary: Lymphatic (or “Forgotten”) Circulation Has to Be Rediscovered. Radiographics 2016; 36:2212-2213. [DOI: 10.1148/rg.2016160192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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16
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Marthaller KJ, Johnson SP, Pride RM, Ratzer ER, Hollis HW. Percutaneous embolization of thoracic duct injury post-esophagectomy should be considered initial treatment for chylothorax before proceeding with open re-exploration. Am J Surg 2015; 209:235-9. [DOI: 10.1016/j.amjsurg.2014.05.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/15/2014] [Accepted: 05/20/2014] [Indexed: 11/28/2022]
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17
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Pamarthi V, Stecker MS, Schenker MP, Baum RA, Killoran TP, Suzuki Han A, O’Horo SK, Rabkin DJ, Fan CM. Thoracic Duct Embolization and Disruption for Treatment of Chylous Effusions: Experience with 105 Patients. J Vasc Interv Radiol 2014; 25:1398-404. [DOI: 10.1016/j.jvir.2014.03.027] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Revised: 03/26/2014] [Accepted: 03/26/2014] [Indexed: 12/22/2022] Open
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Abstract
Chylous leaks, such as chylothorax and chylopericardium, are uncommon effusions resulting from the leakage of intestinal lymphatic fluid from the thoracic duct (TD) and its tributaries, or intestinal lymphatic ducts. The cause can be either traumatic (thoracic surgery) or nontraumatic (idiopathic, malignancy). Treatment has traditionally consisted of dietary modification (nonfat diet) and/or surgery (TD ligation, pleurodesis). Thoracic duct embolization (TDE) has become a viable treatment alternative due to it high success rate and minimal complications. In this article, the authors describe the etiologies of chylothorax, patient population, outcomes, and long-term follow-up of TDE patients. Relevant lymphatic anatomy and physiology are reviewed, with special attention paid to the formation of the duct by tributaries at the cisterna chyli (CC). The technique of TDE is outlined, including bilateral pedal lymphangiography, TD cannulation, and embolic agents used for the procedure.
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Affiliation(s)
- Eric Chen
- Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Singh A, Brisson BA, O'Sullivan ML, Solomon JA, Malek S, Nykamp S, Thomason JJ. Feasibility of percutaneous catheterization and embolization of the thoracic duct in dogs. Am J Vet Res 2011; 72:1527-34. [DOI: 10.2460/ajvr.72.11.1527] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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da Silva CA, Monnet E. Long-term outcome of dogs treated surgically for idiopathic chylothorax: 11 cases (1995–2009). J Am Vet Med Assoc 2011; 239:107-13. [DOI: 10.2460/javma.239.1.107] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gaba RC, Owens CA, Bui JT, Carrillo TC, Knuttinen MG. Chylous Ascites: A Rare Complication of Thoracic Duct Embolization for Chylothorax. Cardiovasc Intervent Radiol 2010; 34 Suppl 2:S245-9. [DOI: 10.1007/s00270-010-9900-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/10/2010] [Indexed: 12/11/2022]
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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 2010; 139:584-89; discussion 589-90. [PMID: 20042200 DOI: 10.1016/j.jtcvs.2009.11.025] [Citation(s) in RCA: 231] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 10/12/2009] [Accepted: 11/04/2009] [Indexed: 12/11/2022]
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Percutaneous Management of High-Output Chylothorax: Case Reviews. Cardiovasc Intervent Radiol 2009; 32:828-32. [DOI: 10.1007/s00270-009-9545-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 12/16/2008] [Accepted: 12/19/2008] [Indexed: 10/21/2022]
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Scorza LB, Goldstein BJ, Mahraj RP. Modern Management of Chylous Leak Following Head and Neck Surgery: A Discussion of Percutaneous Lymphangiography-Guided Cannulation and Embolization of the Thoracic Duct. Otolaryngol Clin North Am 2008; 41:1231-40, xi. [DOI: 10.1016/j.otc.2008.06.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Weisse CW, Berent AC, Todd KL, Solomon JA. Potential applications of interventional radiology in veterinary medicine. J Am Vet Med Assoc 2008; 233:1564-74. [PMID: 19014289 DOI: 10.2460/javma.233.10.1564] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Chick W Weisse
- Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to present a novel radiologic percutaneous transabdominal technique for treating high-output chylothorax by thoracic duct embolization, and to demonstrate that it can be potentially safer than the traditional treatment by surgical open-chest thoracic duct ligation. RECENT FINDINGS Pedal lymphography is initially performed to opacify large retroperitoneal lymph channels; a suitable duct more than 2 mm in diameter is then punctured transabdominally to allow catheterization and embolization of the thoracic duct under fluoroscopic guidance. If feeding lymphatic channels are too small for catheterization, they can often be occluded by needle disruption. This percutaneous interventional technique, which has been used in 60 patients with mostly high-output chylothorax caused by thoracic surgery, resulted in a 65% cure rate with no morbidity. Back-up surgical thoracic duct ligation was performed promptly on suitable lower risk patients when the percutaneous procedure failed. SUMMARY We have found that two thirds of patients presenting with life-threatening chylothorax can be safely treated by percutaneous transabdominal thoracic duct blockage. When successful, this novel interventional procedure can obviate repeat major thoracic surgery and shorten hospital stays.
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Affiliation(s)
- Constantin Cope
- Radiology Department Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Cope C, Kaiser LR. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol 2002; 13:1139-48. [PMID: 12427814 DOI: 10.1016/s1051-0443(07)61956-3] [Citation(s) in RCA: 156] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To demonstrate the applicability, technique, and efficacy of percutaneous transabdominal catheter embolization or needle disruption of retroperitoneal lymphatic vessels in the treatment of high-output or unremitting chylothorax. MATERIALS AND METHODS Forty-two patients (21 men, 21 women; mean age, 56 y; range, 19-80 y) who had chylothorax with various etiologies were referred from the thoracic surgery department for treatment as soon as chylothorax was documented. The thoracic duct was punctured and catheterized via a peritoneal cannula to facilitate embolization with use of microcoils, particles, or glue; if there were no lymph trunks that could be catheterized, attempts were made to disrupt lymph collaterals with use of needles. RESULTS The thoracic duct was catheterized in 29 patients and embolized in 26 patients. In patients with lymph trunks that could be catheterized, treatment resulted in cure within 7 days in 16 patients and partial response with cure within 3 weeks in six patients. In the patients with lymph trunks that could not be catheterized (n = 16), disruption with use of needles resulted in cure in five patients and partial response in two patients. Cure and partial response rates after thoracic duct embolization and needle disruption were 73.8%, with no morbidity. Surgical thoracic duct ligation was performed in seven patients. The nonprocedural mortality rate was 19%. Follow-up was 3 months or longer. CONCLUSIONS Effective percutaneous treatment of high-output or medically uncontrollable chylothorax was performed promptly and safely in more than 70% of referred cases. This procedure should be attempted, especially if patients are very ill, before riskier surgical thoracic duct ligation is considered.
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Affiliation(s)
- Constantin Cope
- Section of Interventional Radiology and Thoracic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104, USA.
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Abstract
Interventional radiology has assumed an expanded role in the management of the pediatric trauma patient. Transcatheter endovascular embolization for the polytraumatized and bleeding patient has proven to be effective and potentially life saving. Nonvascular interventional techniques can be applied to the pediatric trauma patient with curative or temporizing effects. The minimally invasive nature and rapidity of these procedures allows their emergent use in both the unstable and stable pediatric trauma patient.
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Affiliation(s)
- R Christensen
- Department of Radiology, Memorial Hospital, 1400 E Boulder, Colorado Springs, CO 80909, USA
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Cope C, Salem R, Kaiser LR. Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial. J Vasc Interv Radiol 1999; 10:1248-54. [PMID: 10527204 DOI: 10.1016/s1051-0443(99)70227-7] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To prospectively assess the efficacy of percutaneous transabdominal thoracic duct catheterization and embolization in the management of patients with high-output chylothoracic effusions. MATERIALS AND METHODS Eleven consecutive patients (four women and seven men; mean age, 53 years) were referred with chylothorax secondary to esophagectomy (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 opacify the cisterna chyli or major retroperitoneal lymphatic trunks. When patent, 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 catheter; 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 in six patients because of previous abdominal surgery, trauma, or lymphangioleiomyomatosis; the thoracic duct was successfully catheterized in five patients, a 45% technical success rate. Thoracic duct embolization was performed in four patients, with cure of effusion in two. In the other two patients, 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 have the duct incompletely tied. The authors were surprised to find that previous major abdominal surgery, chronic aortic dissection, and lymphangioleiomyomatosis could obliterate major retroperitoneal lymphatic ducts and the cisterna chyli. Percutaneous study of the thoracic duct with aqueous contrast medium was more sensitive than lymphography with iodinated oil. There was no morbidity. CONCLUSIONS Catheterization of the thoracic duct was possible in all patients who had patent major retroperitoneal lymphatic trunks. Thoracic duct embolization was curative in patients with demonstrable duct leakage. Previous abdominal surgery, aortic dissection, and lymphangioleiomyomatosis can lead to silent occlusion of retroperitoneal lymphatic trunks. Percutaneous thoracic duct catheterization and embolization is safe and can replace surgical ligation in some patients.
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Affiliation(s)
- C Cope
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104, USA.
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Cope C. Diagnosis and treatment of postoperative chyle leakage via percutaneous transabdominal catheterization of the cisterna chyli: a preliminary study. J Vasc Interv Radiol 1998; 9:727-34. [PMID: 9756057 DOI: 10.1016/s1051-0443(98)70382-3] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To assess the feasibility of percutaneous transabdominal puncture and catheterization of the cisterna chyli or lymphatic ducts (PTCLD) in patients with postoperative chyloperitoneum and chylothorax, and to identify and possibly embolize the chylous fistula. MATERIALS AND METHODS Five patients had postoperative uncontrolled chyle fistulas. Two patients with chylothorax had thoracic duct (TD) ligation after esophagectomy and neck surgery. The other three patients had chylous ascites after surgery of the pancreas, the aorta, and the esophagus, respectively. After lymphographic opacification, the cisterna chyli (CC) or retroperitoneal lymph ducts were punctured transabdominally with a 21-gauge needle and catheterized with a 3-F catheter to reach the TD if possible. Microcoils were used to embolize a TD laceration. RESULTS Lymph ducts as small as 2-3 mm were catheterized successfully in three patients. The TD was catheterized in two patients; one TD fistula was embolized with cure of chylothorax. In one patient with a surgically tied TD, duct occlusion was confirmed despite continued pleural effusion. Three fistulas, not seen with lymphography, were identified in two of three chylous ascites and one chylothorax. There was no morbidity. As a result of this procedure, four of five patients did not require repeated operation. CONCLUSIONS PTCLD in the study of chyle fistulas was feasible and safe in the management of five patients and clinically useful in four patients; transabdominal catheter lymphography with aqueous contrast medium is more sensitive than pedal lymphography. Further evaluation is necessary.
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Affiliation(s)
- C Cope
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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Cope C, Timms I, Pavcnik D. Percutaneous transthoracic duct catheterization to the neck and esophagus: a feasibility study. J Vasc Interv Radiol 1997; 8:845-9. [PMID: 9314377 DOI: 10.1016/s1051-0443(97)70671-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To assess the feasibility of inserting a drain catheter percutaneously from the cisterna chyli (CC) through the thoracic duct (TD) wall to the neck or esophagus for potential long-term T-cell sampling or drainage in acute or short-term experiments. MATERIALS AND METHODS Percutaneous transabdominal catheterization of the TD from the CC was performed in four animals to insert a 65-cm, 21-gauge needle over a microguidewire. In two dogs, the distal TD was perforated into the neck to connect the TD drain to an access port. In acute experiments on two swine, the esophagus was accessed by puncturing an intraluminal Foley-catheter balloon through the mid TD wall. In one animal, the TD catheter tip was left to drain in the distal esophagus; in the other animal, the catheter distal tip was pulled back through a gastrostomy until the proximal end had retracted into the proximal TD. RESULTS TD-to-neck port connection was well tolerated short-term. One dog developed dehiscence over the port at 10 days necessitating its removal; in the other dog, the whole drain retracted into the neck from the proximal TD. The technique for TD-to-esophagus catheterization in swine was feasible with no acute complications or mediastinal leakage of contrast medium. CONCLUSIONS Transabdominal percutaneous inside-out TD puncture for drainage to a neck port or to the esophagus is feasible in dogs and swine, respectively.
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Affiliation(s)
- C Cope
- Department of Radiology, University of Pennsylvania Medical Center, Philadelphia 19104, USA
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