Anastomosis of the thoracic duct and the azygos vein for the treatment of recurrent chylothoraxes

Anastomosis of the caudal thoracic duct and intercostal vein using a microvascular anastomotic coupler device: Experimental study in six dogs

OBJECTIVE

To describe the technique for anastomosis of the caudal thoracic duct (TD) to the 10th or 11th intercostal vein (ICV) using a microvascular anastomotic coupler (MAC) device in dogs and assess patency of the anastomosis on days 0 and 30.

STUDY DESIGN

Experimental study.

SAMPLE POPULATION

Six adult Beagle dogs.

METHODS

Under general anesthesia, fluoroscopic popliteal lymphangiography was performed and the TD identified. A right ninth or 10th intercostal thoracotomy was performed. Using an operating microscope, the TD and the 10th or 11th ICV were isolated, ligated, and anastomosed using a 1.5 or 2.0 mm MAC. Fluoroscopic popliteal lymphangiography was repeated immediately after surgery and on day 30.

RESULTS

The anastomosis was successful and lymphangiography documented flow into the azygos vein in all six dogs immediately after surgery. At day 30, the anastomosis was patent in four of six dogs. In two dogs, flow through the anastomosis was obstructed due to kinking of the ICV just cranial to the MAC.

CONCLUSION

Anastomosis of the TD and ICV using a MAC was feasible and was shown to maintain patency up to 30 days. When performing the anastomosis, care should be taken to ensure the ICV is not kinked by the MAC.

CLINICAL SIGNIFICANCE

Direct anastomosis of the TD and ICV may have application for treatment of idiopathic chylothorax in dogs by maintaining flow from the abdominal lymphatics to the central venous circulation and thereby preventing the stimulus for collateral circulation and persistent chylous effusion. Further investigation is warranted to assess the efficacy of this technique in dogs affected with idiopathic chylothorax.

Microsurgical central lymphatic reconstruction-the role of thoracic duct lymphovenous anastomoses at different anatomical levels

Introduction

In recent years advances have been made in the microsurgical treatment of congenital or acquired central lymphatic lesions. While acquired lesions can result from any surgery or trauma of the central lymphatic system, congenital lymphatic lesions can have a variety of manifestations, ranging from singular thoracic duct abnormalities to complex multifocal malformations. Both conditions may cause recurrent chylous effusions and downstream lymphatic congestion depending on the anatomical location of the thoracic duct lesion and are associated with an increased mortality due to the permanent loss of protein and fluid.

Methods

We present a case series of eleven patients undergoing central lymphatic reconstruction, consisting of one patient with a cervical iatrogenic thoracic duct lesion and eleven patients with different congenital thoracic duct lesions or thrombotic occlusions.

Results

Anastomosis of the thoracic duct and a nearby vein was performed on different anatomical levels depending on the underlying central lymphatic pathology. Cervical (n = 4), thoracic (n = 1) or abdominal access (n = 5) was used for central lymphatic reconstruction with promising results. In 9 patients a postoperative benefit with varying degrees of symptom regression was reported.

Conclusion

The presented case series illustrates the current rapid advances in the field of central microsurgical reconstruction of lymphatic lesions alongside the relevant literature.

Back to the Future: Lipiodol in Lymphography-From Diagnostics to Theranostics

Lipiodol is an iodinated poppy seed oil first synthesized in 1901. Originally developed for therapeutic purposes, it has mainly become a diagnostic contrast medium since the 1920s. At the end of the 20th century, Lipiodol underwent a transition back to a therapeutic agent, as exemplified by its increasing use in lymphangiography and lymphatic interventions. Nowadays, indications for lymphangiography include chylothorax, chylous ascites, chyluria, and peripheral lymphatic fistula or lymphoceles. In these indications, Lipiodol alone has a therapeutic effect with clinical success in 51% to 100% of cases. The 2 main access sites to the lymphatic system for lymphangiography are cannulation of lymphatic vessels in the foot (transpedal) and direct puncture of (mainly inguinal) lymph nodes (transnodal). In case of failure of lymphangiography alone to occlude the leaking lymphatic vessel as well as in indications such as protein-losing enteropathy, postoperative hepatic lymphorrhea, or plastic bronchitis, lymphatic vessels can also be embolized directly by injecting a mixture of Lipiodol and surgical glues (most commonly in thoracic duct embolization). The aim of this article is to review the historical role of Lipiodol and the evolution of its clinical application in lymphangiography over time until the current state-of-the-art lymphatic imaging techniques and interventions.