Today’s case 12 – Successful selective thoracic duct embolization(TDE)

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Today’s case 12 – Successful selective thoracic duct embolization(TDE)

Today, I will discuss the technique of thoracic duct embolization, which is used to treat chyle leakage resulting from surgical procedures or trauma to the thoracic duct.

Lymphatic intervention to treat chyle leakage is a well-known technique among interventional radiologists, but it is not widely performed.

This is because the technique is relatively complex compared to other vascular procedures, and additionally, the referring physicians may not be aware that chyle leakage symptoms can be effectively treated through this method.

Symptoms caused by chyle leakage, such as lymphedema, chylothorax, mesenteric chylous cyst, and chyluria, can be so debilitating that they significantly reduce the patient’s quality of life over time.

Severe lymphedema on left side lower extremity
(Img from : https://lymphedemateam.com/lymphedema-vs-lipedema/)

The availability of non-surgical intervention as a treatment option for lymphatic leakage disorders is indeed welcome news for patients suffering from these conditions.

However, as previously mentioned, it’s disappointing that the procedure is not yet widely practiced and is only performed at a select few institutions.

Let’s now begin with the case presentation.

Our patient is a 33-year-old woman.

She was referred to us for chylothorax that developed after a robot-assisted total thyroidectomy, which was performed to treat papillary thyroid carcinoma.

The surgery was conducted at another institution, and she was sent to us because there were no physicians there who could perform the lymphatic intervention.

Her symptoms were concerning; her neck was swollen as if she had severe hypothyroidism. Daily aspiration from the swollen neck, which proved to be ineffective, was conducted, yet the symptoms persisted.

Subsequently, she was referred to our department.

We performed lymphangiography to embolize the thoracic duct, and I was involved in this procedure as the first assistant.

Thoracic duct embolization
A 24G spinal needle was used to puncture the inguinal lymph node. The subsequent injection of Lipiodol outlined the efferent lymphatic vessels leading to the upper lymphatic channels.
Due to unsatisfactory Lipiodol migration to the upper channels, an additional lymph node puncture was performed under fluoroscopic guidance.
Only a very small amount of Lipiodol reached the thoracic duct. The operator needed to puncture the thoracic duct under fluoroscopic guidance, targeting the stagnated Lipiodol in the thoracic duct, to insert a microguidewire
The stagnated Lipiodol was not clearly visible on the AP (anteroposterior) image, but could be seen on the true lateral view.
A 21G Chiba needle was used to puncture the thoracic duct under fluoroscopic guidance, but the attempt failed due to insufficient Lipiodol stagnation

This step is crucial in performing lymphatic interventions and can also be time-consuming if puncturing the thoracic duct is not achieved promptly.

To visualize the thoracic duct, puncturing of a lymph node at the L5 level and subsequent Lipiodol injection were performed.
Sufficient visualization of the lymphatic channels was achieved following the Lipiodol injection through the L5 level lymph node.
Subsequently, a 21G Chiba needle was again used to puncture the thoracic duct under fluoroscopic guidance
Then, the micro-guidewire and micro-catheter were inserted. Using the microcatheter, lymphangiography was performed, during which contrast extravasation indicating chyle leakage was observed
Due to the complexity of the route to the culprit branch, we determined that a transabdominal approach was inappropriate
Therefore, we planned to perform the procedure using a retrograde approach through the ductovenous junction. The right common femoral vein was punctured, and a 5F guiding sheath was subsequently inserted.
A through-and-through system was established.
An Optimo PB (balloon catheter) was inserted via the retrograde approach. (red arrow: tip of balloon catheter)
The micro-guidewire was advanced toward the leakage point.
Finally, the micro-guidewire reached the chylothorax.
You can see the loop of the micro-guidewire, indicating that it was inside the cavity.
The microcatheter was advanced as far as possible, and the subsequent lymphangiography revealed the leakage (indicated by the arrow)
We performed embolization using micro-coils and glue, specifically a mixture of NBCA and Lipiodol in a 1:2 ratio
The final lymphangiography revealed that the thoracic duct remained patent, which means that we performed selective embolization of the thoracic duct branches without embolizing the main thoracic duct !

After the procedure, the patient began to eat again.

With the resumption of eating, no additional chyle leakage occurred.

After confirming that eating did not cause a recurrence of the symptoms, the patient was discharged

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