Case Report - (2022) Volume 5, Issue 7
Received: 21-Jul-2022, Manuscript No. IPJIIR-22-14004; Editor assigned: 23-Jul-2022, Pre QC No. IPJIIR-22-14004(PQ); Reviewed: 06-Aug-2022, QC No. IPJIIR-22-14004; Revised: 10-Oct-2022, Manuscript No. IPJIIR-22-14004(R); Published: 17-Oct-2022, DOI: 10.21767/2471-8564.5.7.30
Iatrogenic Thoracic Duct (TD) injury is a serious complication of neck surgery. TD embolization after Intranodal Lymphangiography (INL) has been reported to be safe and successful. Retrograde catheterization of the TD through a cervical lymphocyte without using INL could be challenging due to difficult visualization of the TD. The authors describe a method to increase the turgor of the TD thus facilitate its visualization and cannulation by evoking chyle production using high fat diet in combination with a closed drainage system. The method proved to be practical and safe.
Chyle leak; Thoracic duct injury; Thoracic duct embolization
Inadvertent Thoracic Duct (TD) injury with chylous leakage is a serious complication of neck surgery [1-7]. Percutaneous antegrade and retrograde embolization of the TD following Intranodal Lymphangiogram (INL) have been used with high rates of safety and success. Retrograde visualization and cannulation of the TD under fluoroscopic guidance without INL could be challenging [8]. Here, we report a transcervical percutaneous catheterization of a transected TD at the point of its communication with a cervical lymphatic collection. Retrograde fluoroscopic visualization and cannulation of the TD was possible after 24 hours of a high fat diet coupled with the creation of a closed drainage system.
Institutional review board approval for case reports is not required at our institution. A 28 years old female with a history of papillary thyroid cancer underwent total thyroidectomy with lymph node dissection. The patient was discharged one day postoperatively to present three weeks later with a palpable le t supraclavicular swelling. Ultrasound (US) showed a 6 x 5.6 x 5 cm luid collection. The luid aspirate had a triglyceride concentration of 525 mg/dL consistent with chyle. The patient was readmitted to initiate conservative management namely oral fat restriction, total parenteral nutrition, somatostatin infusion, and percutaneous drainage of the luid collection. Nine days of conservative measures failed to stop chyle leakage. Due to her recent extensive thyroid bed surgery, surgical ligation of the TD was not favored, and TD embolization seemed to be the treatment of choice. Preprocedural Magnetic Resonance Lymphangiography (MRL) using heavily T2 weighted sequences revealed a luid collection in the le t supraclavicular area communicating with a severed TD at its posteromedial aspect (Figure 1).
Figure 1: Coronal heavily T2-weighted MR image showing the entire length of the thoracic duct (white arrow) with a severed end communicating with a fluid collection at the base of the left neck (asterisk).
A plan to attempt retrograde catheterization of TD using the preexisting drainage catheter was formulated. Under fluoroscopic guidance, the fluid collection was aspirated, and iodinated water soluble contrast (Visipaque 270 mg/ml, GE healthcare) was then injected. However, the contrast failed to demonstrate a reflux into the TD (Figure 2).
Figure 2: Spot fluoroscopic image after injection of water soluble iodinated contrast through the drainage catheter with no retrograde filling of the thoracic duct.
Therefore, the drainage catheter was removed over a Bentson wire (cook medical, Europe), and a multipurpose catheter was introduced instead with an attempt to cannulate the TD at the previously MRL visualized communicating junction with the collection, but the TD was inaccessible. Thus, it was assumed that the ongoing conservative therapy (with oral fat restriction and continuous external drainage of the chylous collection) has resulted in a low pressure system with a collapsed TD which is hard to catheterize. Therefore, the drainage catheter was reintroduced and closed to external drainage. Additionally, the patient was placed on a high fat diet for 24 hours to enhance chyle production, and octreotide was held. The hypothesis was that a high outflow of chyle into a closed drainage system would likely increase the turgor of the TD, dilate it and promote its retrograde filling with contrast. The patient was given prophylactic antibiotics coverage (Clindamycin 600 mg). Next day, water soluble contrast medium was injected through the drainage catheter into the chylous collection, this time the distal severed end of the TD at the posteromedial aspect of the collection was clearly visualized with reflux of contrast into the upper third of the TD (Figure 3).
Figure 3: Spot fluoroscopic image obtained after direct injection of contrast into the closed drainage system following 24 hours of a high-fat diet, demonstrating reflux of contrast into the thoracic duct (white arrows).
A micro puncture set (MAK 401 merit medical, Ireland) was used to access the fluid collection under fluoroscopic guidance. The micro puncture needle was pointed towards the severed end of the TD. A wire was introduced and a 5-F dilator (cook medical, Europe) with a manually formed 45 degree angle at its tip was advanced into the collection. A 0.035 glide wire (Terumo, Europe) was then used to selectively catheterize the TD. A 4-F C-2 glide catheter (Terumo, Europe) was advanced to the level of the Cisterna Chyli (CC). A lymphangiogram was obtained using water soluble contrast and concurred with the MRI findings (Figure 4).
Figure 4: Spot fluoroscopic image demonstrating successful retrograde catheterization of the thoracic duct with 4-F Cobra Catheter (arrow at catheter tip) with contrast opacified cisterna chyli (asterisk).
Embolization from the CC up to the severed end of the TD was done using a 1:3 mixture of N-Butyl Cyanoacrylate (NBCA) (Glubran2-GEM, Italy) and lipiodol (Guerbet, France). A column of polymerized glue was seen throughout the TD. However, few minutes later the column started to flocculate (Figure 5A and B).
Figure 5: A) Spot Fluoroscopic image obtained 5 minutes after embolization showing fragmentation of embolic NBCA: Lipiodol (1:3) mixture (white arrows). The embolic material travelled in an ante grade direction and accumulated at the point of leakage into the chylous collection; B) Antegrade migration of the embolic mixture is visualized with accumulation at the leakage site of the thoracic duct into the lymphocyte (arrow heads).
The procedure was aborted anticipating that the glue would seal the leaking end of the TD, but chyle drainage through the catheter continued for 24 hours after the procedure. A plan to re attempt embolization was set. In preparation for the procedure, the drainage catheter was closed again to external drainage and the patient was put once again on a high fat diet. Twenty four hours later, fluoroscopic images showed reanalyzed severed TD. Similar puncturing and catheterization techniques to the initial attempt were utilized. A micro catheter (2.7/2.9 F procreate; Terumo, Europe) was advanced to the CC, 4 mm coils (vortex diamond 18, Boston scientific, Ireland) were deployed in the TD at 3-4 cm intervals and a 1:1 mixture of NBCA and lipiodol was used. Fluoroscopic images taken 10 minutes later showed an adequately solidified mixture throughout the entirety of the TD (Figure 6).
Figure 6: Fluoroscopic image showing successful retrograde embolization of the thoracic duct with NBCA: Lipiodol (1:1) mixture and multiple micro coils.
The drainage catheter was left in situ and no fluid output was detected for 24 hours. A next day CT scan of the neck and chest showed lipiodol cast embolization of the entire TD with no fluid collection in the neck (Figure 7).
Figure 7: Follow up coronal CT scan gram of the neck and chest showing stable NBCA: Lipiodol cast and micro coils throughout the entire thoracic duct 24 hours after embolization.
The drainage catheter was removed, and the patient was discharged home a day later. At one, two and six months follow ups, the patient was asymptomatic, had neither neck nor lower limbs swelling [9-14].
TD injury is a known complication of head and neck surgery with a reported incidence that ranges between 0.5 up to 8% depending on the type of surgery and lymph node dissection (1-6). It is associated with increased morbidity due to prolongation of hospitalization, risk of malnutrition, immunosuppression, and electrolyte imbalance. In many cases, conservative measures are successful in controlling the leakage. However, in those where these measures fail, a surgical or interventional radiological solution would be required. Although surgical intervention was originally thought by some as the optimal approach, it has been associated with increased morbidity and mortality in addition to possible failure. Over the last decade, percutaneous embolization of the TD gained momentum as a safe and successful alternative in the treatment of a leaking lymphatic duct following neck dissection. Most described approaches to TD embolization are with trans abdominal or retrograde accesses following INL. INL is time consuming, logistically demanding and requires oil based contrast which carries an embolic risk. Therefore, different groups tried alternative approaches without the need for INL. Transvenous retrograde embolization after neck dissection has been reported by Arslan. This approach requires the identification of the confluence of TD with the subclavian vein which could be quite challenging. US guided direct puncture of the TD at its venous insertion has been described recently and seems to be a promising alternative. Retrograde access of the TD via a cervical lymphocyte without an INL was done by warren, who stated that although the approach is feasible it is not necessarily amenable in all cases, with the possible failure to visualize and emblaze the injured duct. That failure proved to be true both when Pieper et al attempted a similar approach and during our first attempt to visualize the TD, by injecting contrast material into the lymphocyte. Physiological expansion of the lymphatic duct by increasing the lymphatic flow using a high fat diet and increasing back pressure by clamping the drainage catheter seemed to exert enough pressure on the TD to dilate it and make it accessible to visualization and cannulation. This proved to be efficacious and reproducible since the procedure was repeated after failure of the first embolization. Over expansion of a closed drainage system can result in sepsis especially in a patient with a prolonged external drainage and possible bacterial colonization, therefore, prophylactic antibiotics coverage was used for the procedure. MRL plays a significant role in negating the need for INL too. It provides information on both the anatomy and the pathology of the lymphatic system. In our case, MRL clearly delineated the chylous collection and its point of communication with the severed TD and it played a key role in planning for the procedure. Therefore, we recommend doing MRL using heavily T2 weighted sequences in preparation for all cases of planned cervical retrograde annulation. Although NBCA dilution of 1:3 has been used successfully for TD embolization, the same dilution was reported to be unsuccessful. Furthermore, a dilution of 1:4 was deemed partially successful and required reembolization. This could reflect a difference between NBCA formulations regarding viscosity and rate of polymerization. In our first embolization attempt, a 1:3 dilution of Glubran 2 NBCA was used and monitored for polymerization. Few minutes after the initial polymerization the column flocculated and the TD re opened. Re embolization using a 1:1 dilution with coils was successful. Therefore, if Glubran 2 NBCA formulation were to be used, we recommend a 1:1 dilution with or without coils for a higher rate of success.
In conclusion, the combination of a high fat diet and a closed drainage system seems to dilate the TD thus make it more accessible to catheterization and embolization via a retrograde approach. Although the success of such combination was reproducible in our patient, and averted the need for INL, the future applicability in a series of patients would be more assertive.
Citation: Ahmed A, Qadan l, Ahmed MS (2022) Evoking Chyle Production to Facilitate Cervical Catheterization and Embolization of Injured Thoracic Duct: Case Report. J Imaging Interv Radiol. 5:30.
Copyright: © 2022 Ahmed A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited