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(Circulation. 2000;102:268.)
© 2000 American Heart Association, Inc.

Images in Cardiovascular Medicine

Percutaneous Embolization of Thoracic Duct Injury

Joseph Bonn, MD; David Sperling, MD; Paul Walinsky, MD; John Mannion, MD

From the Department of Radiology (J.B., D.S.), the Department of Medicine (P.W.), and the Department of Surgery (J.M.), Jefferson Medical College and Thomas Jefferson University Hospital, Philadelphia, Pa.

Correspondence to Joseph Bonn, MD, Cardiovascular and Interventional Radiology, Suite 4200 Gibbon, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA 19107.

A 53-year-old woman with coronary artery disease presented with dyspnea 4 days after aortic valve replacement and coronary artery revascularization with a left internal mammary graft to the left anterior descending coronary artery. Frontal chest radiography 8 days after surgery revealed a large left pleural effusion (Figure 1) that on needle aspiration was characterized grossly and chemically as a chylothorax. After reaccumulation of the pleural effusion 3 days later, a tube thoracostomy was performed, producing 2300 mL of chylous fluid in the first 12 hours of drainage. The patient was referred to interventional radiology for diagnosis of a lymphatic leak and possible percutaneous treatment of the leak.

View larger version (110K): [in this window] [in a new window]   Figure 1. Frontal chest radiograph obtained 8 days after cardiac surgery reveals large left pleural effusion.

The cisterna chyli was opacified with oil-based iodinated contrast via pedal lymphatic cannulation. By a technique first described in humans in 1998 by Cope¹ and with the patient under mild conscious sedation, the cisterna chyli was accessed percutaneously in the upper abdomen with the Seldinger technique under fluoroscopic guidance, and a 3F angiographic catheter was passed over a guidewire to the midthoracic duct. Injection of aqueous iodinated contrast at that level opacified the cephalad thoracic duct and demonstrated a lymphatic leak into the left pleural space originating from disrupted thoracic duct branches near the medial apex of the left chest (Figure 2). Embolization was performed by multiple Gianturco coils and gelatin sponge slurry passed through the angiographic catheter into the midthoracic duct to occlude it proximal to the leak (Figure 3). The patient’s thoracostomy drainage declined steadily over the next 3 days, and the tube was removed. Three weeks after thoracic duct embolization, she was asymptomatic and had no pleural effusion on chest radiography (Figure 4). She remains asymptomatic and with a clear chest radiograph 9 months after the procedure.

View larger version (148K): [in this window] [in a new window]   Figure 2. Opacification of thoracic duct by direct catheter injection reveals multiple sites of duct disruption and contrast extravasation (arrows) in apical left chest.

View larger version (165K): [in this window] [in a new window]   Figure 3. After thoracic duct embolization with multiple Gian- turco coils (arrows), duct occlusion is demonstrated by contrast injection proximal to coils.

View larger version (115K): [in this window] [in a new window]   Figure 4. Frontal chest radiograph obtained 3 weeks after thoracic duct embolization demonstrates resolution of pleural effusion.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.

References

1. 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;9:727–734.[Medline] [Order article via Infotrieve]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bonn, J. Articles by Mannion, J. Search for Related Content PubMed PubMed Citation Articles by Bonn, J. Articles by Mannion, J. Related Collections Imaging CV surgery: other