Learning objectives
Review the typical embryology and anatomy of the thoracic duct.
Describe and illustrate,
usingboth schematic diagrams and lymphangiography,
variations in thoracic duct anatomy.
Discuss technical and procedural modifications for successful embolization in the face of challenging anatomic variants.
Background
Chylous leakagesmay be the result of numerous etiologies including injury to the thoracic duct from cardiothoracic surgeries,
malignant obstruction,
trauma,
congenital,
or idiopathic causes.
Such injuries maypresent as chylous pleural effusions,
chylopericardium,
and postoperative chylous wound leaks [1,2,3].
Persistent high output chylothoraces havesignificant mortality rates,
as high as 25-50%,
due to the loss of plasma proteins,
fat-soluble vitamins,
lymphocytes,
triglycerides,
intravascular volume,
and electrolytes [1,3].
While conservative dietary therapies have been attempted to control output,
the vast majority of patients require intervention,
especially if output...
Findings and procedure details
Embryology of the Thoracic Duct[4,5,6]
Lymphatic system develops at the end of the sixth week of life.
Lymphatic vessels form similar to blood vessels as they are derived from hemangioblastic stem cells.
Lymphatic clefts andsacs form around large embryologic veins and develop as evaginations from the venous system.
Lymphatic clefts eventually form extensive plexuses between each other and fuse to form larger vessels including the embryonic right and left thoracic ducts.
Formation of lymph nodes,
beginning predominantly in the ninthweek,
results in a decrease of...
Conclusion
The thoracic duct may be injured in a variety of intrathoracic surgeries thereby necessitating embolization procedures.
Variations in thoracic duct anatomy,
from the location or presence/absence of the cisterna chyli to the intrathoraic course of the thoracic duct,
provide challenges to interventional radiologists during embolization.
Knowledge of thoracic duct embryology and anatomy,
supplemented with extensive imaging correlation,
allows successful treatment with minimal morbidity and mortality.
Personal information
Thank you for visiting!
For additional information,
please do not hesitate to contact us.
Nikunj Rashmikant Chauhan,
MD
PGY V Department of Radiology
Brigham and Women's Hospital
Harvard Medical School
[email protected]
Jeffrey Forris Beecham Chick,
MD,
MPH
PGY V Department of Radiology
Brigham and Women's Hospital
Harvard Medical School
[email protected]
Alisa Siziki Han,
MD
Instructor of Radiology
Brigham and Women's Hospital
Harvard Medical School
[email protected]
Special thanks to Tim Killoran,
MD and Chieh-Min Fan,
MD for their assistance in obtaining the variant cases.
Thanks also...
References
[1] Campagna J and Jain R.
“Thoracic Duct Embolization.” Transcatheter Embolization and Therapy.
Ed David Kessel and Charles Ray.
London: Springer,
2010.
471-472.
[2] Chen E and Itkin M.
Thoraic Duct Embolization for Chylous Leaks.
Semin Interven Radiol.
2011;28:63-74.
[3] Cope,
C.
Management of chylothorax via percutaneous embolization.
Curr Opin Pulm Med.
2004; 10:311–314.
[4] 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...