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Type:
Educational Exhibit
Keywords:
Normal variants, Embolisation, Percutaneous, MR, Lymphography, Lymph nodes, Interventional vascular, Anatomy, Congenital
Authors:
N. Chauhan, J. F. B. Chick, A. Han; Boston, MA/US
DOI:
10.1594/ecr2015/C-1455
Background
Chylous leakages may be the result of numerous etiologies including injury to the thoracic duct from cardiothoracic surgeries,
malignant obstruction,
trauma,
congenital,
or idiopathic causes.
Such injuries may present as chylous pleural effusions,
chylopericardium,
and postoperative chylous wound leaks [1,2,3].
Persistent high output chylothoraces have significant 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 exceeds 1 L/day [2].
Surgical ligation,
while technically successful,
carries significant morbidity and mortality,
with rates of 38% and 2.1%,
respectively [3].
As a result,
percutaneous thoracic duct embolization has become the standard of care for clinically significant chyle leaks.
The technique for performing thoracic duct embolization is well described in the literature and will not be extensively discussed in this presentation (See our exhibit entitled: When,
Why,
and How of Thoracic Duct Embolization for additional procedural discussion).
It is important to note,
however,
that after the lymphatic system is opacified via a pedal cut-down or inguinal node injection,
embolization is generally performed from the point of extravasation or obstruction to the cisterna chyli [2,4].
It is estimated that the typical course of the thoracic duct is present in only 60-40% of patients and variation is essentially the rule [2].
The thoracic duct may vary at any point along its course,
including the cisterna chyli,
intrathoracic course,
the number of ducts,
location of its tributaries,
and point of termination [2].
Knowledge of the embryology of the thoracic duct and its clinically significant variations is beneficial to interventionalists performing embolization procedures.