Endolymphatic Balloon-Occluded Retrograde Abdominal Lymphangiography (BORAL) and Embolization (BORALE) for the Diagnosis and Treatment of Chylous Ascites: Approach, Technical Success, and Clinical Outcomes

Glue Embolization of Lymphopseudoaneurysm for Chylous Ascites after Retroperitoneal Surgery

“…Even though intranodal lymphography and LN embolization have demonstrated favorable clinical outcomes in some cases, a new approach is needed to assess chylous ascites considering the inherent physiological obstacles mentioned above. Some novel lymphangiography methods have been introduced such as intraoperative mesenteric lymphangiography, and balloon-occluded retrograde abdominal lymphangiography and embolization (BORALE), but the former is invasive and the latter requires dedicated devices (e.g., micro-balloons), and can be technically demanding (10,14,15).…”

“…Due to advances in the field of lymphatic intervention, many post-operative lymphatic leakages are currently treated with minimally invasive procedures, such as thoracic duct embolization, or intranodal LN embolization (3)(4)(5)(6)(7). However, chylous ascites remains a difficult condition to diagnose and treat by inguinal intranodal lymphangiography because chylous and non-chylous lymphatic fluids follow different pathways (8)(9)(10).…”

“…It is contained by surrounding kjronline.org tissue before draining into larger spaces, such as the peritoneal cavity, or into lymphoceles (3). Several studies have reported the application of LPA embolization to treat chylous ascites, chylothorax, and lymphoceles (3,8,10).…”

Retrograde transvenous lymphatic embolization for postoperative chylous ascites: A report of three cases and literature review

“…First, the point of leakage may be unknown before the retrograde transverse procedure because it may not be identified with inguinal intranodal lymphangiography or lymphatic scintigraphy when the upstream region is interrupted due to lymph node dissection. Second, the junction of the venous angle and the thoracic duct are usually not visualized with subclavian venography from the subclavian or internal jugular vein due to the presence of an ostial valve at the termination of the thoracic duct [5 , [10] , [11] , [12] , [13] , [14] . In addition, the termination point of the thoracic duct can have various locations, such as the internal jugular vein, jugulo-subclavian angle, subclavian vein, or another vein, and is generally placed within 2 cm of the jugulo-subclavian angle [5 , 15] , making it necessary to grope for the lymphovenous junction.…”

“…Therefore, intranodal lymphangiography and MR lymphangiography are useful for visualization of the lymphovenous junction and facilitate catheter insertion [5 , 14] . Technically, on the basis of previous reports [5 , 10 – 12] , a 4-F or 5-F preshaped catheter, such as RIM catheter or SOS Omni Selective catheter (AngioDynamics, Queensbury, NY, USA) was often used for cannulation of the lymphatic venous junction when it was approached from the left brachial vein. Third, because of the presence of many branches that join from the cervical region and arms or plexiform configuration of the cervical part of the thoracic duct, the contrast agent may not reach the thoracic part even with pressure injection after cannulation of the cervical part [14 , 16] .…”