“Patients” is a virtue: ultrasound-guided intranodal lymphangiogram approach for the treatment of chylous effusions; a new school twist on an old school procedure

Abstract

Learning Objectives: Percutaneous thoracic duct embolization has been shown to be effective in the treatment of recurrent chylous effusions. Many embolic agents have been described in the successful occlusion of the thoracic duct. In this study, we evaluate the role and efficacy of using EVOH copolymer (Onyx) in the treatment of traumatic chylous pleural effusions. Background: A retrospective review was performed of consecutive patients with post-operative chylous pleural effusions treated with thoracic duct embolization using EVOH copolymer at a single institution from 2012-2014. Demographic data, surgical history, procedure details, and toxicities were systematically reviewed. Clinical Findings/Procedure Details: 4 patients (M¼2) were identified that met inclusion criteria. Median age at treatment was 67. Median follow was 125 days (range 24-246). Two patients had undergone robotic assisted surgery and 2 had undergone open thoracotomy. 3 patients had thoracic duct ligation performed at the time of their initial surgery. Median time from surgery to embolization was 7 days (range 3-15). Daily chest tube drainage range was 150 -2000 ml. All patients underwent bilateral ultrasound guided inguinal nodal lymphangiogram. The thoracic duct was then accessed using a 21 or 22 gauge Chiba needle. A thoracic duct leak was identified in 3 patients. Coils were placed initially in the central duct prior to embolization of the leak limit potential systemic flow. Onyx 34 (ev3 Neurovascular, Irvine, California) was used in 4 patients with additional Onyx 18 in 1 patient for embolization. Volume used was 1-2 ml in all patients. All patients had resolution of the chylous effusion within 1 day of embolization. The subjects were discharged from the hospital between 4-7 days post-procedure. 30 days post-procedure complications included an abdominal wall hematoma in 1 patient who was subsequently started on anticoagulation. No patients developed recurrent chyle leaks during the follow up period. Conclusion and/or Teaching Points: EVOH copolymer is a safe and effective agent for percutaneous thoracic duct embolization. This is the largest reported series to date demonstrating the efficacy of this embolic agent in treating chylous effusions in the post-traumatic setting.