Chylothorax secondary to venous outflow obstruction treated with transcervical retrograde thoracic duct cannulation with embolization and venous reconstruction

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Presentation transcript:

Chylothorax secondary to venous outflow obstruction treated with transcervical retrograde thoracic duct cannulation with embolization and venous reconstruction Jeffrey Forris Beecham Chick, MD, MPH, DABR, Anthony N. Hage, BS, Nishant Patel, MD, MBA, Joseph J. Gemmete, MD, FSIR, J. Matthew Meadows, MD, Ravi N. Srinivasa, MD Journal of Vascular Surgery Cases and Innovative Techniques Volume 4, Issue 3, Pages 193-196 (September 2018) DOI: 10.1016/j.jvscit.2018.03.010 Copyright © 2018 The Author(s) Terms and Conditions

Fig 1 Schematic illustration of transcervical retrograde thoracic duct glue embolization and venous reconstruction. A, Thrombotic occlusion of the left axillary and brachiocephalic veins. B, Opacification of the proximal thoracic duct through pressurized venography. C, Transcervical access and glue embolization of the thoracic duct. D, Venous recanalization and stenting of the left axillary and distal brachiocephalic veins. Journal of Vascular Surgery Cases and Innovative Techniques 2018 4, 193-196DOI: (10.1016/j.jvscit.2018.03.010) Copyright © 2018 The Author(s) Terms and Conditions

Fig 2 Frontal digital subtraction venography of the left arm showing complete occlusion of the left axillary and brachiocephalic veins (arrowhead). Numerous collateral veins are seen in the upper chest that reconstitute the superior vena cava (arrow). Journal of Vascular Surgery Cases and Innovative Techniques 2018 4, 193-196DOI: (10.1016/j.jvscit.2018.03.010) Copyright © 2018 The Author(s) Terms and Conditions

Fig 3 After successful crossing of the left axillary and brachiocephalic vein occlusions, pressurized digital subtraction venography within the excluded subclavian vein shows retrograde filling of the thoracic duct (arrow). Tandem occlusions are noted in the axillary and brachiocephalic veins (white arrowheads). The left internal jugular vein is occluded. Contrast material is seen refluxing into a straight-appearing segment of a left lymphatic duct (black arrowhead) and the main thoracic duct. Journal of Vascular Surgery Cases and Innovative Techniques 2018 4, 193-196DOI: (10.1016/j.jvscit.2018.03.010) Copyright © 2018 The Author(s) Terms and Conditions

Fig 4 After multiple unsuccessful transvenous attempts to cannulate the terminal thoracic duct (arrowheads) with various reverse curve catheters, a 21-gauge Chiba needle (arrow) was used to access a lymphatic channel under fluoroscopic guidance. Journal of Vascular Surgery Cases and Innovative Techniques 2018 4, 193-196DOI: (10.1016/j.jvscit.2018.03.010) Copyright © 2018 The Author(s) Terms and Conditions

Fig 5 Once access was obtained, an 0.018-inch Nitrex wire was navigated into the main thoracic duct (arrow). Journal of Vascular Surgery Cases and Innovative Techniques 2018 4, 193-196DOI: (10.1016/j.jvscit.2018.03.010) Copyright © 2018 The Author(s) Terms and Conditions

Fig 6 Frontal fluoroscopic image showing n-butyl cyanoacrylate filling the thoracic duct. The area of disruption within the thoracic duct, likely from central venous occlusion, is seen with glue filling this segment (arrow). A wire is identified crossing the central venous occlusions (black arrowheads). A pigtail catheter is visualized in the right pleural space (white arrowhead). Journal of Vascular Surgery Cases and Innovative Techniques 2018 4, 193-196DOI: (10.1016/j.jvscit.2018.03.010) Copyright © 2018 The Author(s) Terms and Conditions

Fig 7 Frontal left upper extremity venogram showing successful placement of Wallstents in the brachiocephalic and subclavian veins (arrow) with free flow of contrast material from the left arm to the superior vena cava. Stents were extended into the left axillary vein to ensure adequate inflow. Glue is seen within the thoracic duct (arrowheads). Journal of Vascular Surgery Cases and Innovative Techniques 2018 4, 193-196DOI: (10.1016/j.jvscit.2018.03.010) Copyright © 2018 The Author(s) Terms and Conditions