ARRS 2022 Abstracts


E1791. Trans-nodal and Retrograde Lymphangiogram with Embolization of Chylous Leak and Fenestration of Adjacent Lymphatic Ducts
  1. David Mittelstein; Keck School of Medicine of University of Southern California
  2. Ramon Ter-Oganesyan; Keck School of Medicine of University of Southern California
  3. Brian Quinn; Olive View - UCLA Medical Center
Lymphorrhea, or lymphatic leak, is a rare (2.7–3.8%), but well known complication of thoracic and head and neck surgery. These leaks are characterized as lymphatic, involving interstitial fluid and white blood cells, or chylous, involving lymph and emulsified fats. Leaks can occur into the thorax (chylothorax), pericardium (chylopericardium), pertioneum (chyloperitoneum), or retropertioneum. Retroperitoneal leaks are limited by confining interstitial tissue, but chyloperitoneum can involve large volumes and lead to morbidity. Low volume chylous leaks can be managed by limiting oral intake, total parenteral nutrition, and octreotide; however, higher volume leaks (> 1 L/day) require surgical or interventional radiology management. Percutaneous lymphatic interventions are indicated for any high output (> 500 mL/day) leak above the diaphragm or low output leak that fails conservative management. In this educational exhibit, we review imaging findings suggestive of lymphatic leaks. We then describe methods of ultrasound guided trans-nodal lymphatic access, percutaneous fluoroscopic access of cisterna chyli, and retrograde lymphatic access via the thoracic duct. We finally review techniques for lymphatic leak embolization via clinical case review.

Educational Goals / Teaching Points
The goals of this exhibit are to recognize imaging and clinical findings of lymphatic injuries and recognizing chylous leaks; review the trans-nodal lymphatic access through lipodol contrast; review image-guided interventions of lymphatic leaks including glue embolization and fenestration; review retrograde lymphatic access through the thoracic duct; and manage possible complications of lymphatic interventions.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
For this case presentation, images from multiple lymphangiograms performed at our institution will be combined into a unified clinical case presentation for educational purposes. These include: imaging findings of lymphatic leak (CTAP: 16-mm retroperitoneal fluid collection in aortocaval region); transnodal lymphatic access; fluoroscopic-guided percutaneous cisterna chyli access; percutaneous N-butyl cyanoacrylate glue embolization of lymphatic leak; and retrograde lymphatic access from L basilic vein to thoracic duct.

Lymphangiograms are percutaneous minimally invasive procedures that can be used to identify, locate, and embolize lymphatic leaks. The technical success rates for thoracic duct and cisterna chyli cannulation (65–70%) reflects the difficulty of the procedure, particularly as many interventional radiologists may have limited exposure to lymphatic procedures. The clinical success rate for the detection of a leak site with lymphangiography is 65–85%, but of those that are detected, 90–95% of visible chylous leaks are ceased with thoracic duct embolization. This educational exhibit aims to provide detailed procedural guidance for image-guided lymphatic intervention with the goal of resolving lymphatic leaks.