Traumatic Chylothorax: Approach and Outcomes

Abstract

Traumatic chylothorax occurs more often now than in historic reports. In part, this is due to the increased ability to perform more advanced and aggressive thoracic resections and cardiovascular surgeries as well as the improved mortality of cancer patients. If untreated, chylothorax can result in significant morbidity and mortality, particularly in patients with underlying malignancy. Thoracic duct embolization for chylothorax was the first successful lymphatic intervention and has been performed for over 20 years. An overview of the clinical and technical approach to thoracic duct embolization for traumatic chylothorax is presented in addition to a review of outcomes.

Keywords: chylothorax; iatrogenic; interventional radiology; postoperative; thoracic duct embolization; traumatic.

Fig. 1

Overview of lymphatic flow in the body. The lower extremities, left upper extremity, left head, left hemithorax, and subdiaphragmatic organs drain into the cisterna chyli and transit through the thoracic duct emptying into the left venous angle, near the junction of the left internal jugular and subclavian veins. The right upper extremity, head, and hemithorax (drainage pattern shaded yellow) drain to the right lymphatic duct, near the junction between the right internal jugular and subclavian veins.

Fig. 2

A 33-year-old man with chylothorax underwent diagnostic thoracentesis. Chyle is triglyceride rich, turbid, opaque, and resembles buttermilk.

Fig. 3

Treatment algorithm for a known traumatic chylothorax.

Fig. 4

Intranodal lymphangiography. ( a ) Ultrasound-guided access into a lymph node is performed, positioning the needle (white arrowhead) centrally within the lymph node (white arrow). Asterisk—blood vessel. ( b ) Bi-inguinal nodal lymphangiography. A manifold three-way stopcock (black arrowhead) allows for controlled injection from polycarbonate syringes through tubing which is connected to the needle (black arrow). ( c ) Nodal lymphangiogram with the needle (black arrow) in the lymph node produces a rapid result opacifying multiple lymphatic vessels (white arrow) and upstream lymph nodes.

Fig. 5

Establishing central lymphatic access in a 62-year-old male with left chylothorax. ( a ) The needle (white arrow) is angled ∼10 to 20 degrees cephalad. The image intensifier may be similarly angled to help facilitate targeting. ( b ) The needle (black arrowhead) approaches the retroperitoneal target (black arrow). ( c ) As the needle (black arrowhead) punctures the retroperitoneal lymphatic, the contrast (black arrow) is displaced cephalad. ( d ) After puncturing the target successfully and with the needle (white arrowhead) secured, the vessel can be probed with a microwire tip (white arrow) until it freely floats within the lumen toward the upper portions of the chest. The needle can now be exchanged for a microcatheter.

Fig. 6

A 71-year-old man with high-volume right chylothorax following lung cancer resection undergoing thoracic duct embolization. ( a ) Digital subtraction lymphangiography from a needle (white arrowhead) puncturing the cisterna chyli (black arrow) reveals abrupt transection of the thoracic duct with extravasation (black arrowheads) into the right pleural space. ( b ) Multiple microcoils were tightly packed below the level of injury (between the black arrowheads). ( c ) Below the lowest microcoil (black arrowhead), glue was injected (black arrow).