An Algorithmic Approach to Minimally Invasive Management of Nontraumatic Chylothorax

Abstract

Chylothorax is a rare condition characterized by lymph accumulation in the pleural space. When it occurs independent of trauma, it is even more rare and difficult to treat as identification of lymphatic leak is unpredictable. In addition, treatment of this condition with conventional lymphangiography and thoracic duct embolization may not result in positive outcomes. As such, the role of contrast-enhanced dynamic magnetic resonance lymphangiography to guide treatment is key to maximizing success with the advantage of localizing the site of lymphatic leak. Herein, we summarize etiologies of nontraumatic chylothorax, offer an updated treatment algorithm to stratify affected patients and determine appropriate treatment options, and review procedural techniques critical to efficient and effective treatment.

Keywords: chylothorax; chylous; interventional radiology; lymphatic; pleural space; thoracic duct.

Fig. 1

66-year-old male with pulmonary lymphatic perfusion syndrome manifesting with plastic bronchitis and chylothorax. (a) MR lymphangiography MIP reconstruction using heavily T2-weighted sequences demonstrating large lymphatic masses in the right hemithorax and peribronchial lymphatic flow. (b) Catheter lymphangiogram demonstrating transection of the central thoracic duct and filling of the right thoracic lymphatic masses. (c) Completion fluoroscopic image after coil and glue embolization of the thoracic duct.

Fig. 2

74-year-old female with remote history of triple negative breast cancer treated with chemoradiation and idiopathic right chylothorax accumulating 2 liters of fluid every two weeks. (a) MR dynamic lymphangiography MIP of TWIST sequences (Siemens, Erlangen, Germany) after lymphatic groin access and contrast administration demonstrates extensive lymphatic collateralization in the mediastinum and upper retroperitoneum without identification of a single thoracic duct. (b) Cisterna chyli accessed with a 22-gauge needle and lymphangiography performed. (c) Lymphangiogram after deployment of MVP-3Q vascular plug (Medtronic, Dublin, Ireland) and n-BCA glue embolization of the dominant lymphatic conduit.

Fig. 3

Treatment algorithm for non-traumatic chylothorax in the absence of chylous ascites. CE - contrast enhanced, TD-thoracic duct, TDE- thoracic duct embolization.