Long-Term Clinical Outcome of Abdomino-Thoracic Lymphatic Interventions of Traumatic and Non-Traumatic Lymphatic Leakage in Adults

Abstract

The aim of this study was to retrospectively evaluate the long-term results of lymphatic interventions in adults with abdomino-thoracic lymphatic pathologies. Management of abdomino-thoracic chylous effusions in adults undergoing X-ray-lymphangiography with or without lymph-vessel embolization (LVE) from 2010-2018 was reviewed. Patients underwent lymphangiography alone when imaging showed normal findings or lymphatic obstruction without leakage or reflux; otherwise, LVE was performed (leakage, reflux, obstruction with leakage or reflux, lymphatic masses). Technical and clinical success, complications, and long-term outcomes were assessed. 78 patients (47 male, median age 56.3 years) were treated for chylous effusions (60.3% traumatic, 39.7% non-traumatic). Lymphangiography showed leakage (48.7%), reflux (14.1%), obstruction (28.2%), lymphatic masses (5.1%), and normal findings (3.8%). Embolization was performed in 49/78 (62.8%) cases. Overall, treatment was clinically successful in 74.4% (mean follow-up of 28 months), with significant differences between LVE and lymphangiography (91.8% vs. 44.8%; p < 0.001), traumatic and non-traumatic etiologies (89.4% vs. 51.6%; p < 0.001), and leakage locations (p = 0.003). The clinical success of LVE did not differ between leakage etiologies or locations. Complications occurred in 5 patients (2/5 needed treatment). Patients survived significantly longer after successful treatment (2679 vs. 927 days; p = 0.044) and without malignancy (3214 vs. 1550 days; p = 0.043). Lymphatic interventions are safe and effective. LVE should be attempted whenever feasible, as success is high (>90%). Successful intervention has a positive effect on patient survival.

Keywords: chylothorax; chylous ascites; lymphangiography.

Figure 1

Treatment algorithm for abdomino-thoracic lymphatic leakages.

Figure 2

71-year-old man with bilateral chylothorax after esophagectomy. (A) X-ray lymphangiography demonstrated transection of the thoracic duct in the lower thorax with active leakage of contrast agent. After puncture of the thoracic duct, the inserted micro-wire already exits the thoracic duct at the leakage-site. (B) After thoracic duct embolization with micro-coils and a mixture of NBCA/iodized oil (ratio 1:2) leakage ceased immediately without recurrence or clinical sequelae over a follow-up time of 2.5 years.

Figure 3

65-year-old man with a non-traumatic bilateral chylothorax and chylopericardium. (A) X-ray lymphangiography shows chylous reflux from the upper thoracic part of the thoracic duct into dilated and tortuous lymphatic vessels in the mediastinum and cervical soft tissue. The right-sided lymphatic duct at the right venous angle can also be seen. (B) After thoracic duct embolization with micro-coils and a mixture of NBCA/iodized oil (ratio 1:3) leakage ceased within 2 days without clinical sequelae over a follow-up time of 4 years.

Figure 4

Clinical success of interventional treatment categorized according to treatment type (A), etiology (B), and leakage location (C).

Figure 5

Kaplan-Meier charts demonstrating overall survival comparison for etiology of leakage (A), clinical success of interventional treatment (B), concomitant cardiovascular (C) and malignant disease (D).