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Journal of Vascular Surgery. Venous and... Nov 2018The objective of this study was to determine the incidence of vascular and lymphatic complications after attempted transabdominal thoracic duct cannulation.
OBJECTIVE
The objective of this study was to determine the incidence of vascular and lymphatic complications after attempted transabdominal thoracic duct cannulation.
METHODS
There were 58 patients who underwent attempted thoracic duct cannulation. Patients presented with chyle leak in the chest (n = 40), abdomen (n = 9), neck (n = 8), and pelvis (n = 1). Vertebral body level and geographic access, needle gauge, additional access for treatment, technical success, intervention performed, immediate and delayed complications, and follow-up duration were recorded. Imaging and electronic medical records were reviewed at follow-up for complications and treatment success.
RESULTS
Access into the lymphatic system was obtained at L1 (n = 21), T12 (n = 17), L2 (n = 14), L3 (n = 3), T11 (n = 1), L4 (n = 1), and L5 (n = 1). Lymphatic access was achieved in the center (n = 28), on the right (n = 16), or on the left (n = 14) of the vertebral body; 21-, 22-, and 25-gauge needles were used in 45 patients, 12 patients, and 1 patient, respectively. Arm venous and percutaneous supraclavicular access was successful in 15 patients and eight patients, respectively. Cannulation of the thoracic duct was achieved in 52 (89.7%) patients. Embolization, disruption, and stenting were performed in 41 (70.7%), 12 (20.7%), and 2 (3.4%) patients; 3 (5.2%) patients had normal thoracic ducts after successful cannulation. Immediate complications consisted of shearing of the access wire in two (3.4%) patients. Retrospective analysis of initial follow-up imaging in 49 (84.5%) patients revealed the following late complications: inferior vena cava and right renal vein thrombosis and one perinephric lymphatic collection.
CONCLUSIONS
Of 58 patients who had attempted thoracic duct cannulation, successful access was achieved in 90% of patients. Early and delayed complications occurred in 3.4% and 4% of patients, respectively. Thoracic duct cannulation represents a highly successful technique that aids in the treatment of chyle leaks in medically complex patients.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Catheterization; Child; Child, Preschool; Chylothorax; Computed Tomography Angiography; Embolization, Therapeutic; Female; Humans; Infant; Lymphography; Male; Middle Aged; Phlebography; Renal Veins; Retrospective Studies; Thoracic Duct; Treatment Outcome; Vena Cava, Inferior; Venous Thrombosis; Young Adult
PubMed: 30336901
DOI: 10.1016/j.jvsv.2018.05.023 -
Nature Communications Oct 2019Cranial lymphatic vessels (LVs) are involved in the transport of fluids, macromolecules and central nervous system (CNS) immune responses. Little information about...
Cranial lymphatic vessels (LVs) are involved in the transport of fluids, macromolecules and central nervous system (CNS) immune responses. Little information about spinal LVs is available, because these delicate structures are embedded within vertebral tissues and difficult to visualize using traditional histology. Here we show an extended vertebral column LV network using three-dimensional imaging of decalcified iDISCO-clarified spine segments. Vertebral LVs connect to peripheral sensory and sympathetic ganglia and form metameric vertebral circuits connecting to lymph nodes and the thoracic duct. They drain the epidural space and the dura mater around the spinal cord and associate with leukocytes. Vertebral LVs remodel extensively after spinal cord injury and VEGF-C-induced vertebral lymphangiogenesis exacerbates the inflammatory responses, T cell infiltration and demyelination following focal spinal cord lesion. Therefore, vertebral LVs add to skull meningeal LVs as gatekeepers of CNS immunity and may be potential targets to improve the maintenance and repair of spinal tissues.
Topics: Animals; Image Processing, Computer-Assisted; Lymph Nodes; Lymphatic Vessels; Male; Mice, Inbred C57BL; Mice, Transgenic; Microscopy, Confocal; Microscopy, Fluorescence; Spinal Cord Injuries; Spine; Thoracic Duct
PubMed: 31597914
DOI: 10.1038/s41467-019-12568-w -
Journal of Anatomy Jul 2018The thoracic duct (TD) transports lymph drained from the body to the venous system in the neck via the lymphovenous junction. There has been increased interest in the TD... (Review)
Review
The thoracic duct (TD) transports lymph drained from the body to the venous system in the neck via the lymphovenous junction. There has been increased interest in the TD lymph (including gut lymph) because of its putative role in the promotion of systemic inflammation and organ dysfunction during acute and critical illness. Minimally invasive TD cannulation has recently been described as a potential method to access TD lymph for investigation. However, marked anatomical variability exists in the terminal segment and the physiology regarding the ostial valve and terminal TD is poorly understood. A systematic review was conducted using three databases from 1909 until May 2017. Human and animal studies were included and data from surgical, radiological and cadaveric studies were retrieved. Sixty-three articles from the last 108 years were included in the analysis. The terminal TD exists as a single duct in its terminal course in 72% of cases and 13% have multiple terminations: double (8.5%), triple (1.8%) and quadruple (2.2%). The ostial valve functions to regulate flow in relation to the respiratory cycle. The patency of this valve found at the lymphovenous junction opening, is determined by venous wall tension. During inspiration, central venous pressure (CVP) falls and the valve cusps collapse to allow antegrade flow of lymph into the vein. During early expiration when CVP and venous wall tension rises, the ostial valve leaflets cover the opening of the lymphovenous junction preventing antegrade lymph flow. During chronic disease states associated with an elevated mean CVP (e.g. in heart failure or cirrhosis), there is a limitation of flow across the lymphovenous junction. Although lymph production is increased in both heart failure and cirrhosis, TD lymph outflow across the lymphovenous junction is unable to compensate for this increase. In conclusion the terminal TD shows marked anatomical variability and TD lymph flow is controlled at the ostial valve, which responds to changes in CVP. This information is relevant to techniques for cannulating the TD, with the aid of minimally invasive methods and high resolution ultrasonography, to enable longitudinal physiology and lymph composition studies in awake patients with both acute and chronic disease.
Topics: Animals; Heart Failure; Humans; Jugular Veins; Liver Cirrhosis; Saphenous Vein; Thoracic Duct
PubMed: 29635686
DOI: 10.1111/joa.12811 -
American Journal of Physiology. Heart... Nov 2022The cisterna chyli is a lymphatic structure found at the caudal end of the thoracic duct that receives lymph draining from the abdominal and pelvic viscera and lower... (Review)
Review
The cisterna chyli is a lymphatic structure found at the caudal end of the thoracic duct that receives lymph draining from the abdominal and pelvic viscera and lower limbs. In addition to being an important landmark in retroperitoneal surgery, it is the key gateway for interventional radiology procedures targeting the thoracic duct. A detailed understanding of its anatomy is required to facilitate more accurate intervention, but an exhaustive summary is lacking. A systematic review was conducted, and 49 published human studies met the inclusion criteria. Studies included both healthy volunteers and patients and were not restricted by language or date. The detectability of the cisterna chyli is highly variable, ranging from 1.7 to 98%, depending on the study method and criteria used. Its anatomy is variable in terms of location (vertebral level of T10 to L3), size (ranging 2-32 mm in maximum diameter and 13-80 mm in maximum length), morphology, and tributaries. The size of the cisterna chyli increases in some disease states, though its utility as a marker of disease is uncertain. The anatomy of the cisterna chyli is highly variable, and it appears to increase in size in some disease states. The lack of well-defined criteria for the structure and the wide variation in reported detection rates prevent accurate estimation of its natural prevalence in humans.
Topics: Humans; Thoracic Duct; Prevalence
PubMed: 36206050
DOI: 10.1152/ajpheart.00375.2022 -
The Journal of Thoracic and... Sep 2015
Topics: Abnormalities, Multiple; Cardiac Surgical Procedures; Chylothorax; Female; Heart Defects, Congenital; Humans; Male; Pleural Effusion; Pregnancy; Thoracic Duct; Thoracotomy
PubMed: 26232940
DOI: 10.1016/j.jtcvs.2015.07.013 -
The Journal of Thoracic and... Aug 2018To summarize the imaging findings and outcomes of thoracic duct (TD) embolization (TDE) performed in patients with chylous leaks persisting after TD ligation (TDL).
OBJECTIVE
To summarize the imaging findings and outcomes of thoracic duct (TD) embolization (TDE) performed in patients with chylous leaks persisting after TD ligation (TDL).
MATERIALS AND METHODS
In this review of 50 patients (30 males and 20 females; median age, 54 years) referred for TDE following unsuccessful surgical TDL, records were reviewed for lymphangiographic findings, technical success of TDE, and outcome of TDE. Comparisons between groups were performed using the Fisher exact test.
RESULTS
The causes of chylothorax were traumatic in 39 patients (78%) and nontraumatic in 11 (22%). Lymphangiography identified missed TDL in 30 patients (60%) and complete TDL in 15 patients (30%); however, in 12 of these 15 patients, collaterals around the ligation site supplying the leak could be identified. Incomplete ligation was observed in 4 patients (8%). In 1 patient (2%), a second TD was identified circumventing a complete ligation of the main TD. TDE was performed in 49 patients, and TD disruption was performed in 1 patient. Resolution of the chylous leak occurred in 45 patients (90%). There were 3 minor complications that resulted in no clinical sequela.
CONCLUSIONS
TDE produced cessation of chylous leak in the majority of the patients with persistent chylothorax after surgical TDL. Missed ligation is the most common finding on lymphangiography in patients with failed TDL. These findings support the use of image-guided closure of TD leaks.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Chylothorax; Embolization, Therapeutic; Female; Humans; Ligation; Lymphography; Male; Middle Aged; Retrospective Studies; Thoracic Duct; Young Adult
PubMed: 29759734
DOI: 10.1016/j.jtcvs.2018.02.109 -
British Journal of Anaesthesia Mar 1991A 2.5-kg female developed bilateral chylothoraces 10 days after surgery for coarctation of the aorta. Initial conservative management consisted of intermittent positive...
A 2.5-kg female developed bilateral chylothoraces 10 days after surgery for coarctation of the aorta. Initial conservative management consisted of intermittent positive pressure ventilation, drainage of chylous fluid and enteral feeding, but there was no diminution in loss of chyle. Ligation of the thoracic duct and pleurectomy were performed subsequently to reduce the large daily losses of chyle, amounting to nearly three times the child's circulating blood volume. Brawny oedema of the right upper quadrant of the body developed rapidly after the duct ligation and right pleurectomy. A further period of conservative treatment was required before the latter complication resolved. The literature relating to this iatrogenic complication and to fluid and nutritional losses in paediatric chylothorax is reviewed and discussed.
Topics: Aortic Coarctation; Chylothorax; Drainage; Enteral Nutrition; Female; Humans; Infant, Newborn; Ligation; Parenteral Nutrition; Pleura; Positive-Pressure Respiration; Postoperative Complications; Thoracic Duct
PubMed: 1901725
DOI: 10.1093/bja/66.3.387 -
Thoracic Surgery Clinics Nov 2018Intraoperative fluorescence imaging (FI) with indocyanine green has several potential uses during esophagectomy. Intravascular injection for enhancing the visualization... (Review)
Review
Intraoperative fluorescence imaging (FI) with indocyanine green has several potential uses during esophagectomy. Intravascular injection for enhancing the visualization of conduit vascularity and assessing macro and microperfusion has the most literature support and may help reduce anastomotic leaks. Peritumoral injection has been reported for use in identifying sentinel nodes during lymphadenectomy and intralymphatic injection may be used to help preserve or ligate the thoracic duct. The authors' own technique of FI for conduit assessment is described. They routinely use this strategy to guide anastomosis placement and reduce leaks.
Topics: Anastomosis, Surgical; Anastomotic Leak; Coloring Agents; Esophageal Neoplasms; Esophagectomy; Gastrointestinal Tract; Humans; Indocyanine Green; Intraoperative Care; Optical Imaging; Sentinel Lymph Node; Thoracic Duct
PubMed: 30268302
DOI: 10.1016/j.thorsurg.2018.07.009 -
The Journal of Thoracic and... Sep 2016
Topics: Chyle; Fistula; Humans; Thoracic Duct
PubMed: 27312788
DOI: 10.1016/j.jtcvs.2016.05.031 -
Journal of Vascular Surgery. Venous and... Sep 2020An 11-year-old girl with kaposiform lymphangiomatosis presented with recurrent chylous pericardial effusions that were refractory to pericardial drainage and medical...
An 11-year-old girl with kaposiform lymphangiomatosis presented with recurrent chylous pericardial effusions that were refractory to pericardial drainage and medical therapy. Magnetic resonance imaging demonstrated a prominent lymphatic duct with anterior mediastinal extension into the left clavicular region and a region of high signal that was favored to represent a low-flow lymphatic malformation. The patient underwent direct access thoracic duct lymphangiography with thoracic duct embolization and sclerotherapy of the large left-sided neck and pericardial lymphatic malformation. After the procedure, her pericardial effusions resolved, and she has remained asymptomatic for 15 months.
Topics: Child; Embolization, Therapeutic; Female; Humans; Lymphangiectasis; Lymphatic Abnormalities; Pericardial Effusion; Sclerotherapy; Thoracic Duct; Treatment Outcome
PubMed: 32653407
DOI: 10.1016/j.jvsv.2020.03.013