July 8, 2024
Traumatic disruption or occlusion of the thoracic duct leads to chylothorax, a condition characterized by chyle leakage into the pleural space. Conservative management with dietary adjustments is often the first-line approach. However, for refractory cases, traditional surgical options include thoracic duct ligation and pleurodesis. Percutaneous thoracic duct embolization (PTDE), a minimally invasive procedure performed by interventional radiologists, offers a viable alternative to surgery. Moreover, repeat PTDE is a viable option for cases with initial embolization failure, potentially delaying or even avoiding surgical intervention.
An 18-year-old trauma patient transferred from another facility presented with bilateral neck and chest stab wounds. A chest tube was placed for left hemopneumothorax. Drainage transitioned to milky, seropurulent fluid, concerning for chyle. Initial conservative management was ineffective. Interventional radiology (IR) performed thoracic duct embolization (TDE), achieving an initial reduction in chest tube output, but drainage subsequently returned to pre-embolization levels. A repeat TDE was then performed, resulting in definitive resolution of the chylothorax.
This case report describes a patient with traumatic chylothorax who exhibited treatment resistance to both conservative management and PTDE. Repeat PTDE ultimately achieved successful resolution of the chylothorax.
trauma; chylothorax; percutaneous thoracic duct embolization
An 18-year-old male with penetrating neck and chest injuries by stab wounds presented to an outside facility. Following chest tube placement for a left hemopneumothorax, he was transferred to our Level I Trauma Center. On arrival, he had a stable Glasgow Coma Scale (GCS) score of 15 and vital signs. Admission to the surgical intensive care unit (ICU) was followed by CT angiography, which demonstrated a left lower lobe parenchymal defect with associated hematoma and pleural effusion (Figure 1).
Figure 1. Initial CTA Showing Pneumothorax and Soft Tissue Emphysema. Published with Permission
Initial chest tube drainage revealed serosanguineous fluid, which transitioned to a milky seropurulent effusion. A similar milky fluid was concurrently noted draining from the left neck wound. The neck wound was subsequently cleansed and drained with a Penrose drain inserted at bedside. Chemical analysis confirmed chyle with elevated triglyceride levels of 667 mg/dL in the drained fluid. Despite a seven-day trial of conservative management with NPO status and TPN, significant chyle output persisted via the chest tube, ranging from 400 to 1100 mL/day (Figure 2).
Figure 2. Preembolization Chest X Ray Demonstrating Left Hydropneumothorax with Chest Tube in Situ. Published with Permission
Interventional radiology performed a lymphangiogram to evaluate lymphatic drainage of the pelvic, abdominal, and thoracic regions. The study identified active extravasation from the thoracic duct near the clavicular head. The interventional radiologist then embolized the leaking segment using coils and glue (Figures 3-6). While chest tube drainage briefly declined, it returned to pre-procedure levels by postoperative day 2.
Figure 3. Early Filling of Cisterna Chyli over L1 (arrow). Published with Permission
Figure 4. Lymphangiogram via Inguinal Lymph Node Cannulation Demonstrating Opacification of Lumbar Nodes, Cisterna Chyli, and Lower Thoracic Duct. Published with Permission
Figure 5. Lymphangiogram: Active Contrast Extravasation (arrow). Published with Permission
Figure 6. Initial Coil Placement at Defect. Published with Permission
Repeat chest CTA revealed a localized air-fluid collection in the left hemithorax, concerning for empyema. However, imaging review suggested an anatomic variant: a posteromedially positioned thoracic duct coursing along the left aorta, lateral to the vertebral column. Given this anomaly, a second IR embolization attempt was undertaken. Accessing the thoracic duct via the left neck proved challenging due to its proximity to the subclavian junction. Therefore, we opted for a re-approach of the previously embolized cisterna chyli through the epigastrium, followed by successful repeat embolization with glue (Figures 7-10).
Figure 7. Retrograde Access to Thoracic Duct at Subclavian Junction. Published with Permission
Figure 8. Retrograde Microcatheter Access to Thoracic Duct. Published with Permission
Figure 9. Repeat Access to Thoracic Duct. Published with Permission
Figure 10. Coil Pack Positioned Within Thoracic Duct. Published with Permission
Chest tube drainage demonstrated a declining trend over the subsequent five days (Figure 11). Dietary advancement did not trigger an increase in output. Based on these findings, the chest tube was removed, and the patient was discharged home.
Figure 11. Chest X Ray, POD 5. Published with Permission
The thoracic duct arises from the cisterna chyli located at the T12-L2 level, which collects lymph from the lower extremities, pelvis, and abdomen. The cisterna chyli begins para-aortic on the right side, courses cephalad along the right paravertebral gutter, and traverses the diaphragmatic hiatus into the thoracic cavity. At the level of T5-T6, it crosses the midline to the left of the esophagus and typically terminates at the left subclavian vein.
The thoracic duct exhibits significant anatomic variability, with a classic course observed in only 40-60% of individuals. This variability manifests in several forms:
Traumatic chylothorax arises from thoracic duct disruption, secondary to trauma, or benign/malignant occlusion.3 Penetrating injuries are rare causes, whereas surgery in the thorax, esophagus, or abdomen represents the most frequent culprits.
Chylothorax management is highly etiology-dependent, with options ranging from conservative to surgical approaches. Interventional radiology (IR) with percutaneous thoracic duct embolization (PTDE) represents a recent advancement in treatment strategies.4 When determining the optimal approach, a key factor is the volume of chyle drained over 24 hours, with higher output suggesting a greater likelihood of needing surgery.5
Conservative management focuses on minimizing chyle flow and promoting leak closure. This includes:
A case series by Zabeck et al. (n=82) reported a success rate of 16% (13 cases) with conservative management using dietary modifications alone.5 Expanding treatment to include video-assisted thoracoscopic surgery (VATS) or pleurodesis increased the overall success rate to 69%. However, 32% (26 cases) ultimately required thoracotomy with thoracic duct ligation or repeat procedures.5
Thoracic duct embolization has emerged as a minimally invasive alternative to surgery for chylothorax, boasting high success rates and a minimal complication profile. A case series by Itkin et al. reported a 90% success rate with TDE when the thoracic duct was successfully catheterized.6 However, in cases where TDE fails, surgical intervention remains necessary. This usually entails a thoracotomy with thoracic duct ligation and pleurodesis.
Following failed initial antegrade TDE, repeat embolization via either the retrograde or antegrade approach offers a viable alternative to surgery. Recent studies suggest superior success rates when the retrograde transcervical approach is included alongside the traditional antegrade transabdominal approach for initial cannulation.7 Mounting evidence from multiple studies supports the retrograde approach as both effective and safe for repeat TDE.4,7
We report a case of traumatic chylothorax that proved refractory to both conservative management and initial PTDE. Given this treatment failure, we opted for repeat PTDE instead of proceeding with surgical thoracic duct ligation. This repeat intervention successfully achieved resolution of the chylothorax.
Following unsuccessful percutaneous embolization for chylothorax, repeat embolization using either a retrograde or repeat antegrade approach should be considered before resorting to surgical thoracic duct ligation.
Philip GJa,b,c; Foerster Ka,b; Fischer KJa,d; Grizzell Be; Rust Kf
George J. Philip, MD, MPH
Kansas Surgical Consultants
3243 E. Murdock Street
Ste. 404
Wichita, KS 67208
Email: gphilip@kansassurgical.com
The authors have no conflicts of interest to disclose.
The authors have no relevant financial relationships or in-kind support to disclose.
Received: October 25, 2021
Revision received: March 26, 2022
Accepted: April 5, 2022