Cardiovasc Intervent Radiol (2014) 37:1103–1106 DOI 10.1007/s00270-013-0811-z

CASE REPORT

CT-guided Injection of N-butyl Cyanoacrylate Glue for Treatment of Chylous Leak after Aorto-mesenteric Bypass Kevin C. Ching • Ernesto Santos • Kevin McCluskey Geetha Jeyabalan



Received: 11 September 2013 / Accepted: 6 November 2013 / Published online: 7 December 2013 Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2013

Abstract Lymphangiography and thoracic duct embolization are well-described techniques for the diagnosis and treatment of thoracic lymphatic leaks refractory to conservative treatment. However, thoracic duct embolization is not an option in patients with abdominal chylous leaks. The present report describes a 68-year-old man who underwent an aortomesenteric bypass complicated by a high-output postoperative chylothorax ([2,000 ml/day) and chylous ascites ([7,000 ml/paracentesis). Ultrasoundguided intranodal lymphangiography demonstrated a retroperitoneal lymphatic leak tracking along the vascular graft into the peritoneal cavity. Computed tomographyguided lymphatic duct occlusion with N-butyl cyanoacrylate glue was performed, resulting in successful treatment of both chylothorax and chylous ascites. Keywords Chylous ascites  Lymphangiography  Lymphatic leaks  N-Butyl cyanoacrylate

K. C. Ching (&)  E. Santos  K. McCluskey Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street, 3950 Presby South Tower, Pittsburgh, PA 15213, USA e-mail: [email protected] E. Santos e-mail: [email protected]

Introduction Lymphatic leakage is an unusual complication after retroperitoneal lymph node dissection and has been described after vascular, gynecological, and urological interventions [1, 2]. Abdominal aortic surgery is the procedure that most commonly results in chylous complications via injury to retroperitoneal lymphatics, and in particular the cisterna chyli. Although lymphatic leaks account for only 1 % of all complications after aortic surgery, this procedure is implicated in over 80 % of the cases of postsurgical chylous ascites [3]. The clinical presentation of lymphatic leaks includes chylous ascites and/or retroperitoneal fluid collections and in severe cases dyspnea and malnourishment. Bipedal lymphangiography has been the traditional imaging study for identifying the site of lymphatic leaks and facilitating surgical repair. This technique is difficult and dependent on operator experience. The management of abdominal lymphatic leaks is controversial, escalating from conservative treatment (paracentesis, diet manipulation, octreotide) to radiological intervention and finally to surgery. Our case report describes the use of a novel technique, image-guided intranodal lymphangiography to diagnose an active lymphatic leak that was successfully occluded with computed tomography (CT)-guided injection of N-butyl cyanoacrylate (NBCA) glue and ethiodized oil.

K. McCluskey e-mail: [email protected]

Case Report

G. Jeyabalan Division of Vascular Surgery, University of Pittsburgh Medical Center, UPMC Passavant Professional Offices, 9100 Babcock Boulevard, Pittsburgh, PA 15237, USA e-mail: [email protected]

Institutional review board approval is not required at our institution for case reports. A 68-year-old man with chronic mesenteric ischemia underwent aortohepatic and superior mesenteric artery bypass with placement of a tunneled

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Fig. 1 Intranodal lymphangiogram via bilateral ultrasound-guided inguinal lymph node injection of Lipiodol

superior mesenteric artery (SMA) graft within the left paraaortic retroperitoneum. On postoperative day 4, the patient developed progressive abdominal distension and a large right pleural effusion. The patient returned to the operating room for exploration on postoperative day 11 and was found to have chylous ascites of 2,500 ml without and identifiable lymphatic leak. The patient started on total parenteral nutrition with bowel rest. Catheters were placed in the large right pleural effusion evacuating 1,200–2,000 ml/day, and peritoneal drainage evacuated up to 7,500 ml of chylous ascites almost weekly. Fluid analysis revealed a triglyceride level of 926 mg/dl from the ascitic fluid and 1,153 mg/dl from the pleural effusion, confirming a lymphatic source. On postoperative day 37, interventional radiology was consulted for lymphangiography and possible thoracic duct embolization. Ultrasound-guided intranodal lymphangiography was performed by injecting a total of 4 ml of ethiodized oil (Lipiodol; Guerbet, Paris, France) through a 25-gauge needle directly into the hilum of a left inguinal lymph node. Intranodal injection was repeated with similar technique through a right inguinal node, and the contrast was tracked cranially through pelvic and retroperitoneal lymphatic channels by intermittent fluoroscopy (Fig. 1). Approximately 35 min after the initial injection of Lipiodol, a focus of extravasation was identified adjacent to surgical clips in the left para-aortic region at the L2–L3 vertebral level (Fig. 2A). The extravasated Lipiodol was seen tracking along the SMA bypass graft and adjacent bowel loops into the peritoneal cavity (Fig. 2B). The thoracic duct opacified at 51 min after injection, and no other leaks were visualized. Direct puncture and conventional thoracic duct embolization could not be performed because the lymphatic injury was proximal to the cisterna chyle. Because

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therapeutic lymphography alone can be an effective treatment for lymphatic leaks, we decided to allow a trial of observation and close monitoring of drain outputs. Because the patient continued to have persistent high output chylothorax and symptomatic chylous ascites, we attempted CT-guided lymphatic duct obliteration on postoperative day 53. Under conscious intravenous sedation, the patient was placed in the right lateral decubitus position. A 22-gauge Chiba needle (Cook Medical Inc., Bloomington, IN) was advanced under intermittent CT fluoroscopy into the left paravertebral space (Fig. 3A), targeting the surgical clips where Lipiodol extravasation was previously identified on lymphangiogram. After confirming placement with a small injection of water soluble contrast, 1 ml of 1:1 NBCA glue and Lipiodol mixture was injected under CT guidance (Fig. 3B). The patient was then placed in the left lateral decubitus position, and the procedure was repeated with an additional 1 ml of NBCA and Lipiodol injected from a right paravertebral approach. Within a few days after the CT-guided injection, chylous output from the pleural catheters dwindled and the pleural effusion resolved on chest radiography. The patient continued to have symptomatic accumulation of chylous ascites requiring frequent paracentesis. Because overall chylous output improved after the first injection, a second CT-guided glue injection was deemed appropriate, and the patient returned 14 days later. The 22-gauge Chiba needle was placed in the left para-aortic space, between the aorta and the SMA graft. The stylet was removed, and chylous fluid immediately began draining spontaneously from the needle hub. This time, a total of 2 ml of NBCA and Lipiodol was injected. Three days after the second lymphatic duct obliteration, there was no reaccumulation of chylous ascites and only minimal output from the pleural drains. The patient was discharged home soon after with no recurrence of either the pleural effusion or ascites during 3 months of clinical follow-up. There were no complications from the intranodal lymphangiogram or the NBCA:Lipiodol injection.

Discussion Chylothorax and chylous ascites are troublesome postoperative complications after major thoracic and retroperitoneal surgery, occurring in up to 3.9 % of patients undergoing esophagectomy and less than 1 % postoperative patients overall [4, 5]. Large accumulations of pleural and peritoneal chyle may result in abdominal pain, nausea, steatorrhea, lower extremity edema, and symptomatic dyspnea. Patients with lymphatic leaks are also at an increased risk for infection and have a higher postoperative morbidity. Initial management of lymphatic leaks usually

K. C. Ching et al.: CT-guided Glue Injection

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Fig. 2 At 35 min after Lipiodol injection, extravasated Lipiodol pooled (A) in the left para-aortic region at the L2–L3 level (arrows) and proceeded (B) to track along the aortomesenteric bypass graft (arrows) from the retroperitoneum into the peritoneal cavity

Fig. 3 Under CT guidance, a 22-gauge Chiba needle (A) was targeted at the lymphatic leak, and (B) 1 ml of NBCA glue and Lipiodol (arrow) was injected

involves catheter drainage of the chylous fluid, total parenteral nutrition, and a trial of bowel rest. Since Cope first described cannulation of the cisterna chyle and embolization with fibered platinum microcoils, interventional radiologists have developed additional minimally invasive techniques for managing lymphatic leaks. These include needle disruption of lymphatic tracts and transvenous retrograde access of the thoracic duct for embolization [6, 7].

NBCA glue and microspheres have also been reported as successful occlusive agents for thoracic duct embolization after traditional catheterization of the cisterna chyle [6]. Percutaneous glue injection for lymphatic leaks has been reported in two patients. Itou et al. [8] described a postnephrectomy patient with chylous ascites who was treated with coil embolization of an organized lymphocele followed by glue injection. A second report described

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injection of glue directly into a central lymphatic duct for embolization after a patient developed chylous ascites after puncture of the cisterna chyle for thoracic duct embolization [9]. Our technique did not involve coil embolization before glue and Lipiodol injection, and rather than injecting the lumen of a lymphatic channel, we occluded the known site of lymphatic injury. Sealing the left para-aortic lymphatic leak in our patient treated both the chylous ascites and chylothorax without requiring a separate thoracic injection. Although needle disruption of lymphatic ducts for treatment of lymphatic injury is well described, we decided against this technique because of the close proximity of the vascular graft and the multiple needle passes that would be required [6]. Our use of ultrasound-guided intranodal lymphangiography rather than bipedal lymphangiography circumvented a lengthy and tedious catheterization of pedal lymphatics and allowed use of a much smaller volume of ethiodized oil. This technique for performing intranodal lymphangiography was first described by Rajebi et al. [10]. In our patient, the site of lymphatic duct injury was localized only 37 min after intranodal injection of 8 ml of Lipiodol, compared to traditional pedal lymphangiography requiring up to 3 h of lymphatic transit time and 30 ml of ethiodized oil in the case described by Itou et al. [8]. In addition to providing more rapid opacification of lymphatic channels and localization of the lymphatic injury, the smaller volume of ethiodized oil required for intranodal lymphangiography can aid CT-guided occlusion. Spurious Lipiodol in the retroperitoneum may obscure visualization during injection of glue and Lipiodol, as noted in the case by Gaba et al. [9]. Because most central lymphatic ducts are located in the retroperitoneum and mediastinum, they are often easily accessible with CT guidance, minimizing risk of injury to adjacent organs and vital structures. Chylous leakage is an unusual but potentially devastating complication after retroperitoneal surgery, with a difficult therapeutic approach. This case report demonstrates

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the use image-guided intranodal lymphangiography and CT-guided injection of NBCA glue for treatment of massive chylothorax and chylous ascites. For patients with a retroperitoneal lymphatic leak in which traditional thoracic duct embolization is not indicated, CT-guided injection of glue and Lipiodol can be a feasible alternative for treatment of postoperative chylous ascites and chylothorax. Conflict of interest of interest.

The authors declare that they have no conflict

References 1. Pabst TS, McIntyre KE, Schilling JD et al (1993) Management of chyloperitoneum after abdominal aortic surgery. Am J Surg 166:194–198 2. Jansen TT, Debruyne FM, Delaere KP, de Vries JD (1984) Chylous ascites after retroperitoneal lymph node dissection. Urology 23:565–567 3. Combe J, Buniet JM, Douge C et al (1992) Chylothorax and chylous ascites following surgery of an inflammatory aortic aneurysm. J Mal Vasc 17:151–156 4. Hoffer EK, Bloch RD, Mulligan MS et al (2001) Treatment of chylothorax: percutaneous catheterization and embolization of the thoracic duct. AJR Am J Roentgenol 176:1040–1042 5. Chen E, Itkin M (2011) Thoracic duct embolization for chylous leaks. Semin Interv Radiol 28:63–74 6. Cope C, Kaiser LR (2002) Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol 13:1139–1148 7. Koike Y, Hirai C, Nishimura J et al (2013) Percutaneous transvenous embolization of the thoracic duct in the treatment of chylothorax in two patients. J Vasc Interv Radiol 24:135–137 8. Itou C, Koizumi J, Myojin K et al (2013) A case of refractory chylous ascites after nephrectomy successfully treated with percutaneous obliteration using adhesive glue. Jpn J Radiol 31:71–74 9. Gaba RC, Owens CA, Bui JT et al (2011) Chylous ascites: a rare complication of thoracic duct embolization for chylothorax. Cardiovasc Interv Radiol 34(suppl 2):S245–S249 10. Rajebi MR, Chaudry G, Padua HM et al (2011) Intranodal lymphangiography: feasibility and preliminary experience in children. J Vasc Interv Radiol 22:1300–1305

CT-guided injection of N-butyl cyanoacrylate glue for treatment of chylous leak after aorto-mesenteric bypass.

Lymphangiography and thoracic duct embolization are well-described techniques for the diagnosis and treatment of thoracic lymphatic leaks refractory t...
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