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19 Vascular Thoracic Interventions
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Fig. 19.3 (a) Selective angiogram of a pathological right intercostal
artery in a patient with hemoptysis demonstrates features of Hypertrophy
(dashed arrow), hypervascularity (white arrow) and Tortuosity (solid
black arrow) of the vessel. (b) Left bronchial arteriogram in a patient
with hemoptysis demonstrates hypertrophy (black arrow) and hypervascularity (white arrow) of the left bronchial artery. (c) Left superior
intercostal arteriogram in a patient with hemoptysis demonstrates neovascularity (solid black arrow) of the branches in the region of the dis-
19.2.2.4 Tips andTricks
• Study the CT angiography carefully and plan the
procedure.
• Evaluate the likely site of bleeding on CT and make a
priority-based list of the arteries to be embolized.
• Use different catheters based on the anatomy/branching
pattern if difculty in hooking the arteries.
• Always do super selective catheterization before injecting
embolizing agent.
eased left upper lobe. (d) Lateral thoracic arteriogram revealing
tortuosity (dotted arrow), neovascularity (white arrow) and bronchopulmonary shunting (solid black arrow) in a patient with hemoptysis. (e)
Right intercostobronchial arteriogram showing neovascularity in parenchymal branches of the bronchial component (black arrow). (f) Right
bronchial angiogram showing hypertrophy (black dotted arrow),
Neovascularity (black solid arrow), and bronchopulmonary shunting
(solid black arrow)
• In difcult-to-cannulate subclavian artery branches, use
radial artery approach.
• If the patient continues to bleed after embolization of all
the culprit arteries, consider pulmonary artery embolization to close the shunt.
The detailed pulmonary artery interventions are covered
in Chap. 19.
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a
Fig. 19.4 (a) Right bronchial arteriogram in a patient with hemoptysis
reveals hypertrophy (black arrow), tortuosity (white arrow) and neovascularity (star). (b) Slightly delayed run reveals the bronchopulmonary
shunting (dotted arrow) present. (c) Selective arteriogram demonstrates
ectopic bronchial artery (black arrow) arising from the right subclavian
artery. (d) Selective arteriogram of the right internal mammary artery in
a patient with hemoptysis demonstrates hypertrophy (solid black
arrow), neovascularity (dotted arrow) and bronchopulmonary shunting
(asterisk). (e) Left superior intercostal artery angiogram demonstrating
neovascularity (black arrow) and bronchopulmonary shunting (white
arrow)
19 Vascular Thoracic Interventions
Fig. 19.5 Native angiogram showing an ectopic bronchial artery arising from the left subclavian artery and supplying the left lung
parenchyma
19.3 Pulmonary Artery Pseudoaneurysm (PAPA)/Pulmonary AVM (PAVM) Embolization
19.3.1 Pre-Procedure Evaluation
Split bolus CT angiography or CT pulmonary angiography is
the best modality for diagnosis and planning.
PAPA—CT is also helpful in assessing the cause of PAPA
(Fig.19.6). The most common mechanism is erosion of the
vessel wall induced by an adjoining lung infection [7]. Other
causes include neoplasms, trauma, and iatrogenic [1].
PAVM—Contrast echocardiography is used as a screening test and is based on right to left shunt created by PAVMs.
If contrast appears in the left atrium within three heartbeats
after injection, it is considered positive. CT has higher sensitivity than DSA for picking up PAVMs—83 vs. 70% [8].
They typically appear on CT as a well-dened peripheral,
rounded, or lobulated solid nodule with the presence of a
single (simple PAVM) or multiple (complex PAVM) feeding
artery and one or more tortuous efferent draining veins.
19.3.1.1 Indications forPAVM Embolization [9]
• Any (solitary or multiple) PAVM with the following
features:
– Feeding artery having 2mm or greater diameter.
– Increase in size of venous sac or feeding artery.
– Symptomatic hypoxaemia.
– Paradoxical emboli.
215
19.3.1.2 Technique
The treatment options for PAPA include:
• Endovascular coil embolization—is generally the most
commonly used treatment option.
• Endovascular stent grafts or stent-assisted coil embolization—to maintain vascular patency.
• Percutaneous USG/CT-guided thrombin/glue injection—
used in peripherally placed pseudoaneurysms surrounded
by consolidation (Fig.19.7).
On DSA, PAPAs are classied into four types [1]. Type A
PAPA is characterized by patent feeding pulmonary artery
without any bronchial or non-bronchial systemic feeder.
Type B has feeders from bronchial or non-bronchial systemic arteries and pulmonary arteries. Type C has only bronchial or non-bronchial systemic artery feeders. Type D
PAPAs have the same occlusion of the feeding pulmonary
artery as type C PAPAs, but they also have slow systemic
arterial opacication that cannot be detected on catheterdirected angiography.
For type A and B PAPAs, both BAE and pulmonary artery
embolization are done. For types C and D, rst BAE is done
and then percutaneous glue/thrombin injection is done if the
patient continues to bleed.
The goal of PAVM embolization is to close the feeder
arteries as close as possible to the nidus (Fig. 19.8). All
possible care should be taken to prevent air bubbles in the
catheter system as it can lead to paradoxical embolism.
The hub of the catheter should be kept under water in
water bath, and all wire exchanges should be done under
water.
Access route—The femoral vein route is used to access
the pulmonary artery. ECG leads should be placed to monitor
for arrhythmia while crossing the right heart chambers with
catheters and wires.
Sheaths and catheters—Usually a 6F 11 cm vascular
sheath is used in adults for maintaining vascular access.
Longer (7F 90 cm) sheaths can be used to maintain stability
and give strength to the catheter and microcatheters. 5F
Picard catheter and 2.7F Progreat microcatheter are used to
deploy microcoils.
Embolic agent—Platinum coils/microcoils are the most
commonly used embolizing agent. Coil diameter should be
20–25% larger than the artery to be embolized [9]. Vascular
plugs are becoming more and more popular for PAVM embolization as they have the ability to occlude large-diameter
feeding arteries with single plugs (thus reducing procedure
time and radiation exposure) and occlusion over a shorter
length of vessel, thereby reducing the likelihood of occluding vessels supplying normal lung [10]. Vascular plugs
should be oversized by 30–50% relative to the target vessel
diameter at the occlusion site.
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Fig. 19.6 CT chest angio images in a patient with a past history of
pulmonary tuberculosis admitted to the hospital with acute hemoptysis.
Coronal (a), axial (b) images in the mediastinal and axial lung window
images (c) at the same level show a large cavity in the left upper lobe
(cross) and pseudoaneurysm in the wall of the cavity (white arrows)
a
de
Fig. 19.7 CT Chest angiography coronal MIP image (a) reveals a pul-
monary AVM (solid white arrow) in right lower lobe with VRT image
(b) depicting the feeding artery (dotted white arrow) and the draining
vein (dashed white arrow). Subtraction angiography image (c) in the
After femoral vein puncture and securing access with vascular sheath, the catheter (Picard 5F) with guidewire is
passed through IVC, right atrium, right ventricle and main
pulmonary artery. The catheter is then directed towards right
or left pulmonary artery depending upon the diseased segment. The sheath can then be exchanged over exchange
length wire with a longer sheath for stability. The feeding
same patient shows the pulmonary AVM. After deployment of an
Amplatzer vascular plug II in the feeding artery (solid black arrow) and
an adjacent coil (arrowhead) in another small feeding artery (d), a
native angiogram (e) shows closure of the pulmonary AVM
artery is then superselectively accessed using catheter and
guidewire and taking DSA runs for guidance. Once the catheter is secure within the target artery, microcatheter and wire
(Progreat microcatheter) are used to cross the neck of the
pseudoaneurysm. Microcoils (18-x-x) are then deployed to
close the backdoor, neck, and front door of the PAPA.If the
size of the artery is large, coils (35-x-x) can be deployed
19 Vascular Thoracic Interventions
217
a
bc
de
Fig. 19.8 (a) CT Angiogram chest before the procedure shows a pseu-
doaneurysm (solid white arrow) within the wall of a cavity in RML with
surrounding consolidation. (b) In supine position, a 22G needle (dotted
white arrow) has been inserted into the pseudoaneurysm, perpendicularly to the pleural surface, through the parenchymal consolidation, in
order to reduce the risk of pneumothorax. (c) The peri-procedure CT
scan in sagittal plane shows the correct positioning of the needle (white
arrowhead) within the pseudoaneurysm, followed by injection of
20–30% of 0.2ml glue. Final CT angiogram (d and e) in sagittal and
axial mediastinal window demonstrates complete lling of the pseudoaneurysm (solid white arrows) and the artery feeding it with nonopacication of the pseudoaneurysm
using the main catheter (5F Picard). If the catheter cannot be
advanced beyond the pseudoaneurysm neck, glue may be
used for distal embolization followed by proximal coil
embolization. A repeat DSA run is taken after 10minutes
from the main catheter to conrm the thrombosis of
PAPA.For PAVM embolization, the microcatheter should be
placed as close to the nidus as possible, beyond any normal
vessel supplying the parenchyma. The guiding catheter
should also be as close as possible to provide support during
coil deployment. In a large feeding artery anchor technique,
scaffold technique or balloon-occlusion technique can be
used to prevent coil migration. Similar to coils, vascular
plugs should also be deployed as distal as possible. They
have a relatively rigid delivery system which carries the plug,
through the catheter to the site of embolization. The plug is
anchored to the delivery system by a screw mechanism
which is manually turned counterclockwise to deploy the
plug.
19.3.2 Post-Procedure Care
Neurological examination should be done to rule out signicant air embolism. Patients should be monitored for 24hours
in the hospital and can be discharged after that. The primary
disease should be further evaluated and treated to prevent
recurrent haemoptysis.
19.3.3 Complications
• Air embolism
• Post-embolization syndrome
• Rupture of the pseudoaneurysm can rarely occur
• Non-target embolization.
19.3.4 Tips andTricks
• Study the CT angiography and plan the size of coils to be
employed accordingly.
• Keep one size larger and one size smaller coils readily
available as DSA vessel size may differ from CT angiography because of spasm.
• Keep an eye on the ECG monitor while crossing right
heart chambers for arrhythmia.
• Before deploying coil, make sure that your catheter has
sufcient length inside the artery of interest to prevent
non-target embolization.
• Use coaxial technique, scaffold technique and anchor
technique for precise deployment.
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J. Kazimi et al.
19.4 Interventions inSuperior Vena Cava
Syndrome
Superior vena cava (SVC) syndrome refers to a group of
signs and symptoms specic to anatomic regions drained by
SVC, resulting from any disease process (malignant or
benign) that leads to partial or complete obstruction of blood
ow through the SVC (Table 19.4). Clinical features can
range from mild to severe (Table19.5) and presentation can
range from acute life-threatening to indolent.
Endovenous intervention has emerged as a rst-line treatment for the management of severe or life-threatening SVC
syndrome irrespective of aetiology [1]. For grade 1 or 2
symptoms in malignant SVC obstruction, endovenous intervention is reserved for persistent or recurrent symptoms following tumour-specic treatment. There is insufcient
evidence to support primary SVC stenting in asymptomatic
individuals [1].
Scoring system of Kishi is used to quantify gravity of
symptoms and provides a cut-off score for endovascular
stenting (Table19.6) [2]. A score above 4 is an indication of
SVC endoprosthesis. While the role of SVC stenting is well
established in malignant obstruction, in benign SVC obstruc-
tion the current trend is towards using endovascular repair as
rst-line therapy and reserving open surgical repair for
patients who fail endovenous interventions [3].
19.4.1 Pre-Procedure Evaluation
Contrast-enhanced multi-detector CT (CECT) has a high
degree of sensitivity in determining the location and severity
of SVCO (Fig.19.9) [4]. CT also provides information relevant to technical success of intervention such as demonstration of the extent of involvement and any thrombosis [4, 5].
Sensitivity and specicity of MRI in diagnosing SVCO
approach 100% [6, 7]. Length of venous obstruction, involve-
ment of brachiocephalic veins and presence of acute thrombosis are important factors to assess on CECT or MRI.
Diagnostic venography is usually performed prior to
stenting, and it provides information about the location and
the severity of the disease thereby guiding the precise deployment of stent [1].
19.4.2 Technique
Table 19.4 Causes of SVC syndrome
Malignant Benign
External compression/
inltration
Lung cancer
Lymphoma
Metastasis
Sarcoma
Plasmacytoma
Table 19.5 Grading of symptoms due to SVC syndrome
Grade Severity Clinical ndings
0 Asymptomatic Only radiological feature of SVCO
1 Mild Vascular distension of head and neck
2 Moderate Dysphagia, impairment of jaw, head or
3 Severe Cerebral oedema (headache/dizziness)
4 Life-
threatening
5 Fatal Death
External
compression Intraluminal brosis
Tumours
Fibrosing
mediastinitis
vessels, oedema of face and neck,
cyanosis
eyelid movements, visual disturbances
Laryngeal oedema
Syncope after bending
Cerebral oedema (confusion, obtundation)
Laryngeal oedema (stridor)
Syncope without precipitating factors
Hypotension
Renal insufciency
Indwelling catheter
related
Intracardiac devices like
pacemakers
TB
Hypercoagulable state
Idiopathic
Syphilis
Femoral, internal jugular, subclavian or upper limb veins can
be used as the site of access, which is determined by favourable anatomy and operator preference. Common femoral
veins and IJVs are the most used sites for access owing to
least access-related complication rates [8].
A diagnostic venogram is performed prior to denitive
intervention and provides information regarding the extent
of the disease, collaterals and coexisting thrombus. If extensive thrombus is seen, pharmacomechanical therapies should
be considered [9]. After preliminary cavogram, the next step
Table 19.6 Scoring system for symptoms due to SVC syndrome
Signs and symptoms Grade
Neurologic symptoms
Blackout, coma
Dizziness, blurry vision, headache, amnesia
Altered mental status
Unease
Laryngopharyngeal or thoracic symptoms
Laryngeal oedema/orthopnoea
Shortness of breath, hoarseness, stridor, dysphagia, tongue
swelling
Pleural effusion/cough
Nasal and facial signs or symptoms
Epistaxis or rhinorrhoea, lip oedema, nasal stiffness
Facial swelling
Venous dilatation
Neck vein or arm vein distension, upper extremity
swelling or upper body plethora
Note: Total score is calculated as the sum of the highest grade in each
class
4
3
2
1
3
2
1
2
1
1
ab
19 Vascular Thoracic Interventions
Fig. 19.9 CT angiography
chest images in a patient with
known small cell carcinoma
reveals a homogenous,
conuent, mildly enhancing
soft-tissue attenuation lesion
(white arrow) centred in the
mediastinum (a).The lesion is
causing complete encasement
and marked luminal
narrowing of the SVC (white
arrow in a and b) with chest
wall collaterals (short arrow)
in (a) and mediastinal
collaterals (arrowhead) in (a).
Coronal images in (c) show
paratracheal and subcarinal
extent of the lesion with
complete extent of the SVC
encasement (dashed white
arrow) depicted in image (d)
219
c d
is to cross the stenosis or occlusion by a guidewire followed
by angioplasty and/or stenting. If the site of obstruction cannot be crossed, a different access site can be attempted.
Antegrade-retrograde access from femoral and internal jugular or upper limb veins can be tried in difcult situations.
Snare can also be used to establish a through and through or
“body-oss” access to increase stability in difcult cases
[10].
Once occlusive lesion is crossed balloon pre-dilatation
should be done which helps in easy crossing of the stent
delivery system. Consensus is lacking in routine predilatation and in determining the appropriate size of balloon.
Authors following routine serial slow pre-dilatation claim
less SVC ruptures; however, evidence is lacking and universally not practised [10–13]. If brachiocephalic or subclavian
veins are involved, bilateral ‘kissing’ or ‘Y’ stenting can be
done; however, extension of the stent to either brachioce-
seen in about 70–80% patients in whom pre-dilatation was
not done [13, 18, 19].
Completion venogram excludes complications like rupture and conrms appropriate placement of stent with good
ow and disappearance of collaterals. Complete coverage of
the session with <30% residual stenosis is considered as
technical success [13, 20].
Most commonly self-expanding bare metal stents are
used [5, 13, 16–18]. Generally, stents should be oversized by
2mm with reference to vessel diameter of normal-appearing
segment on CT or Venogram, to prevent stent migration [13,
19]. Technical success rate for SVC stenting ranges from
95% to 100% [4, 5, 16]. Stents are 87–100% in relieving
SVCO at initial presentation [21]. Covered stents have superior patency rate in malignant SVCO [22]. Stenting offer
more rapid and sustained relief from symptoms compared to
radiotherapy and chemotherapy [23–26].
phalic veins is satisfactory for symptomatic relief [5, 13–17].
Stents with diameter > 16 mm were associated with
higher rates of rupture, tamponade and pulmonary oedema
19.4.3 Complications
[5]. Stents with diameters up to 24mm can be deployed [13].
Landing zones of at least 10mm should be available for
optimum length estimation. Sixty percent of this excess
length should be placed at proximal landing zone, extending
to brachiocephalic vein if needed, to reduce the risk of distal
migration [19]. For longer lesions, telescoping stents can be
used. Post dilatation may be required in residual stenosis,
Major complications like rupture, tamponade, arrhythmias,
stent migrations, infection and thrombotic events have been
reported in approximately 4% of cases [1, 22]. Complication
risk is statistically greater with stents >16 mm, occlusive
lesions, associated thrombosis and bare metal stent [5].
Covered stents are associated with increased risk of migra-
220
J. Kazimi et al.
tion and covering brachiocephalic conuence [28]. Minor
complications occur in 3.2% of cases. Puncture site haematoma, re-stenosis and pain in the chest are considered minor
complications [28]. Complications associated with stenting
and chemo-radio-therapy are comparable [29].
Acute overload syndrome with pulmonary oedema can
occur following SVC recanalization requiring treatment with
diuretics, PPV support and monitoring in ICU.Inadequate
vessel measurement and subsequent suspicious stent sizing
can lead to stent migration into RA with signicant morbidity and mortality [19].
19.4.4 Post-Procedure Follow-Up
There is lack of consensus among studies regarding the type,
duration and efcacy of anticoagulation therapy post stenting [1, 5, 17, 30–32]. Long-term anticoagulation therapy
with aspirin, heparin or warfarin did not appear to reduce the
risk of re-thrombosis [5, 31]. On the contrary, bleeding risk
increases.
Post-procedural follow-up is done using CT [25]. For persistent or recurrent symptoms, repeat venography and interventions like thrombus aspiration, thrombolysis and
re-stenting may be required.
Multiple factors impact the management such as aetiology (Table19.1), local expertise, age and rate of chyle accumulation [35]. For most patients with low volume (i.e., <1L
per day) post-operative chyle leaks or with chylothorax for
nonsurgical reasons (e.g., malignancy), conservative therapy
is suggested rather than the more invasive options (e.g.,
pleurodesis with or without percutaneous thoracic duct
embolization (TDE), or surgical interventions).
For most patients with high-output (i.e., >1 L per day)
post-operative chyle leaks, early intervention is suggested
rather than prolonged conservative therapy. Percutaneous
interventional techniques such as TDE/thoracic duct disruption (TDD) or therapeutic lymphangiography with Lipiodol
have gained popularity as the initial management [36, 37].
19.5.1 Pre-Procedure Evaluation
Pre-procedure evaluation should include assessment of the
aetiology, anatomy of the thoracic duct, site of leak and level
of obstruction. Lymphangiography and cross-sectional imaging play an important role in providing information regarding
these parameters. Lymphatic abnormalities are evaluated by
the non-invasive imaging techniques, MRI lymphangiography
and CT lymphangiography which are preferred over conventional lymphangiography for comprehensive assessment [38].
19.5 Thoracic Duct Interventions
19.5.2 Lymphangiography Technique
Chylothorax is a form of lipid effusion and refers to accumulation of chyle within pleural cavity, resulting from obstruction or disruption of the thoracic duct or one of its major
tributaries [33]. The causes of chylothroax are summarized
in Table19.7. Triglyceride concentration in the pleural uid
of >110mg/dl is used for diagnosis of chylothorax, a level
less than 50mg/dl excludes the possibility of chylothorax,
and a level between 50 and 110mg/dl requires chylomicrons
analysis on electrophoresis [34].
Table 19.7 Causes of chylothorax
Non-traumatic Traumatic
Malignant Non-malignant Surgical Non-surgical
Lymphoma
Other malignancies (e.g.,
mediastinal, metastatic
malignancies, primary lung
malignancy, sarcoma, leukaemia)
Lymphangioleiomyomatosis
Intestinal lymphangiectasis
Lupus
Tuberculosis
Sarcoidosis
Venous thrombosis
Tuberous sclerosis
Filariasis
Heart failure
Down syndrome
Noonan syndrome
Idiopathic
Protein losing enteropathy
Cirrhosis
Lymphangiography involves instillation of a contrast agent
into the lymphatic system. Contrast can be administered
either into the interstitial spaces in the dorsal web spaces of
feet or directly into the lymphatic channel at the dorsum of
the foot or within the cortico-medullary junction of inguinal
lymph node, respectively called as pedal and intranodal lymphangiography. For TDE/TDD intranodal lymphangiography is preferred.
Cardiovascular
Aortic
Esophagectomy
Lobectomy
Pneumonectomy
Mediastinal mass resection
Bochdalek herniorrhaphy
Central venous catheterization
Neck surgery
Spine surgery
Pacemaker insertion
Penetrating or
Non-penetrating
Trauma to the neck,
Thorax and upper
Abdomen
Vomiting
Coughing
Yawning
Straining
19 Vascular Thoracic Interventions
221
Intranodal lymphangiography is performed under USG
guidance with a needle-syringe system. The system consists
of a spinal needle connected to the syringe by a connector. A
25G x 3.5 inch spinal needle is connected to a 3ml polycarbonate syringe by 6-inch connector tube with a volume of
approx. 2 ml [39]. Bilateral inguinal nodes are commonly
chosen sites, and the most distal lymph node is punctured
with the needle. Shallow needle angle favours better anchoring of the needle in skin and sub-cutaneous tissue. A controlled jab helps in penetrating node capsule. Needle tip
should be positioned at cortico-medullary junction. Hilar
position results in venous intravasations [39].
Contrast Agent: Water-based contrast agents like gadolinium and non-ionic iodinated contrast agents or oil-based
agents like lipiodol can be used. Lipiodol is the preferred
agent for TDE, as it stays within the lymphatic system, and
in cases of leak it has been shown to seal the site of leak by
promoting inammation around the site of extravasation
[40]. A total of 0.1ml/kg is given in each limb. In adults,
the upper limit for each limb is 10ml and 14ml for both
limbs combined. Lipiodol is given at a slow rate of
0.2–0.4 ml/min either manually or using the dedicated
lymphangiogram pump or more commonly an advanced
anaesthesia injection pump is used. A dose of >20 ml
should be cautiously used especially in lympho-venous
communication. Upward serial uoroscopic spot images
are obtained every 5–10 minutes over the course of
Lipiodol injection [41].
19.5.3 Thoracic Duct Embolization Technique
There are essentially three steps of thoracic duct embolization: cannulation of the duct followed by direct ductography
and then embolization with glue and/or coils.
Cannulation of duct: Key to successful cannulation is
identication of cisterna chyli (CC) which is located at L1–
L2 level, CC is identied by inow point. At this point lymphatic ducts quickly lose their denition and clarity, because
of lymphatic inow from intestinal and hepatic lymphatics.
Thoracic duct should be accessed below this point through
one of the lumbar lymphatic ducts preferably on the right
side to prevent access point leakage. Once the site of puncture is identied, cannulation is performed with 21 or 22G,
15 to 20cm chiba needle (Cook Inc., Bloomington, IN). A
5–10 degree angulation at distal 2 cm of needle provides
directionality [42]. Aortic puncture should be avoided by a
right transabdominal approach.
The target duct is accessed in 15–20 degree left posterior
oblique uroscopic view and as cranio-caudal angulation
after local anaesthesia [38]. Quick deliberate jabs can help
ensure that the needle passes directly through compliant
intervening structures like small and large bowels without
signicant deection. Puncture should be made across the
duct, and after this, probing is done using a stiff 0.018
inch/0.014 inch guidewire.
Once the lumen of the duct is approached, the wire
should advance easily into the upper thoracic duct (TD).
This smooth advancement indicates that the wire has correctly entered the lumen. If the tip of wire does not advance
smoothly straight up the duct, it should be pulled back into
the needle. The needle is then withdrawn by a fraction of
mm, and the duct is probed again in a similar manner. This
process is repeated until the wire either advances into the
lymphatic duct or the needle tip is no longer in proximity to
the target point. In the latter case, another puncture attempt
should be made. After successful access microcatheter is
advanced over the wire. Wire is then removed, and contrast
agent is injected with 1 ml syringe to detect site of leak
[38]. Once identied, embolization of TD is started proximal to leak. First a coil should be deployed to provide
matrix for glue embolization. Microcatheter should be
ushed with a maximum of 0.2ml of 5% dextrose. Large
amounts of 5% dextrose can accumulate in TD thereby
delaying glue polymerization and subsequently resulting in
recanalization of glue cast. Fifty percent of n-butyl cyanoacrylate (n-BCA) (Trull, Cordis, Johnson & Johnson,
Warren, NJ) is used for embolization, which provides
ample time for polymerization.
Retrograde access to the central lymphatic system offers
an alternative to the transabdominal approach by providing
descending entry through either transvenous or transcervical
methods. Transvenous access is commonly performed via
the left upper arm, where a 5fr reverse curve catheter is introduced through the left subclavian vein to cross the terminal
valves of the thoracic duct. In contrast, transcervical access
involves the use of a 22-gauge needle to puncture the cervical portion of the thoracic duct, guided by uoroscopy, ultrasound or both, with a microwire then advanced towards the
cisterna chyli. These retrograde approaches are particularly
advantageous in patients with coagulopathy or large abdomens, as they avoid the need for a transabdominal puncture.
Additionally, these approaches provide a valuable option
when the target is not identied during lymphangiography.
Retrograde techniques can be used along with transabdominal techniques to facilitate treatment of non-traumatic lymphatic disorder and providing the ability to perform
procedures like lymphatic drainage, balloon plasty or stenting. However, challenges include dealing with anatomical
variations, such as thick or short neck, tortuous or plexiform
terminations of TD and anomalous course of TD [43, 44].
The reported technical success for TD catheterization is
about 67% [45]. Clinical success rate has been reported as
high as 90% [45]. Thoracic duct disruption provides 55%
clinical success rate [45]. Success is higher with coil and
glue combination (91%) compared to coil alone (84%) [45].
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19.5.4 Complications
19.5.4.1 Complications Related
toLymphangiography
Most commonly encountered complication is extravasation
[46] which rarely results in a major complication. Transient
pain, fever and vomiting can occur [47]. Major complications related to pulmonary, cerebral and visceral oil embolization can occur [46]. Pulmonary oil embolism occurs due to
migration of oil from TD into venous side [48], seen more
commonly in cases with lymphatic obstruction [49].
Pulmonary infarction (0.25%), pulmonary oedema (0.03%),
lipoid pneumonia (0.04%) and haemoptysis have been
reported [50]. ARDS and Lofer syndrome have also been
described [51]. Cerebral embolism can manifest within minutes to hours after lymphangiography with seizures or altered
mental status [52]. Cerebral embolism is seen in patients
with right to left shunt, lympho-venous shunts to the pulmonary veins. Another mechanism proposed is loss of ltering
capability of pulmonary capillaries due to ethiodized oil
overload [52]. Hepatic and renal artery oil embolism have
also been reported [53, 54].
19.5.4.2 Central Lymphatic Access Complications
Percutaneous transabdominal approach is the most commonly used technique [55]. This approach can transgress
vascular and visceral structures causing complications like
perihepatic haemorrhage, periaortic haematoma, bile peritonitis and pancreatitis [56, 57].
19.5.5 Contraindications toThoracic Duct
Embolization
• Allergy to contrast agents.
• In-correctable coagulopathy.
• Severe pulmonary disease.
• Right to left shunt.
• Abdominal aortic aneurysm [58].
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