Thoracic Duct Embolization Technique & Results
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1 Thoracic Duct Embolization Technique & Results Edward W. Lee, MD, PhD, MSc Assistant Professor Director of Research Interventional Radiology Department of Radiology AGA AASLD JCCC CTSI CCTP TRIC AACR UCLA Medical Center David Geffen School of Medicine at UCLA
2 Edward Lee, M.D., Ph.D., MSc No relevant financial relationship reported
3 Contents Case How to do TDE Pre-TDE Evaluation Techniques Post-TDE Follow-up Clinical Results Conclusion
4 Case TDE
5 51 F TDE Case Pulmonary lymphangioleiomyomatosis Asymptomatic for 48 yrs Symptomatic chylous effusion started in thoracentesis/week On Sirolimus for LAM No change on her chylous effusion IR intervention requested
6 How To Do TDE TDE
7 Pre-TDE Evaluation: Fluid evaluation Confirm diagnosis of chylous fluid (> 110 mg/dl Triglyceride) Conservative Treatment Thoracentesis; Fluid resuscitation; low fat/mct diet/tpn Evaluation of recent images (pelvic CT or US) Groin lymph node mapping TDE Pre-TDE Evaluation
8 Recent abdominal/pelvis CT TDE Techniques
9 Techniques 1. Pedal or Intranodal lymphangiogram 2. Trans-abdominal Cysterna Chyli Cannulation 3. Thoracic Duct Catheterization 4. Coil or Glue Embolization Lee EW et al. Korean J Radiol 2014
10 Techniques Materials & Methods: o Moderate sedation o Abx = cefazolin 1 gm IV x 1 o 1% Isosulfan Blue + 1% Lidocaine or 1% Methylene Blue + 1% Lidocaine (ONLY FOR PEDAL LYMPHANGIOGRAM) o 30G needle (Cook Inc.) (ONLY FOR PEDAL LYMPHANGIOGRAM) o ~ 20 ml of Ethiodol or Lipidol o If cisterna chyli is not opacified, 20 ml of saline can be injected. o 21 or 22G, 15 or 20 cm Chiba needle o Trans-abdominal approach o Stiff wire V18, NITREX o Microcatheter o Iodinated water-soluble contrast to identify the leak o Embolization above (if possible) and below the leak o Coils, Trufill (1:2.5 with Ethiodol); probably not Onyx.
11 Techniques Injection of 50:50 solution of 1% Lymphazurin (methylene blue) & 1% Lidocaine into the web of feet (Red Arrows) min to see the streaks of lymphatics (Black arrows) Carefully dissect the pedal lymphatic.
12 Techniques Cannulation of lymphatics with 30G lymphangiogram Needle (Cook Medical) Use a magnifying Loop to cannulate Stick the lymphatics out of the skin and cannulate Lee EW et al. Korean J Radiol 2014
13 Techniques Inject Lipiodol through the cannulated lymphatics Usually < 20 cc of Lipiodol If needed, can bolus 20 cc saline to push the Lipiodol Identify the Cisterna Chyli
14 Pedal Lymphangiogram. TDE Techniques
15 NO MORE PEDAL LYMPHANGIOGRAM?
16 Techniques Ultrasound surveillance of bilateral groins US guided cannulation of groin lymph node using 25G x 2 or 3 inch spinal needle Lee EW et al. Korean J Radiol 2014
17 Techniques 25G spinal needle access Lipiodol injection at 12 cc/hr rate using Hobbs Lymphangiogram Pump or anesthesia infusion pump. Intranodal Lymphangiogram
18 Techniques Spot lymphangiogram images every 5-10 mins Intranodal Lymphangiogram
19 Identifying Cisterna Chyli or the largest lymphatics TDE Techniques
20 Identifying lymphatic leaks TDE Techniques
21 Techniques Trans-abdominal Cisterna Chyli Cannulation 1. 22G Chiba 2. Stiff 014 or 018 microwire (Nitrex, V14, V18)
22 Techniques Embolization of lymphatic leak microcoils 2. Pushable vs. Detachable
23 Techniques Embolization of thoracic duct and lymphatic leak 1. n-bca Glue 2. Onyx???
24 Post-TDE Follow Up: 2-4 days of inpatient monitoring Routine lab Imaging (CXR/KUB) follow up in 1-2 days CT follow up in high risk patients or concerning for complications Routine thoracic surgery or pulmonology follow ups TDE Post-TDE Follow Up
25 Clinical Results TDE
26 History 1989: First TDE in Dog by Pardo et al from U of Tennessee (Vet Surg 1989) 1995 : Swine study by Dr. Constantine Cope (JVIR 1995) 1996: Swine/Canine study by Dr. Constantine Cope (JVIR 1996)
27 History 1998: First 5 Pts U Penn (JVIR) 1999: 11 Pts U Penn (JVIR) 2002: 42 Pts U Penn (JVIR) 2009: 109 Pts in U Penn (J Thorac Cardiovasc Surg) Dr. Itkin 2014: 105 Pts in BWH (JVIR) 2016: 40 Patients in UCLA
28 Clinical Results 106 pts in 13 yrs Technical Success rate = 67% (73/106) Clinical Success rate = 90% (64/71) Complications = 3% (PE, leg edema) Itkin et al. J Thorac Cardiovas Surg 2010
29 Itkin et al. J Thorac Cardiovas Surg 2010 TDE Clinical Results
30 Clinical Results 34 pts in 13 yrs Technical Success rate = 71% (24/34) Clinical Success rate = % depends on underlying lymphangiographic findings Nadolski et al. Chest 2013
31 Clinical Results 105 pts in 9 yrs (53 TDEs; 42 TDDs) Technical Success rate = 79% (95/120) Clinical Success rate = 72% (38/53) Minor Complications = 6.7% (2 PE, 1 PVT, 2 retained wires) Pamarthi et al. JVIR 2015
32 Nadolski & Itkin, JVIR 2012 TDE Clinical Results
33 Koike et al. JVIR 2012 TDE Clinical Results
34 UCLA Data TDE
35 UCLA Clinical Results N = 40 (from ) Technical Success Lymphangiogram = 38/40 (95%) TD Cannulation = 32/40 (80%) TD Embolization = 30/32(94%) Clinical Outcome Improvement of chylothorax (Trig<100) = 29/32 (91%) Complete resolution of chylothorax = 28/32 (88%) Complications = 5/40 (12.5%) Infection, non-symptomatic Lipiodol PE, Leg edema
36 Conclusion TDE: 1. Not easy but Safe, effective, and reproducible. 2. Significant impact on patient care; potentially a life-saving procedure.
37 THANK YOU
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