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Abstract No. 251: Percutaneous thoracic duct ablation for treatment of thoracic duct injuries and chylous effusions: a single center experience
JVIR 䡲 Scientific Session
Wednesday 䡲 S103
Results: Of the 23 patients with CPA, 12 (52%) were male, 11 (48%) female, and average age of 57 years (SD 19). Of the patients who suffered CPA, 56% had diabetes mellitus, 48% hypertension, and 78% significant kidney disease. Of the patients with kidney disease, 56% were already dialysis dependent; an additional 8.7% were undergoing central venous catheter placement for new hemodialysis. 78.3% had ASA classification of 3 or greater and 56.5% had conscious sedation during the procedure. Relative risk of an arrest during dialysis shunt interventions compared to arterial interventions was 3.6 ((95% CI: [1.0, 11.3]), p ⫽ 0.045). 8 of 23 (35%) expired: 1 (12.5%) during resuscitation and 7 (87.5%) after resuscitation (p ⫽ 0.070). Conclusion: Those patients suffering CPA in IR procedures are characterized by significant co-morbid illness, specifically renal insufficiency. Patients experiencing CPA most often were undergoing hemodialysis access-related procedures. Despite a high survival rate for IR-arrest at the time of resuscitation, there appears to be a higher mortality rate in the post-resuscitation phase.
Procedure Arterial Interventions Transarterial Chemoembolization Aortic Stent Graft Venous Intervention Dialysis Shunt Management Fistula Declot Biliary Interventions GU Interventions Biopsy/Dx Fluid Aspiration Tumor RadiofrequencyAblation Brachytherapy All Encounters
10:54 AM
# Codes
# Encounters
Frequency (%)
Exact 95% Confidence Interval
4 0
5068 265
0.08 0.00
[0.02, 0.20%] [0.00, 1.38]
1 11 6
65 21660 2142
1.54 0.05 0.28
[0.04, 8.28] [0.03, 0.09] [0.10, 0.61]
5 0 1 1 0
444 1493 3394 290 114
1.13 0.00 0.03 0.34 0.00
[0.37, [0.00, [0.00, [0.01, [0.00,
0 23
27 36489
0.00 0.06
[0.00,12.78] [0.04, 0.09]
2.61] 0.25] 0.16] 1.91] 3.19]
Abstract No. 251
Percutaneous thoracic duct ablation for treatment of thoracic duct injuries and chylous effusions: a single center experience
Purpose: To review the technical and clinical outcomes of percutaneous thoracic duct ablation (PTDA) in patients with symptomatic chylous pleural effusions. Materials and Methods: Retrospective review was conducted on 106 patients (70 male/36 female) who underwent 121 consecutive PTDAs from 11/2002 to 7/2011 at an academic teaching hospital. Data reviewed included underlying diagnosis, cause of effusion, technical approach, and subsequent surgical interventions. Technical success was defined as successful PTDA by embolization (Type 1) or needle maceration (Type 2). Clinical success was defined as resolution of the effusion without additional surgical or percutaneous intervention. Results: 106 subjects underwent 121 PTDA. Technical success was 90.6% (96/106) with 79.2% (84/106) achieved on first attempt. Causes of technical failures included inadequate foot lymphatics or no cisterna chyli (20), unfavorable retroperitoneal anatomy (3), patient over-sedation (1), and equipment failure (1). Technical successes included 52 type 1 and 43 type 2 PTDAs,
Cause of Effusion
# of Cases (n⫽121)
% of Cases
Clinical Success
Significance of Difference* (p value)
Iatrogenic (overall) Esophagectomy Pneumonectomy Pleurectomy Lobectomy Spontaneous
112 50 16 19 6 9
92.6% 41.3% 15.7% 13.2% 5.0% 7.4%
54.5% 58.0% 81.3% 31.6% 33.3% 11.1%
– 0.57 0.03 0.04 0.41 0.02
* When comparing corresponding group to the remainder of the Iatrogenic group. Spontaneous group was compared to the entire Iatrogenic group.
11:02 AM
Abstract No. 252
Feasibility of ultrasound guided intranodal lymphangiogram for thoracic duct embolization G. Nadolski, M. Itkin; Hospital of the University of Pennsylvania, Philadelphia, PA Purpose: To test the feasibility of opacifying the thoracic duct (TD) using ultrasound (US) guided injection of inguinal/femoral lymph nodes with lipiodol as part of thoracic duct embolization (TDE). Materials and Methods: HIPAA waiver and IRB approval were granted prior to beginning the study. A total of 6 consecutive patients (2F, 4M; mean age 59.2 yrs) underwent US guided intranodal lymphangiogram (INL) for TDE to treat chylothorax. INL was performed by positioning the tip of a 25 G needle in the center of an inguinal or femoral lymph node using real time US guidance and then injecting lipiodol. After identification of the TD, it was catheterized and embolized if indicated. The times from initiating the procedure until: (1) injection of contrast into lymphatics, (2) identification of a target lymphatic for catheterization, (3) catheterization of the TD and (4) embolization of TD were recorded. These times were compared to those of a control group consisting of the previous 6 patients (2F, 4M; mean age 66.7 yrs) who had undergone TDE to treat chylothorax using tradition pedal lymphangiography (PL). Results: In all patients undergoing INL, the lymphangiogram and TD catheterization were performed successfully. In the INL group, TDE was performed successfully in all but one patient, in whom the TD was found to be normal. In the PL group, the TD was visualized and successfully embolized in all cases. The average times from initiating the procedure in the INL and PL groups until: (1) injection of contrast into lymphatics were 20.5⫾8.6 and 46.5⫾22.6 minutes (p⬍0.05), (2) identification of a target lymphatic for catheterization were 60.5⫾18.2 and 110.5⫾31.6 minutes (p⬍0.01), (3) catheterization of the TD were 79.0⫾28.9 and 128.2⫾37.0 minutes (p⬍0.05) and (4) embolization of TD were 125.8⫾49.0 and 152.8⫾36.4 minutes (p⫽NS).
WEDNESDAY: Scientific Sessions
V. Pamarthi1,2, M.S. Stecker2, S. O’Horo2, A. Han2, C. Fan2; 1Harvard Medical School, Boston, MA; 2 Angiography and Interventional Radiology, Brigham and Women’s Hospital, Boston, MA
with clinical success rates of 75.0% (39/52) and 53.5% (23/43) respectively. Overall, PTDA clinical success was 64.6% (62/96). Underlying pathologies included esophageal adenocarcinoma (41), mesothelioma (31), lung neoplasms (11), and spontaneous chylous effusions (9). A table summarizing major causes, case distribution, and success rate is below. Conclusion: PTDA is a minimally invasive treatment for thoracic duct injuries, which in our series resolved thoracic duct leaks in 64.6% of technically successful procedures. PTDA clinical success rate is affected by factors including type of inciting surgery and PTDA technique. PTDA is significantly less effective for treating spontaneous chylothorax.
Wednesday 䡲 S103
Results: Of the 23 patients with CPA, 12 (52%) were male, 11 (48%) female, and average age of 57 years (SD 19). Of the patients who suffered CPA, 56% had diabetes mellitus, 48% hypertension, and 78% significant kidney disease. Of the patients with kidney disease, 56% were already dialysis dependent; an additional 8.7% were undergoing central venous catheter placement for new hemodialysis. 78.3% had ASA classification of 3 or greater and 56.5% had conscious sedation during the procedure. Relative risk of an arrest during dialysis shunt interventions compared to arterial interventions was 3.6 ((95% CI: [1.0, 11.3]), p ⫽ 0.045). 8 of 23 (35%) expired: 1 (12.5%) during resuscitation and 7 (87.5%) after resuscitation (p ⫽ 0.070). Conclusion: Those patients suffering CPA in IR procedures are characterized by significant co-morbid illness, specifically renal insufficiency. Patients experiencing CPA most often were undergoing hemodialysis access-related procedures. Despite a high survival rate for IR-arrest at the time of resuscitation, there appears to be a higher mortality rate in the post-resuscitation phase.
Procedure Arterial Interventions Transarterial Chemoembolization Aortic Stent Graft Venous Intervention Dialysis Shunt Management Fistula Declot Biliary Interventions GU Interventions Biopsy/Dx Fluid Aspiration Tumor RadiofrequencyAblation Brachytherapy All Encounters
10:54 AM
# Codes
# Encounters
Frequency (%)
Exact 95% Confidence Interval
4 0
5068 265
0.08 0.00
[0.02, 0.20%] [0.00, 1.38]
1 11 6
65 21660 2142
1.54 0.05 0.28
[0.04, 8.28] [0.03, 0.09] [0.10, 0.61]
5 0 1 1 0
444 1493 3394 290 114
1.13 0.00 0.03 0.34 0.00
[0.37, [0.00, [0.00, [0.01, [0.00,
0 23
27 36489
0.00 0.06
[0.00,12.78] [0.04, 0.09]
2.61] 0.25] 0.16] 1.91] 3.19]
Abstract No. 251
Percutaneous thoracic duct ablation for treatment of thoracic duct injuries and chylous effusions: a single center experience
Purpose: To review the technical and clinical outcomes of percutaneous thoracic duct ablation (PTDA) in patients with symptomatic chylous pleural effusions. Materials and Methods: Retrospective review was conducted on 106 patients (70 male/36 female) who underwent 121 consecutive PTDAs from 11/2002 to 7/2011 at an academic teaching hospital. Data reviewed included underlying diagnosis, cause of effusion, technical approach, and subsequent surgical interventions. Technical success was defined as successful PTDA by embolization (Type 1) or needle maceration (Type 2). Clinical success was defined as resolution of the effusion without additional surgical or percutaneous intervention. Results: 106 subjects underwent 121 PTDA. Technical success was 90.6% (96/106) with 79.2% (84/106) achieved on first attempt. Causes of technical failures included inadequate foot lymphatics or no cisterna chyli (20), unfavorable retroperitoneal anatomy (3), patient over-sedation (1), and equipment failure (1). Technical successes included 52 type 1 and 43 type 2 PTDAs,
Cause of Effusion
# of Cases (n⫽121)
% of Cases
Clinical Success
Significance of Difference* (p value)
Iatrogenic (overall) Esophagectomy Pneumonectomy Pleurectomy Lobectomy Spontaneous
112 50 16 19 6 9
92.6% 41.3% 15.7% 13.2% 5.0% 7.4%
54.5% 58.0% 81.3% 31.6% 33.3% 11.1%
– 0.57 0.03 0.04 0.41 0.02
* When comparing corresponding group to the remainder of the Iatrogenic group. Spontaneous group was compared to the entire Iatrogenic group.
11:02 AM
Abstract No. 252
Feasibility of ultrasound guided intranodal lymphangiogram for thoracic duct embolization G. Nadolski, M. Itkin; Hospital of the University of Pennsylvania, Philadelphia, PA Purpose: To test the feasibility of opacifying the thoracic duct (TD) using ultrasound (US) guided injection of inguinal/femoral lymph nodes with lipiodol as part of thoracic duct embolization (TDE). Materials and Methods: HIPAA waiver and IRB approval were granted prior to beginning the study. A total of 6 consecutive patients (2F, 4M; mean age 59.2 yrs) underwent US guided intranodal lymphangiogram (INL) for TDE to treat chylothorax. INL was performed by positioning the tip of a 25 G needle in the center of an inguinal or femoral lymph node using real time US guidance and then injecting lipiodol. After identification of the TD, it was catheterized and embolized if indicated. The times from initiating the procedure until: (1) injection of contrast into lymphatics, (2) identification of a target lymphatic for catheterization, (3) catheterization of the TD and (4) embolization of TD were recorded. These times were compared to those of a control group consisting of the previous 6 patients (2F, 4M; mean age 66.7 yrs) who had undergone TDE to treat chylothorax using tradition pedal lymphangiography (PL). Results: In all patients undergoing INL, the lymphangiogram and TD catheterization were performed successfully. In the INL group, TDE was performed successfully in all but one patient, in whom the TD was found to be normal. In the PL group, the TD was visualized and successfully embolized in all cases. The average times from initiating the procedure in the INL and PL groups until: (1) injection of contrast into lymphatics were 20.5⫾8.6 and 46.5⫾22.6 minutes (p⬍0.05), (2) identification of a target lymphatic for catheterization were 60.5⫾18.2 and 110.5⫾31.6 minutes (p⬍0.01), (3) catheterization of the TD were 79.0⫾28.9 and 128.2⫾37.0 minutes (p⬍0.05) and (4) embolization of TD were 125.8⫾49.0 and 152.8⫾36.4 minutes (p⫽NS).
WEDNESDAY: Scientific Sessions
V. Pamarthi1,2, M.S. Stecker2, S. O’Horo2, A. Han2, C. Fan2; 1Harvard Medical School, Boston, MA; 2 Angiography and Interventional Radiology, Brigham and Women’s Hospital, Boston, MA
with clinical success rates of 75.0% (39/52) and 53.5% (23/43) respectively. Overall, PTDA clinical success was 64.6% (62/96). Underlying pathologies included esophageal adenocarcinoma (41), mesothelioma (31), lung neoplasms (11), and spontaneous chylous effusions (9). A table summarizing major causes, case distribution, and success rate is below. Conclusion: PTDA is a minimally invasive treatment for thoracic duct injuries, which in our series resolved thoracic duct leaks in 64.6% of technically successful procedures. PTDA clinical success rate is affected by factors including type of inciting surgery and PTDA technique. PTDA is significantly less effective for treating spontaneous chylothorax.