- Email: [email protected]
Treatment of traumatic chylous pleural effusion using ethylene vinyl alcohol (EVOH) copolymer
S200
Posters and Exhibits
Learning Objectives: 1. Be able to explain the technique, indications and contraindications for lymphangiography.2. Understand the roles of lymphoscintigraphy and lymphangiography and how the two studies can combine to further enhance the quality of patient care. Background: Background: Previously the primary imaging technique to evaluate lymph nodes for cancer and infection, lymphangiography has been overtaken by cross-sectional and nuclear imaging. It however remains important in patients with chylous ascites and/or effusions for surgical planning or direct percutanous intervention. Clinical Findings/Procedure Details: Technique: Traditional technique involves four basic steps. 1) Injection of blue dye in the web spaces of the hands or feet. 2) Cutdown and cannulation of a blue lymphatic duct. 3) Slow injection of fat-based dye. 4) Periodic fluoroscopy, radiography and/or CT. Intranodal technique involves three basic steps. 1) Ultrasoundguided puncture of a groin lymph node. 2) Slow injection of fatbased dye. 3) Periodic fluoroscopy, radiography and/or CT. Complications: Severe complications are extremely rare. Minor complications include dye reaction and infection at the injection site. Conclusion and/or Teaching Points: 1. Traditional lymphangiography is still a highly valued procedure; at our institution, we have performed 158 lymphangiograms over the last 10 years with 18 embolizations. 2. Major indications include chylothorax, chylous ascites, chyluria, chyloptysis and unexplained extremity lymphedema. 3. Lymphangiography can be performed at a tertiary institution by an integrated Interventional Radiology and surgical team.
Educational Exhibit
Abstract No. 459
Treating nonvascular disease with the Amplatzer vascular plug: an illustrative review of novel applications in interventional radiology practice
Posters and Exhibits
S. Ahmed1, D. Marker1, K. Hong2; 1Radiology, Johns Hopkins University School of Medicine, Baltimore, MD; 2 Vascular and Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD Learning Objectives: The objective of this exhibit is to provide a review of our experience with novel applications of the Amplatzer vascular plug (AVP) in interventional radiology practice. We will present illustrative cases where AVP was employed to treat non-vascular pathology. In addition, we will supplement our discussion with a survey of the literature on non-vascular use of AVP. Background: AVP is a self-expandible nitinol mesh embolic device that was first approved by the FDA for peripheral vascular embolizations, and serves as an efficient and costeffective alternative to coils and detachable balloons. The Amplatzer family of vascular plugs includes four models, each with a unique design and features to treat a broad range of primarily vascular entities. With increased recognition of its versatility, the Amplatzer plug is now being employed to treat non-vascular pathology refractory to traditional methods. Clinical Findings/Procedure Details: We will present illustrative cases of non-vascular use of AVP, including treatment of bronchopulmonary and esophagopleural fistulas, biliary and
’
JVIR
gallbladder leaks, ureteral leaks and fistulas, enterocutenous leaks, and bronchial stump leaks. We will discuss technical details for success, as well as pre- and post-procedure clinical data and imaging to review patient selection and clinical outcomes. We will also review the potential advantages and drawbacks of using AVP versus other embolic agents/devices in various clinical scenarios. Conclusion and/or Teaching Points: AVP is a novel occlusion device that is traditionally used to treat a variety of vascular conditions. However, its use has been expanded to non-vascular disease with promising results. This illustrative exhibit will familiarize its readers with new clinical indications for using the Amplatzer plug, including a review of patient selection, technical details with tips to optimize outcomes, and post-procedure follow-up.
Educational Exhibit
Abstract No. 460
Novel applications of the Onyx liquid embolic system: illustrative review of treating peripheral vascular, genitourinary, and gastrointestinal pathologies S. Ahmed1, D. Marker1, K. Hong2; 1Radiology, Johns Hopkins University School of Medicine, Baltimore, MD; 2 Vascular and Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD Learning Objectives: We will review our experience with offlabel use of Onyx through illustrative cases where Onyx was preferable to traditional embolic agents, and provide intraprocedural descriptions for success. Background: Onyx is a non-adhesive liquid embolic agent FDA-approved for embolization of intracranial aneurysms. Its surgical handling characteristics allow for controlled delivery and cohesive deposition. Given its versatility, Onyx has the potential to successfully treat non-neurovascular pathology. Clinical Findings/Procedure Details: Combining our institution’s experiences with a review of the current literature, we will present unique indications for employing the Onyx embolic system, including peripheral vascular, genitourinary (GU), and gastrointestinal (GI) pathologies. A broad range of cases will be presented, including the followingbiliary leaks, gallbladder leaks, urinary leaks and fistulas (eg. ureteral-spinal fistula), enterocutaneous fistula, GI bleed, portal vein embolization, and peripheral arterio-venous malformations.In addition, we will provide intra-procedural descriptions for success, as well as pre- and post-procedure clinical data and imaging to review patient selection and clinical outcomes. Conclusion and/or Teaching Points: The versatility of Onyx can be exploited to treat peripheral vascular, GI, and GU pathologies. A comprehensive understanding of its application for unique indications is essential in interventional radiology practice.
Educational Exhibit
Abstract No. 461
Treatment of traumatic chylous pleural effusion using ethylene vinyl alcohol (EVOH) copolymer J. Kessler1, J. Kim2, D. Raz2, J.J. Park1; 1Radiology, City of Hope National Medical Center, Duarte, CA; 2Surgery, city of hope medical center, Duarte, CA
JVIR
’
Posters and Exhibits
S201
Learning Objectives: Percutaneous thoracic duct embolization has been shown to be effective in the treatment of recurrent chylous effusions. Many embolic agents have been described in the successful occlusion of the thoracic duct. In this study, we evaluate the role and efficacy of using EVOH copolymer (Onyx) in the treatment of traumatic chylous pleural effusions. Background: A retrospective review was performed of consecutive patients with post-operative chylous pleural effusions treated with thoracic duct embolization using EVOH copolymer at a single institution from 2012-2014. Demographic data, surgical history, procedure details, and toxicities were systematically reviewed. Clinical Findings/Procedure Details: 4 patients (M¼2) were identified that met inclusion criteria. Median age at treatment was 67. Median follow was 125 days (range 24-246). Two patients had undergone robotic assisted surgery and 2 had undergone open thoracotomy. 3 patients had thoracic duct ligation performed at the time of their initial surgery. Median time from surgery to embolization was 7 days (range 3-15). Daily chest tube drainage range was 150 -2000 ml. All patients underwent bilateral ultrasound guided inguinal nodal lymphangiogram. The thoracic duct was then accessed using a 21 or 22 gauge Chiba needle. A thoracic duct leak was identified in 3 patients. Coils were placed initially in the central duct prior to embolization of the leak limit potential systemic flow. Onyx 34 (ev3 Neurovascular, Irvine, California) was used in 4 patients with additional Onyx 18 in 1 patient for embolization. Volume used was 1-2 ml in all patients. All patients had resolution of the chylous effusion within 1 day of embolization. The subjects were discharged from the hospital between 4-7 days post-procedure. 30 days post-procedure complications included an abdominal wall hematoma in 1 patient who was subsequently started on anticoagulation. No patients developed recurrent chyle leaks during the follow up period. Conclusion and/or Teaching Points: EVOH copolymer is a safe and effective agent for percutaneous thoracic duct embolization. This is the largest reported series to date demonstrating the efficacy of this embolic agent in treating chylous effusions in the post-traumatic setting.
Educational Exhibit
Abstract No. 462
Lymphatic intervention for various kinds of lymphorrhea M. Inoue1, M. Kojima2, T. Akiyoshi2, M. Nakagawa3, S. Nakatsuka3; 1Radiology, Hiratsuka City Hospital, hiratsuka, Japan; 2Surgery, Hiratsuka City Hospital, hiratsuka, Japan; 3Diagnostic Radiology, Keio University, School of Medicine, Tokyo, Japan
Educational Exhibit
Abstract No. 463
“Patients” is a virtue: ultrasound-guided intranodal lymphangiogram approach for the treatment of chylous effusions; a new school twist on an old school procedure K.K. Das, I. Babin, R. Nayyar, D. Zhang; Radiology, SUNY Upstate Medical University, Syracuse, NY Learning Objectives: Our Educational Exhibit will provide up to date information on recent advancements in minimally invasive treatment of chylothorax using thoracic duct embolization. We will focus on the advantages of using ultrasound guided intranodal injection over the traditional pedal approach by detaling cases performed at our institution. Additionally, review of literature will examine why thoracic duct embolization should be a first-line therapeutic procedure for chylothorax. Background: Thoracic duct embolization via pedal angiography has been previously described with variable clinical success rates ranging between 51-71%. The main reasons attributed to technical failure includes lack of visualization of the cisterna chili or inadequate pedal lymphatic vessels for successful cannulation. Ultrasound guided intranodal contrast injection to opacify the cisterna chyli is a promising technique to increase technical and clinical success, and has been described in several case reports and case series with favorable results. The use of ultrasound guided intranodal lymphangiography appears to be less technically challenging, less time consuming, and does not require specialized equipment that may not be available in all radiology departments.
Posters and Exhibits
Learning Objectives: Learning Objectives: To review and illustrate, with clinical experiences, the indications, technique, and current status of lymphatic intervention in treating various kinds of lymphorrhea. Background: Lymphorrhea can develop as an iatrogenic complication of surgery. Lymph node dissection is main cause of abdominal lymphorrhea. Injury of hepatic lymphatics is rare and a consequence of nodal dissection in the hepatoduodenal ligament. Chylothorax results from thoracic duct injury. High-output lymphorrhea is a critical condition associated
with adverse sequelae including immunocompromise and nutritional depletion. Thus, early intervention has been advocated recently. Clinical Findings/Procedure Details: The treatment consists of diagnostic lymphangiography followed by embolization or sclerotherapy. Intranodal lymphography (IL) is useful in demonstrating fistula arising from paraaortic, lumbar lymphatics, or thoracic duct; however, a fistula arising from hepatic lymphatics can only be diagnosed by hepatic lymphography. Appropriate lymphangiography was performed to opacify the leakage of lymph fluid. Low-output lymphorrhea might cure followed by lymphangiography alone. In case of high-output chylothorax, the cisterna chyli is accessed with a 21 gauge Chiba needle, using a right paramedian percutaneous approach under fluoroscopic guidance after IL. Then, 0.018-inch guidewire is advanced through the needle. A microcatheter is advanced into the thoracic duct over the wire. Finally, glue combined with coil is used to embolize the thoracic duct. When leakage from hepatic lymphatics is suspected, the liver is punctured close to the right portal vein using a 21-gauge needle and transhepatic lymphography could visualize the fistula. Then, embolization using Onyx through the needle is one of the treatment of choice. Another strategy is sclerotherapy. Drainage tube is inserted near the fistula. If intrahepatic lymphatics is visualized with contrast materials via drainage tube, sclerotherapy using OK-432 is performed. Conclusion and/or Teaching Points: Interventional radiologists should be familiar with various lymphography techniques and management of lymphorrhea.
Posters and Exhibits
Learning Objectives: 1. Be able to explain the technique, indications and contraindications for lymphangiography.2. Understand the roles of lymphoscintigraphy and lymphangiography and how the two studies can combine to further enhance the quality of patient care. Background: Background: Previously the primary imaging technique to evaluate lymph nodes for cancer and infection, lymphangiography has been overtaken by cross-sectional and nuclear imaging. It however remains important in patients with chylous ascites and/or effusions for surgical planning or direct percutanous intervention. Clinical Findings/Procedure Details: Technique: Traditional technique involves four basic steps. 1) Injection of blue dye in the web spaces of the hands or feet. 2) Cutdown and cannulation of a blue lymphatic duct. 3) Slow injection of fat-based dye. 4) Periodic fluoroscopy, radiography and/or CT. Intranodal technique involves three basic steps. 1) Ultrasoundguided puncture of a groin lymph node. 2) Slow injection of fatbased dye. 3) Periodic fluoroscopy, radiography and/or CT. Complications: Severe complications are extremely rare. Minor complications include dye reaction and infection at the injection site. Conclusion and/or Teaching Points: 1. Traditional lymphangiography is still a highly valued procedure; at our institution, we have performed 158 lymphangiograms over the last 10 years with 18 embolizations. 2. Major indications include chylothorax, chylous ascites, chyluria, chyloptysis and unexplained extremity lymphedema. 3. Lymphangiography can be performed at a tertiary institution by an integrated Interventional Radiology and surgical team.
Educational Exhibit
Abstract No. 459
Treating nonvascular disease with the Amplatzer vascular plug: an illustrative review of novel applications in interventional radiology practice
Posters and Exhibits
S. Ahmed1, D. Marker1, K. Hong2; 1Radiology, Johns Hopkins University School of Medicine, Baltimore, MD; 2 Vascular and Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD Learning Objectives: The objective of this exhibit is to provide a review of our experience with novel applications of the Amplatzer vascular plug (AVP) in interventional radiology practice. We will present illustrative cases where AVP was employed to treat non-vascular pathology. In addition, we will supplement our discussion with a survey of the literature on non-vascular use of AVP. Background: AVP is a self-expandible nitinol mesh embolic device that was first approved by the FDA for peripheral vascular embolizations, and serves as an efficient and costeffective alternative to coils and detachable balloons. The Amplatzer family of vascular plugs includes four models, each with a unique design and features to treat a broad range of primarily vascular entities. With increased recognition of its versatility, the Amplatzer plug is now being employed to treat non-vascular pathology refractory to traditional methods. Clinical Findings/Procedure Details: We will present illustrative cases of non-vascular use of AVP, including treatment of bronchopulmonary and esophagopleural fistulas, biliary and
’
JVIR
gallbladder leaks, ureteral leaks and fistulas, enterocutenous leaks, and bronchial stump leaks. We will discuss technical details for success, as well as pre- and post-procedure clinical data and imaging to review patient selection and clinical outcomes. We will also review the potential advantages and drawbacks of using AVP versus other embolic agents/devices in various clinical scenarios. Conclusion and/or Teaching Points: AVP is a novel occlusion device that is traditionally used to treat a variety of vascular conditions. However, its use has been expanded to non-vascular disease with promising results. This illustrative exhibit will familiarize its readers with new clinical indications for using the Amplatzer plug, including a review of patient selection, technical details with tips to optimize outcomes, and post-procedure follow-up.
Educational Exhibit
Abstract No. 460
Novel applications of the Onyx liquid embolic system: illustrative review of treating peripheral vascular, genitourinary, and gastrointestinal pathologies S. Ahmed1, D. Marker1, K. Hong2; 1Radiology, Johns Hopkins University School of Medicine, Baltimore, MD; 2 Vascular and Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD Learning Objectives: We will review our experience with offlabel use of Onyx through illustrative cases where Onyx was preferable to traditional embolic agents, and provide intraprocedural descriptions for success. Background: Onyx is a non-adhesive liquid embolic agent FDA-approved for embolization of intracranial aneurysms. Its surgical handling characteristics allow for controlled delivery and cohesive deposition. Given its versatility, Onyx has the potential to successfully treat non-neurovascular pathology. Clinical Findings/Procedure Details: Combining our institution’s experiences with a review of the current literature, we will present unique indications for employing the Onyx embolic system, including peripheral vascular, genitourinary (GU), and gastrointestinal (GI) pathologies. A broad range of cases will be presented, including the followingbiliary leaks, gallbladder leaks, urinary leaks and fistulas (eg. ureteral-spinal fistula), enterocutaneous fistula, GI bleed, portal vein embolization, and peripheral arterio-venous malformations.In addition, we will provide intra-procedural descriptions for success, as well as pre- and post-procedure clinical data and imaging to review patient selection and clinical outcomes. Conclusion and/or Teaching Points: The versatility of Onyx can be exploited to treat peripheral vascular, GI, and GU pathologies. A comprehensive understanding of its application for unique indications is essential in interventional radiology practice.
Educational Exhibit
Abstract No. 461
Treatment of traumatic chylous pleural effusion using ethylene vinyl alcohol (EVOH) copolymer J. Kessler1, J. Kim2, D. Raz2, J.J. Park1; 1Radiology, City of Hope National Medical Center, Duarte, CA; 2Surgery, city of hope medical center, Duarte, CA
JVIR
’
Posters and Exhibits
S201
Learning Objectives: Percutaneous thoracic duct embolization has been shown to be effective in the treatment of recurrent chylous effusions. Many embolic agents have been described in the successful occlusion of the thoracic duct. In this study, we evaluate the role and efficacy of using EVOH copolymer (Onyx) in the treatment of traumatic chylous pleural effusions. Background: A retrospective review was performed of consecutive patients with post-operative chylous pleural effusions treated with thoracic duct embolization using EVOH copolymer at a single institution from 2012-2014. Demographic data, surgical history, procedure details, and toxicities were systematically reviewed. Clinical Findings/Procedure Details: 4 patients (M¼2) were identified that met inclusion criteria. Median age at treatment was 67. Median follow was 125 days (range 24-246). Two patients had undergone robotic assisted surgery and 2 had undergone open thoracotomy. 3 patients had thoracic duct ligation performed at the time of their initial surgery. Median time from surgery to embolization was 7 days (range 3-15). Daily chest tube drainage range was 150 -2000 ml. All patients underwent bilateral ultrasound guided inguinal nodal lymphangiogram. The thoracic duct was then accessed using a 21 or 22 gauge Chiba needle. A thoracic duct leak was identified in 3 patients. Coils were placed initially in the central duct prior to embolization of the leak limit potential systemic flow. Onyx 34 (ev3 Neurovascular, Irvine, California) was used in 4 patients with additional Onyx 18 in 1 patient for embolization. Volume used was 1-2 ml in all patients. All patients had resolution of the chylous effusion within 1 day of embolization. The subjects were discharged from the hospital between 4-7 days post-procedure. 30 days post-procedure complications included an abdominal wall hematoma in 1 patient who was subsequently started on anticoagulation. No patients developed recurrent chyle leaks during the follow up period. Conclusion and/or Teaching Points: EVOH copolymer is a safe and effective agent for percutaneous thoracic duct embolization. This is the largest reported series to date demonstrating the efficacy of this embolic agent in treating chylous effusions in the post-traumatic setting.
Educational Exhibit
Abstract No. 462
Lymphatic intervention for various kinds of lymphorrhea M. Inoue1, M. Kojima2, T. Akiyoshi2, M. Nakagawa3, S. Nakatsuka3; 1Radiology, Hiratsuka City Hospital, hiratsuka, Japan; 2Surgery, Hiratsuka City Hospital, hiratsuka, Japan; 3Diagnostic Radiology, Keio University, School of Medicine, Tokyo, Japan
Educational Exhibit
Abstract No. 463
“Patients” is a virtue: ultrasound-guided intranodal lymphangiogram approach for the treatment of chylous effusions; a new school twist on an old school procedure K.K. Das, I. Babin, R. Nayyar, D. Zhang; Radiology, SUNY Upstate Medical University, Syracuse, NY Learning Objectives: Our Educational Exhibit will provide up to date information on recent advancements in minimally invasive treatment of chylothorax using thoracic duct embolization. We will focus on the advantages of using ultrasound guided intranodal injection over the traditional pedal approach by detaling cases performed at our institution. Additionally, review of literature will examine why thoracic duct embolization should be a first-line therapeutic procedure for chylothorax. Background: Thoracic duct embolization via pedal angiography has been previously described with variable clinical success rates ranging between 51-71%. The main reasons attributed to technical failure includes lack of visualization of the cisterna chili or inadequate pedal lymphatic vessels for successful cannulation. Ultrasound guided intranodal contrast injection to opacify the cisterna chyli is a promising technique to increase technical and clinical success, and has been described in several case reports and case series with favorable results. The use of ultrasound guided intranodal lymphangiography appears to be less technically challenging, less time consuming, and does not require specialized equipment that may not be available in all radiology departments.
Posters and Exhibits
Learning Objectives: Learning Objectives: To review and illustrate, with clinical experiences, the indications, technique, and current status of lymphatic intervention in treating various kinds of lymphorrhea. Background: Lymphorrhea can develop as an iatrogenic complication of surgery. Lymph node dissection is main cause of abdominal lymphorrhea. Injury of hepatic lymphatics is rare and a consequence of nodal dissection in the hepatoduodenal ligament. Chylothorax results from thoracic duct injury. High-output lymphorrhea is a critical condition associated
with adverse sequelae including immunocompromise and nutritional depletion. Thus, early intervention has been advocated recently. Clinical Findings/Procedure Details: The treatment consists of diagnostic lymphangiography followed by embolization or sclerotherapy. Intranodal lymphography (IL) is useful in demonstrating fistula arising from paraaortic, lumbar lymphatics, or thoracic duct; however, a fistula arising from hepatic lymphatics can only be diagnosed by hepatic lymphography. Appropriate lymphangiography was performed to opacify the leakage of lymph fluid. Low-output lymphorrhea might cure followed by lymphangiography alone. In case of high-output chylothorax, the cisterna chyli is accessed with a 21 gauge Chiba needle, using a right paramedian percutaneous approach under fluoroscopic guidance after IL. Then, 0.018-inch guidewire is advanced through the needle. A microcatheter is advanced into the thoracic duct over the wire. Finally, glue combined with coil is used to embolize the thoracic duct. When leakage from hepatic lymphatics is suspected, the liver is punctured close to the right portal vein using a 21-gauge needle and transhepatic lymphography could visualize the fistula. Then, embolization using Onyx through the needle is one of the treatment of choice. Another strategy is sclerotherapy. Drainage tube is inserted near the fistula. If intrahepatic lymphatics is visualized with contrast materials via drainage tube, sclerotherapy using OK-432 is performed. Conclusion and/or Teaching Points: Interventional radiologists should be familiar with various lymphography techniques and management of lymphorrhea.