3Sultan Mana Mania Alamri,1,2Mohammad Farouq Badran
1King Fahad Medical City, 2King Faisal Specialist Hospital & Research Center, 3King Faisal Medical City
Chylothorax can cause serious hypovolemia, electrolyte imbalances, starvation, and immunological compromise in a short period. High venous pressure and obstructed thoracic duct drainage can impact post-Fontan lymphatic circulation. Instead of embolizing or disturbing the thoracic duct, a thoracic duct stent-graft reconstruction may be considered to eliminate the site of leak while maintaining the normal physiologic lymphatic drainage channel.
Material(s) and Method(s):
A 5-year-old male patient, has a history of congenital heart disease with double inlet left single ventricle, pulmonary atresia, ventricular septal defect, underwent ductus arterisus stenting and Glenn procedure with left pulmonary artery stenosis during the first year of his life.
Recently the patient underwent an extra-cardiac fontan procedure which was complicated by persistent right sided pleural effusion. A chest tube was placed during the surgery.,the right-sided pleural effusion showed a high drain output of about more than 500 cc / 24 hours which was confirmed by fluid analysis to a chylothorax. The patient has conservative therapy with low fat diet however it failed, The patient was brought to the radiology department for an enhanced US lymphatic scan and Dynamic MR lymphangiogram. showed left internal jugular vein immediate contrast flow confirming the patency of the thoracic duct.The patient was booked by the interventional radiology service for lymphangiography and possible thoracic duct intervention.
The procedure was performed under general anesthesia in a supine position. Lipiodol was injected showed a small amount of contrast agent leaking from the right side.
The patient was monitored for 10 days, with no improvement of the right-sided effusion.
The patient was brought to the interventional radiology department for thoracic duct intervention. Via The left brachial vein and direct cisterna chyli access, . Lymphangiogram and Cone-beam CT with 3 D reformat was obtained confirming no evinced of leak. However, there were multiple abnormal plexiform small ducts at the level of T8 and cistern chyli . A 5-mm, 10-cm VIABAHN endoprosthesis was deployed within the thoracic duct, excluding the plexiform lymphatic channels. Post stenting lymphangiogram showed patent stent with brisk flow and total resolution of the previously seen plexiform lymphatic channels.
For the treatment of chylothorax, thoracic duct stent-graft reconstruction may be a technically successful and safe alternative to thoracic duct embolization, disruption, and surgical ligation, while also potentially preserving anterograde flow in the central lymphatics. More investigation and follow-up are required.