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The lymphatic system is critical in fluid balance homeostasis. Yet, until recently, lymphatic imaging has been outside of mainstream medicine due to a lack of robust imaging and interventional options. However, during the last 20 years, both clinical lymphatic imaging and interventions have shown dramatic advancement. The key to imaging advancement has been the interstitial delivery of contrast agents through lymphatic-rich tissues. These techniques include intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography. These methods provide the ability to image and recognize lymphatic anatomy and pathologic conditions. Percutaneous thoracic duct catheterization and embolization became the first widely accepted interventional technique for the management of chyle leaks. Advances in interstitial lymphatic embolization, as well as liver and mesenteric lymphatic interventions, have broadened the scope of possible lymphatic interventions. Also, recent techniques of lymphatic decompression allow for the treatment of a variety of lymphatic disorders. Finally, immunologic studies of central lymphatic fluid reveal the potential of lymphatic interventions on immunity. These advances herald an exciting new chapter for lymphatic imaging and interventions in the coming years.

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In patients with recalcitrant mechanical thoracic duct obstruction, microsurgical lymphovenous bypass is an emerging therapeutic option. We herein discuss the preoperative workup, share our current operative technique, and evaluate preliminary outcomes with an emphasis on changes in physiology. Methods: A retrospective review of adult patients who underwent thoracic duct lymphovenous bypass by a single surgeon and interventional radiologist from 2019 to 2022 was performed. Demographics, comorbidities, perioperative data, and postoperative outcomes were collected. Results: Nine patients were included in the study. Immediate postoperative heart rate increased significantly among this heterogeneous patient population, but within 4-6 hours the change in heart rate was no longer significant. Mean arterial pressure and oxygen requirement were not significantly different before and after bypass. Conclusions: Thoracic duct lymphovenous bypass seem to be well tolerated in the short-term even in patients with cardiopulmonary comorbidities. Further data are necessary to continue to better understand the resulting physiologic changes and to optimize patient outcomes.

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Thoracic duct occlusion can lead to devastating complications, resulting in recalcitrant chylothoraces, ascites, generalized lymphedema, metabolic derangement, and death. Lymphatic extravasation has traditionally been managed conservatively and, in recent years, using minimally invasive techniques, such as thoracic duct ligation and embolization. However, these measures are often limited in application and therapeutic success, resulting in chronically difficult conditions with few modalities available for definitive management. Advances in microsurgery have allowed for surgical treatment and resolution of peripherally-based lymphatic pathology, though microsurgical intervention to address central lymphatic abnormalities is scarcely described. This report is the first series detailing experiences utilizing microsurgical thoracic duct lymphovenous bypass in a refractory adult population with thoracic duct occlusion. Four patients successfully underwent the procedure, with three achieving complete resolution of symptoms. The fourth patient enjoyed partial resolution, though ubiquitous lymphatic deformities have conferred recurrent residual lower-extremity peripheral edema requiring future intervention. Postoperatively, patent anastomoses were confirmed under magnetic resonance lymphangiography. This series demonstrates the feasibility of microsurgical thoracic duct lymphovenous bypass as a promising technique in treating patients suffering from thoracic duct occlusion. This intervention is effective for recalcitrant chylothorax, chylous ascites, and generalized lymphedema, particularly when traditional and interventional radiological techniques are unsuccessful.

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We describe a 69-year-old dialysis-dependent patient who developed intractable ascites after zone 2 aortic reconstruction for a type IA thoracic endovascular aneurysm repair endoleak. Investigation as to the cause of ascites revealed a unique set of clinical circumstances leading to intractable bloody ascites. Investigation included imaging and invasive testing to diagnose the culprit mechanism. Ultimately, interventional catherization of the left subclavian vein illustrated an abnormally elevated pressure in the left subclavian vein. It was thus determined that, owing to the combination of a left brachiocephalic (innominate) vein occlusion after surgical ligation and in situ left brachiobasilic arteriovenous dialysis graft, there was overcirculation through the thoracic duct. Retrograde flow through the pop-off thoracic duct led to hematogenous ascites. Ligation of the left brachiobasilic arteriovenous dialysis graft resulted in near instantaneous and complete resolution of the ascites.

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With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

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An adolescent with plastic bronchitis due to congenital heart disease had altered mental status after an interventional lymphatic procedure in which lipiodol contrast was used. Neuroimaging revealed cerebral lipiodol embolization due to direct shunting between lymphatic channels and pulmonary veins. Cerebral lipiodol embolization is a potential neurologic morbidity associated with interventional lymphatic procedures.

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BACKGROUND: Thoracic duct embolization (TDE) is an acceptable alternative procedure for treating traumatic chylothorax. The purpose of this study is to demonstrate efficacy of TDE in treating nontraumatic chylous effusions. METHODS: A retrospective review of 34 patients was conducted assessing technical and clinical success of TDE for nontraumatic chylous effusions. RESULTS: Thirty-four patients (mean age, 59 years; 27 female patients) with nontraumatic chylous effusions underwent TDE. Presentations included 21 unilateral chylothoraces (61.8%), nine bilateral chylothoraces (26.5%), two isolated chylopericardiums (5.9%), and two pleural effusions with chylopericardium (5.9%). TDE was technically successful in 24 of 34 patients (70.6%). The thoracic duct could not be catheterized in four of 34 (11.8%). Cisterna chyli was not visualized in six of 34 patients (17.6%), and, thus, TDE was not attempted. Follow-up was available for 32 patients. Four lymphangiographic patterns were observed: (1) normal thoracic duct in 17.6% of patients (six of 34), (2) occlusion of thoracic duct in 58.8% (20 of 34), (3) failure to opacify thoracic duct in 17.6% (six of 34), and (4) extravasation of chyle in 5.9% (two of 34). Clinical success varied with the lymphangiographic pattern. The clinical success rate was 16% (one of six) in cases of normal thoracic duct, 75% (15 of 20 patients) in occlusions of the thoracic duct, 16% (one of six) in cases of failure to opacify the thoracic duct, and 50% in two cases of chyle extravasation. Lymphangiography alone cured two patients (6.5%). CONCLUSION: TDE was most successful in cases of thoracic duct occlusion and extravasation. Lymphangiography is important for identifying the cause of chylous effusions and selecting patients who benefit most from TDE.

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