A chylothorax is formed by the accumulation of chyle in the pleural space. We present a case of recurrent idiopathic chylothoraces successfully treated with percutaneous thoracic duct embolization.CASE REPORT: A 65 year-old male lifelong never-smoker presented to pulmonary clinic for evaluation of a persistent left sided pleural effusion. He complained of exertional dyspnea. His past medical history included congestive heart failure. The physical exam was notable for diminished left sided breath sounds and dullness to percussion. Computed tomography (CT) of the chest demonstrated left sided pleural effusion with compressive atelectasis of the left base. Thoracentesis revealed a turbid yellow odorless effusion. Pleural fluid analysis were consistent with a transudative chylothorax. Pleural fluid and serum characteristics are shown in the following table
Pleural Fluid and Serum Chemical CharacteristicsSourceLDH (U/L)Protein (g/dl)Triglyceride (mg/dl)Cholesterol (mg/dl)Albumin (g/dl)Glucose (mg/dl)WBC countPleural931.7152291.0279240Serum3227.1871454.01447500:Lymphangiography revealed a leak in the thoracic duct below the level of the left main stem bronchus. The duct was percutaneously catheterized in retrograde fashion from the neck and embolized with platinum coils.DISCUSSION: The leading cause of chylothorax is tumor disrupting the thoracic duct, with lymphomas comprising the majority of cases. A significant number of chylothoraces are considered to be idiopathic. A pleural fluid triglyceride level above 110 mg/dl supports the diagnosis of chylothorax and a level less than 50 mg/dl makes the diagnosis less likely. Some patients with chyloform pleural effusions can have triglyceride levels above 110 mg/dl, but they will likely have cholesterol levels above 200 mg/dl. Our patient successfully underwent lymphangiography followed by percutaneous thoracic duct embolization resulting in resolution of the chylothorax. A unique feature of our case is that the embolization was performed via retrograde approach to the thoracic duct.
Chylothorax treated with minimally invasive percutaneous thoracic duct embolization offers an advantage in patients unable to tolerate a more aggressive surgical approach. Percutaneous coil embolization of the thoracic duct is a potential treatment option for patients with recurrent idiopathic chylothoraces.
M.C. DeArment, None.