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Maxim Itkin, MD; Gregory J. Nadolski, MD
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From the Department of Radiology, Section Interventional Radiology, Hospital of the University of Pennsylvania.

Correspondence to: Maxim Itkin, MD, Department of Radiology, Section Interventional Radiology, Hospital of the University of Pennsylvania, 1 Silverstein, 3400 Spruce St, Philadelphia, PA 19104; e-mail: itkinmax@gmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(2):579. doi:10.1378/chest.12-2608
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Published online
To the Editor:

We thank Dr López-Gutiérrez for his interest in our recent work in CHEST.1 The etiology of idiopathic chylothorax has indeed been hardly investigated and in most parts remains unsolved. We suggest that all cases of idiopathic chylothorax can be divided into two major categories: (1) occlusion of the upper part of the thoracic duct (TD) with development of compensatory collaterals and (2) chylous leak in the presence of a lymphatic malformation.

We believe that the cause of TD occlusion is subclinical trauma. In these cases, multiple lymphatic collaterals develop as a new route to the venous system. If one of these collaterals abut a serous surface (pleural, pericardial, or peritoneal), it can rupture and then result in a chylous leak.2 Traditional lymphangiogram can easily diagnose TD occlusion.

MRI ductography,3 which uses noncontrast fluid-weighted MRI sequences, allows visualization of not only the TD but also other abnormal lymphatic structures such as congenital lymphatic malformations. We hypothesize that an unidentified insult can result in a rupture of these structures and leakage of the chyli. If a leak from these structures happens proximal to the cisterna chyli, TD embolization (TDE) can be devastating, diverting all the flow from the TD into the leak.

Over the years, we have developed an algorithm to diagnose and treat idiopathic chylous effusions. We first perform magnetic resonance ductogram to identify TD and other lymphatic structures/malformations. Then, we perform conventional or intranodal lymphangiography.4 In cases of occlusion of the upper portion of the TD or demonstration of the leak, TDE usually cures chylothorax. In cases where TD is patent and the flow is normal, TDE should be avoided. Occasionally, oily-based contrast introduced during lymphangiogram can facilitate closure of the leak.5

More distal occlusion of the TD leaves a longer segment of the TD intact, creating more opportunities for development of new lymphovenous anastomosis. The advantage of the TDE vs thoracic duct ligation is the ability to visualize the leak and occlude TD close to the leakage point (comparing to proximal supradiaphragmatic ligation of the TD in thoracic duct ligation). This potentially can result in development of more lymphovenous communications after TDE and reduction of the chylothorax recurrence.

Finally, future development of new imaging lymphatic agents may provide us with deeper insight into anatomy, physiology, and flow dynamics in the lymphatic system. Hopefully, these new insights will trigger further research and understanding of this vital yet overlooked “human plumbing” system.

References

Nadolski GJ, Itkin M. Thoracic duct embolization for nontraumatic chylous effusion: experience in 34 patients. Chest. 2013;143(1):158-163.
 
Itkin M, Swe NM, Shapiro SE, Shrager JB. Spontaneous chylopericardium: delineation of the underlying anatomic pathology by CT lymphangiography. Ann Thorac Surg. 2009;87(5):1595-1597. [CrossRef] [PubMed]
 
Okuda I, Udagawa H, Takahashi J, Yamase H, Kohno T, Nakajima Y. Magnetic resonance-thoracic ductography: imaging aid for thoracic surgery and thoracic duct depiction based on embryological considerations. Gen Thorac Cardiovasc Surg. 2009;57(12):640-646. [CrossRef] [PubMed]
 
Nadolski GJ, Itkin M. Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization. J Vasc Interv Radiol. 2012;23(5):613-616. [CrossRef] [PubMed]
 
Matsumoto T, Yamagami T, Kato T, et al. The effectiveness of lymphangiography as a treatment method for various chyle leakages. Br J Radiol. 2009;82(976):286-290. [CrossRef] [PubMed]
 

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Tables

References

Nadolski GJ, Itkin M. Thoracic duct embolization for nontraumatic chylous effusion: experience in 34 patients. Chest. 2013;143(1):158-163.
 
Itkin M, Swe NM, Shapiro SE, Shrager JB. Spontaneous chylopericardium: delineation of the underlying anatomic pathology by CT lymphangiography. Ann Thorac Surg. 2009;87(5):1595-1597. [CrossRef] [PubMed]
 
Okuda I, Udagawa H, Takahashi J, Yamase H, Kohno T, Nakajima Y. Magnetic resonance-thoracic ductography: imaging aid for thoracic surgery and thoracic duct depiction based on embryological considerations. Gen Thorac Cardiovasc Surg. 2009;57(12):640-646. [CrossRef] [PubMed]
 
Nadolski GJ, Itkin M. Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization. J Vasc Interv Radiol. 2012;23(5):613-616. [CrossRef] [PubMed]
 
Matsumoto T, Yamagami T, Kato T, et al. The effectiveness of lymphangiography as a treatment method for various chyle leakages. Br J Radiol. 2009;82(976):286-290. [CrossRef] [PubMed]
 
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