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Lymphangiography

Lymphangiography. Accession 104300 Erica Fields, DVM. Andie Caudill. 3 year old SF mixed breed Chylothorax diagnosed in March 2007 (appx 18 mos prior to this study) History of coughing since adoption in May 2006 No other causes for chylothorax were identified Lymphangiography requested.

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Lymphangiography

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  1. Lymphangiography Accession 104300 Erica Fields, DVM

  2. Andie Caudill • 3 year old SF mixed breed • Chylothorax diagnosed in March 2007 (appx 18 mos prior to this study) • History of coughing since adoption in May 2006 • No other causes for chylothorax were identified • Lymphangiography requested

  3. Chyle • Milky fluid absorbed by intestinal lacteals • Lymph and chylomicrons (triglycerides) • Normal drainage through abdominal lymphatics, cisterna chyli, thoracic duct, into venous circulation near heart Fossum, et al. 2004

  4. Chylothorax • Accumulation of chyle in pleural space • Reasons for chylothorax: • Heart disease (cardiomyopathy, heartworms, pericardial effusion, Tetralogy, tricuspid dysplasia, cor triatriatum dexter) • Cranial mediastinal masses (thymoma, lymphoma) • Venous thrombi/masses • Fungal granuloma • Congenital thoracic duct anomaly Fossum, et al. 2004

  5. Pleural fluid

  6. Lymphangiography-techniques • Radiographic techniques • Mesenteric lymph node injection • Popliteal lymph node injection • Can mix methylene blue with contrast medium • CT techniques • Mesenteric lymph node injection • WE DO popliteal injection (not in lit yet) Naganobu, et al. 2006

  7. Normal thoracic duct anatomy • Multiple branches with anastomoses • Mediastinal—ventral to azygous vein, dorsal to aorta • Thin-walled, may be hard to see • Inserts on left external jugular, left subclavian, left brachiocephalic, azygous, cranial vena cava, others Esterline, et al. 2005

  8. Ligation of cisterna chyli Thoracic duct branch Abdominal lymphatics

  9. Thoracic duct branch

  10. Thoracic duct Extravasated contrast medium

  11. Surgical Options • Thoracic duct ligation • En bloc (13/14 cadavers) • Dissection (53% success) • Thoracoscopic • Pericardectomy (98% success w/TDL) • Pleuroperitoneal shunting (palliative) • Thoracic duct embolization • Cisterna chyli ablation/ligation Esterline, et al. 2005

  12. Thoracic Duct Ligation • Dissection method—aided by methylene blue • En bloc resection—all tissues dorsal to aorta (includes azygous vein!) • Try to catch all branches • 13/14 cadavers successful McDonald, et al. 2008

  13. Pericardectomy Fossum, et al. 2004

  14. Back to Andie… • Right 9th ICS thoracotomy • Thoracic duct was isolated and ligated • Methylene blue injection of mesenteric LN post-ligation to confirm (30 min) • Sub-phrenic pericardectomy • Recovered well, went home 4 d later, doing well!

  15. References • Esterline ML, Radlinsky MG, Biller DS, Mason DE, Roush JK, Cash WC. 2005. Comparison of radiographic and computed tomography lymphangiography for identification of the canine thoracic duct. Veterinary Radiology and Ultrasound; 46 (5): 391-395. • Fossum TW, Mertens MM, Miller MW, Peacock JT, Saunders A, Gordon S, Pahl G, Makarski LA, Bahr A, Hobson PH. 2004. Thoracic duct ligation and pericardectomy for treatment of idiopathic chylothorax. Journal of Veterinary Internal Medicine; 18: 307-310. • MacDonald NJ, Noble PM, Burrow RD. Efficacy of en bloc ligation of the thoracic duct: descriptive study in 14 dogs. 2008. Veterinary Surgery; 37: 696-701. • Naganobu K, Ohigashi Y, Akiyoshi T, Hagio M, Miyamoto T, Yamaguchi T. 2006. Lymphography of the thoracic duct by percutaneous injection of iohexol into the popliteal lymph node: experimental study and clinical application. Veterinary Surgery; 35: 377-381.

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