SPR: Thoracic duct embolization has potential for pediatrics

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BOSTON--Thoracic duct embolization (TDE) is a promising new radiology (IR) technique in children with intractable thoracic chylous drainage, said Marc. S. Keller, MD, from the department of radiology at the Children’s Hospital of Philadelphia, during an interventional scientific paper session at the Society for Pediatric Radiology (SPR) annual conference on Thursday.

Keller and his colleagues established that the treatment of TDE in children can be more complicated than in adults and the same treatment methods for adults may be ineffective in children. Noting several possible treatment options, Keller said that cardiac surgery may injure the thoracic duct in children and thoracic duct ligation could leave some children tethered to hospital care with ongoing fluid, protein and lymphocyte losses, along with a risk of sepsis.

Mentioning several reports and experiences in adult literature in regard to TDE, Keller and his researchers speculated that TDE would possibly be an effective treatment for child patients as well for the obstruction and re-routing of lymphatic flow to alleviate ongoing intractable pleural and pericardial chylous drainage.

The researchers recruited four patients who were referred by cardiac intensivists for their study. One patient was a young adult presenting with intractable chylous ascites, and the remaining three patients consisted of infants with persistant intrathoracic accumulations requiring tubes. After informed consent was collected from the young adult and the parents of the infants, diagnositic lymphography was performed initially using either an ionized oil or a water soluble contrast in a safe manner based upon the presence or absence of a right to left shunt, explained the authors.

Once the thoracic duct was imaged and a treatable condition was established, transhepatic access to the upper abdominal thoracic duct was attempted after the patient was administered general anaesthesia.  If access was achieved and the study confirmed a treatable condition, TDE was performed with coils or NBCA glue, they wrote.

In total, six procedures were completed in the four patients. It was discovered by the study that the young adult with a failing fontan did not have a ductal leak and the researchers determined that his ascites was a result of cirrhosis.

Within the three infants, Keller and colleagues said that one infant immediately ceased all drainage after the TDE treatment method and tubes were removed the following day. The second infant immediately ceased all left pleural drainage, which allowed for the removal of one tube.  The right area was tried to increase the embolization, but was found to be unsuccessful. However, Keller noted that despite this attempt, “drainage magically stopped” after a few weeks and the tubes were removed. The third infant underwent two unsuccessful attempts to cannulate the ducts, but eventually succumbed to complication of the intractable chylous leak.

While Keller noted that further study regarding TDE in children is warranted, he explained that intractable thoracic chylous drainage is a rare condition and therefore hard for physicians to achieve a great deal of experience. However, he and his colleagues have utilized this method in other patients over the course of the past year, in addition to the aforementioned infant cases.

“The results and successes of the treatment, whether they are for one day, one week or one month after the procedure are very dramatic and extremely gratifying,” said Keller.