LymphangiographyLymphangiography

Accession 104300Accession 104300

Erica Fields, DVMErica Fields, DVM

Andie CaudillAndie Caudill

3 year old SF mixed breed3 year old SF mixed breedChylothorax diagnosed in March 2007 Chylothorax diagnosed in March 2007

(appx 18 mos prior to this study) (appx 18 mos prior to this study) History of coughing since adoption in History of coughing since adoption in

May 2006May 2006No other causes for chylothorax were No other causes for chylothorax were

identifiedidentifiedLymphangiography requested Lymphangiography requested

Fossum, et al. 2004Fossum, et al. 2004

ChyleChyle

Milky fluid absorbed by intestinal Milky fluid absorbed by intestinal lactealslacteals

Lymph and chylomicrons Lymph and chylomicrons (triglycerides)(triglycerides)

Normal drainage through abdominal Normal drainage through abdominal lymphatics, cisterna chyli, thoracic lymphatics, cisterna chyli, thoracic duct, into venous circulation near duct, into venous circulation near heartheart

Fossum, et al. 2004Fossum, et al. 2004

ChylothoraxChylothorax

Accumulation of chyle in pleural spaceAccumulation of chyle in pleural space Reasons for chylothorax:Reasons for chylothorax:

Heart disease (cardiomyopathy, heartworms, Heart disease (cardiomyopathy, heartworms, pericardial effusion, Tetralogy, tricuspid pericardial effusion, Tetralogy, tricuspid dysplasia, cor triatriatum dexter)dysplasia, cor triatriatum dexter)

Cranial mediastinal masses (thymoma, Cranial mediastinal masses (thymoma, lymphoma)lymphoma)

Venous thrombi/massesVenous thrombi/masses Fungal granulomaFungal granuloma Congenital thoracic duct anomalyCongenital thoracic duct anomaly

Pleural fluid

Naganobu, et al. 2006Naganobu, et al. 2006

Lymphangiography-Lymphangiography-techniquestechniques

Radiographic techniquesRadiographic techniquesMesenteric lymph node injectionMesenteric lymph node injectionPopliteal lymph node injectionPopliteal lymph node injectionCan mix methylene blue with contrast Can mix methylene blue with contrast

mediummediumCT techniquesCT techniques

Mesenteric lymph node injectionMesenteric lymph node injectionWE DO popliteal injection (not in lit yet)WE DO popliteal injection (not in lit yet)

Esterline, et al. 2005Esterline, et al. 2005

Normal thoracic duct Normal thoracic duct anatomyanatomy

Multiple branches with anastomosesMultiple branches with anastomosesMediastinal—ventral to azygous vein, Mediastinal—ventral to azygous vein,

dorsal to aortadorsal to aortaThin-walled, may be hard to seeThin-walled, may be hard to see Inserts on left external jugular, left Inserts on left external jugular, left

subclavian, left brachiocephalic, subclavian, left brachiocephalic, azygous, cranial vena cava, othersazygous, cranial vena cava, others

Abdominal lymphatics

Ligation of cisterna chyli

Thoracic duct branch

Thoracic duct branch

Extravasated contrast medium

Thoracic duct

Esterline, et al. 2005Esterline, et al. 2005

Surgical OptionsSurgical Options

Thoracic duct ligationThoracic duct ligationEn bloc (13/14 cadavers)En bloc (13/14 cadavers)Dissection (53% success)Dissection (53% success)ThoracoscopicThoracoscopic

Pericardectomy (98% success w/TDL)Pericardectomy (98% success w/TDL)Pleuroperitoneal shunting (palliative)Pleuroperitoneal shunting (palliative)Thoracic duct embolizationThoracic duct embolizationCisterna chyli ablation/ligationCisterna chyli ablation/ligation

McDonald, et al. 2008McDonald, et al. 2008

Thoracic Duct LigationThoracic Duct Ligation

Dissection method—aided by Dissection method—aided by methylene bluemethylene blue

En bloc resection—all tissues dorsal En bloc resection—all tissues dorsal to aorta (includes azygous vein!)to aorta (includes azygous vein!)Try to catch all branchesTry to catch all branches13/14 cadavers successful13/14 cadavers successful

Fossum, et al. 2004Fossum, et al. 2004

PericardectomyPericardectomy

Increased flow throughthoracic duct

Chylothorax results inpericardial thickening,

further increasing right sided venous

pressure

Increased right sided Venous pressure

Back to Andie…Back to Andie…

Right 9Right 9thth ICS thoracotomy ICS thoracotomyThoracic duct was isolated and ligatedThoracic duct was isolated and ligatedMethylene blue injection of mesenteric Methylene blue injection of mesenteric

LN post-ligation to confirm (30 min)LN post-ligation to confirm (30 min)Sub-phrenic pericardectomy Sub-phrenic pericardectomy Recovered well, went home 4 d later, Recovered well, went home 4 d later,

doing well! doing well!

ReferencesReferences Esterline ML, Radlinsky MG, Biller DS, Mason DE, Roush JK, Esterline ML, Radlinsky MG, Biller DS, Mason DE, Roush JK,

Cash WC. 2005. Comparison of radiographic and Cash WC. 2005. Comparison of radiographic and computed tomography lymphangiography for identification computed tomography lymphangiography for identification of the canine thoracic duct. Veterinary Radiology and of the canine thoracic duct. Veterinary Radiology and Ultrasound; 46 (5): 391-395. Ultrasound; 46 (5): 391-395.

Fossum TW, Mertens MM, Miller MW, Peacock JT, Saunders Fossum TW, Mertens MM, Miller MW, Peacock JT, Saunders A, Gordon S, Pahl G, Makarski LA, Bahr A, Hobson PH. A, Gordon S, Pahl G, Makarski LA, Bahr A, Hobson PH. 2004. Thoracic duct ligation and pericardectomy for 2004. Thoracic duct ligation and pericardectomy for treatment of idiopathic chylothorax. Journal of Veterinary treatment of idiopathic chylothorax. Journal of Veterinary Internal Medicine; 18: 307-310.Internal Medicine; 18: 307-310.

MacDonald NJ, Noble PM, Burrow RD. Efficacy of en bloc MacDonald NJ, Noble PM, Burrow RD. Efficacy of en bloc ligation of the thoracic duct: descriptive study in 14 dogs. ligation of the thoracic duct: descriptive study in 14 dogs. 2008. Veterinary Surgery; 37: 696-701.2008. Veterinary Surgery; 37: 696-701.

Naganobu K, Ohigashi Y, Akiyoshi T, Hagio M, Miyamoto T, Naganobu K, Ohigashi Y, Akiyoshi T, Hagio M, Miyamoto T, Yamaguchi T. 2006. Lymphography of the thoracic duct by Yamaguchi T. 2006. Lymphography of the thoracic duct by percutaneous injection of iohexol into the popliteal lymph percutaneous injection of iohexol into the popliteal lymph node: experimental study and clinical application. node: experimental study and clinical application. Veterinary Surgery; 35: 377-381. Veterinary Surgery; 35: 377-381.