Thoracic duct embolization used as a generic term includes different types of image-guided accesses to the TD: The frequently used percutaneous antegrade access, usually transperitoneal and quite rarely also retroperitoneal (Pamarthi et al. 2014; Itkin et al. 2010; Nadolski and Itkin 2013), and the less frequently used retrograde access, usually transvenous, rarely directly transcutaneous (Pamarthi et al. 2014; Mittleider et al. 2008; Koike et al. 2013).
The transperitoneal antegrade access carries the risk of peritoneal organ penetration including arteries, the biliary system and the intestine with an estimated morbidity rate of about 10% (Pieper 2018). Venous, lymphatic, biliary and other complications, including pulmonary emboli, pancreatitis and peritonitis have been described (Schild and Pieper 2020) and are related to the transabdominal route of the needle and microcatheter.
The transvenous retrograde access may technically be considered more challenging, as it requires retrograde intubation of the lymphovenous junction with the ostial valve as well as the insertion of a microcatheter possibly the long way down of the whole TD including all retrograde valve-passages (Koike et al. 2013). In cases of complete transection of the TD, a retrograde approach may not be expedient because it might be impossible to cross the lesion and enter the proximal section of the TD (Pieper and Schild 2015). Apart from that it avoids possible injuries of intraperitoneal organs and structures and therefore is the substantially less invasive and more physiologic approach to the TD. In addition, the retrograde transvenous access is associated with much less discomfort for the patient and so, unlike the transabdominal access, does not require analgosedation or general anaesthesia.
Retrograde transvenous TDE was first described by Mittleider et al. in 2008 (Mittleider et al. 2008). In contrast to antegrade trans- or retroperitoneal TDE, there are only very few case reports on retrograde transvenous TDE (Kariya et al. 2018; Mittleider et al. 2008; Koike et al. 2013; Chung et al. 2015). In the meta-analysis of Kim et al. (Kim et al. 2018) of 9 publications with 310 cases of TDE technical success was achieved in 62.9%. However, only 2 of 310 (0,6%) TDEs have been performed with a retrograde transvenous approach. Kim et al. come to the conclusion, that TDE is associated with high clinical success and low technical success. The recent publication of Kariya et al. about „transvenous retrograde thoracic ductography“, which is technically comparable to retrograde transvenous TDE, reports a technical success rate of 61.5% in 13 cases with significantly higher rates in patients with the so-called simple type (80%) than with the so-called plexiform type of the cervical part of the TD. However, the catheter could be inserted to the cisterna chyli in only 46.2% of patients. Kariya states „this technique is safe and does not require any special devices or instruments “(Kariya et al. 2018).
In the case we present, catheterisation of the TD was quite challenging mainly due to a very small calibre of the TD. The probable reason for this was poor filling of the distal TD due to the large pro-ximal leakage, as expected in a high-output situation. This specific problem of the retrograde approach has been addressed theoretically in a publication by Chung et al. (Chung et al. 2015) and is confirmed by our case. During our intervention minimal injuries of the TD with subsequent contrast medium extravasation due to guidewire-manipulations occurred. We continued the procedure being convinced that such incidents will not cause complications, in particular as long as the TD is embolized afterwards.
A literature search in the databases PubMed and LIVIVO using the terms “laparoscopic fundoplication AND chylous ascites” and “laparoscopic fundoplication AND chyloperitoneum” was conducted. We found 8 publications with 9 corresponding cases. Only one of these was treated with TDE, however with the usual antegrade transabdominal approach and direct glue embolization via the needle without cannulation of the TD (Hwang et al. 2012). Thus, to the best of our knowledge our case is the first one reported of chylous ascites following fundoplication effectively treated with retrograde transvenous TDE.
