- Case report
- Open Access
- Open Peer Review
Chylothorax following endovascular aortic repair with subclavian revascularization - a case report
© Hsu et al.; licensee BioMed Central Ltd. 2014
- Received: 2 June 2014
- Accepted: 26 September 2014
- Published: 1 November 2014
Thoracic endovascular aortic repair (TEVAR) is becoming increasingly popular due to reduced perioperative morbidity and mortality compared with open surgical repair. However, complications can occur when the left subclavian artery is involved. When performing TEVAR with left carotid-subclavian artery bypass the stent graft will extend to the left common carotid artery. We herein present the case of a patient with a type B aortic dissection with an acute intramural hematoma. Chylothorax was noted after TEVAR with left carotid-subclavian artery bypass.
A 66-year-old female with descending aortic dissection that was treated conservatively developed the sudden onset of back pain. Aortic computed tomography (CT) showed a type B intramural aortic dissection. TEVAR with left carotid-subclavian artery bypass was performed. Left chylothorax was noted after surgery with drainage of up to 1000 mL per day. Conservative management was ineffective. Thoracoscopic ligation of the thoracic duct was performed with resolution of the chyle leakage.
Chylothorax can occur after TEVAR with carotid-subclavian artery bypass and likely results from thoracic duct injury. When conservative treatments fail, ligation of the thoracic duct cephalad to aortic hiatus can resolve the chyle leakage.
- Aortic Dissection
- Stent Graft
- Thoracic Duct
- Left Subclavian Artery
- Thoracoscopic Surgery
Thoracic endovascular aortic repair (TEVAR) is becoming increasingly popular due to reduced perioperative morbidity and mortality compared with open surgical repair . We herein present the case of a patient with a type B aortic dissection with an acute intramural hematoma. Left chylothorax was noted after TEVAR with left carotid-subclavian artery bypass.
TEVAR was developed to address degenerative aneurysmal disease including aortic dissection, aortic transection, intramural hematoma, and penetrating aortic ulcer ,. When treating proximal lesions, the left subclavian artery will be covered and the stent graft will extend to the left common carotid artery ,. The principal branches arising from the subclavian artery are the thyrocervical trunk, which gives rise to the ascending and transverse cervical arteries, the suprascapular artery, and the inferior thyroid artery; the costocervical trunk; the internal mammary artery; and the vertebral artery. Thus, there are many potential complications following subclavian artery occlusion including upper extremity ischemia, stroke, spinal cord ischemia, and myocardial ischemia -. Carotid-subclavian artery bypass was designed to resolve subclavian artery occlusion. Unfortunately, many complications following carotid-subclavian artery bypass can occur including vocal cord paralysis, phrenic nerve palsy, vagus nerve injury, bleeding, thoracic duct injury, lymphocele, and sympathetic nerve injury resulting in Horner syndrome -.
Chylothorax results from disruption or obstruction of the thoracic duct and subsequent leakage of chyle (lymphatic fluid of intestinal origin) into the pleural space . The pleural effusion typically has a high triglyceride concentration, and often a turbid or milky white appearance. The etiologies of chylothorax can be categorized as nontraumatic or traumatic ,. Malignancy is the leading cause of nontraumatic chylothorax. Surgical procedures in the area of the thoracic duct or nearby structures can result in disruption of the thoracic duct or shearing of lymphatic tributaries, and account for the majority of traumatic chylothorax cases.
The thoracic duct is the largest lymph vessel, and extends from the second lumbar vertebra to the root of the neck. It enters the thorax through the aortic opening of the diaphragm between the aorta and the azygos vein. At the level of the fifth thoracic vertebra, the thoracic duct inclines towards the left side to enter the superior mediastinum and ascends behind the aortic arch and the thoracic part of the left subclavian artery, between the left side of the esophagus and the left pleura, to the thoracic inlet. In the neck, the arch of the thoracic duct rises 3 or 4 cm (up to 6 cm) above the clavicle and curves anterior to the vertebral artery and vein, the left sympathetic trunk, the thyrocervical artery or its branches, the left phrenic nerve, and the medial border of scalenus anterior. It then passes posterior to the left common carotid artery, vagus nerve, and internal jugular vein, and finally ends by opening into the angle of the junction of the left subclavian vein and the internal jugular vein.
Shimado and Sato reported four types of thoracic duct terminations . Type A (38%) terminated at the venous angle, type B (27%) at the terminal end of the internal jugular vein, type C (28%) at the terminal end of the external jugular vein, and type D (7%) was described as a complex branching pattern. Each type was further subdivided depending upon the number of terminal branches, some of which drained directly into the subclavian vein. The termination is usually (87.5 to 100% of the time) within 1 cm of the venous angle . Langford and Daudia reported 21 ducts (87.5%) terminated as a single vessel, two ducts (8.33%) showed a bifid termination, and one duct (4.2%) had three terminal branches. Five thoracic ducts (20.8%) showed branching and re-anastamosing patterns prior to their termination, irrespective of the number of terminal branches . The presence of such complex patterns is an additional risk factor for iatrogenic trauma, and a potent source of confusion when faced with the surgical management of a chyle leak.
When TEVAR is performed at the proximal portion of the aorta, as in our patient, the left subclavian artery will be covered by the membrane portion of the stent graft and the subclavian artery will be occluded. Left carotid-subclavian artery bypass is performed at the same time. The thoracic duct drains chyle into the blood stream via the left subclavian vein. It is possible to injury the thoracic duct when performing the bypass, to result in chyle leakage. We believe this is what occurred in our patient.
For patients with traumatic chylothorax, initial conservative management rather than surgical intervention is recommended. Conservative management includes chest tube drainage, and either bowel rest with total parenteral nutrition (TPN) or a high protein-reduced fat diet with medium chain triglyceride (MCT) supplementation ,. Attention to fluid and electrolyte management, nutrition, and the daily volume of pleural drainage are necessary. If the amount of chylous fluid drainage is >1 L per day through the chest tube, early thoracic duct ligation is recommended. Patients draining more than 1 L/day are unlikely to respond to conservative therapy, and usually require surgical intervention within 5 to 7 days . In contrast, patients with?<?500 mL of chest tube drainage in the first 24 hours after cessation of oral intake and initiation of TPN tend to improve with conservative management . If pleural drainage continues after 14 days of conservative therapy, some studies recommand thoracic duct ligation as a longer duration of conservative therapy is associated with nutritional depletion and high mortality rates ,.
The advent of thoracoscopic surgery over the last decade has changed the approach to the management of a number of chest diseases. Because of fewer and smaller incisions, thoracoscopic surgery is associated with less pain, faster postoperative recovery, shortened hospital stay, and decreased long-term morbidity. Intrathoracic postoperative adhesions are milder with thoracoscopic surgery compared to open thoracotomy. Thoracoscopic surgery has the advantage of shortened recuperation time and decreased blood loss -. Because of the benefits associated with thoracoscopic surgery, we utilized a thoracoscopic approach and the thoracic duct was reached through the right pleural cavity, and ligated just cephalad to the aortic hiatus. Postoperatively, there was no chylothorax recurrence in our patient during the 3 months follow-up.
Subclavian revascularization procedures can be performed with relatively low risk, and complications are rare. Chylothorax can occur after TEVAR with carotid-subclavian artery bypass from neck exploration and likely results from thoracic duct injury. When conservative treatments fail, ligation of the thoracic duct cephalad to aortic hiatus by thoracoscopic surgery can resolve the chyle leakage.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
YJH carried out the manuscript. PRC collected references. YSL took the pictures of the case report. HYF performed the operation of the patient. CKC coordinated all authors and revised the manuscript. All authors read and approved the final manuscript.
Thanks all medical colleagues to participate in the care of this patient. They made the treatment becoming success.
- Murad MH, Rizvi AZ, Malgor R, Carey J, Alkatib AA, Erwin PJ, Lee WA, Fairman RM: Comparative effectiveness of the treatments for thoracic aortic transection [corrected]. J Vasc Surg. 2011, 53: 193-199. 10.1016/j.jvs.2010.08.028. e191-121View ArticlePubMedGoogle Scholar
- Clough RE, Mani K, Lyons OT, Bell RE, Zayed HA, Waltham M, Carrell TW, Taylor PR: Endovascular treatment of acute aortic syndrome. J Vasc Surg. 2011, 54: 1580-1587. 10.1016/j.jvs.2011.07.034.View ArticlePubMedGoogle Scholar
- Buth J, Harris PL, Hobo R, van Eps R, Cuypers P, Duijm L, Tielbeek X: Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. a study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg. 2007, 46: 1103-1110. 10.1016/j.jvs.2007.08.020. discussion 1110-1101View ArticlePubMedGoogle Scholar
- Woo EY, Carpenter JP, Jackson BM, Pochettino A, Bavaria JE, Szeto WY, Fairman RM: Left subclavian artery coverage during thoracic endovascular aortic repair: a single-center experience. J Vasc Surg. 2008, 48: 555-560. 10.1016/j.jvs.2008.03.060.View ArticlePubMedGoogle Scholar
- Peterson BG, Eskandari MK, Gleason TG, Morasch MD: Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg. 2006, 43: 433-439. 10.1016/j.jvs.2005.11.049.View ArticlePubMedGoogle Scholar
- Feezor RJ, Martin TD, Hess PJ, Klodell CT, Beaver TM, Huber TS, Seeger JM, Lee WA: Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR). J Endovasc Ther. 2007, 14: 568-573. 10.1583/1545-1550(2007)14[568:RFFPSD]2.0.CO;2.View ArticlePubMedGoogle Scholar
- Feezor RJ, Lee WA: Management of the left subclavian artery during TEVAR. Semin Vasc Surg. 2009, 22: 159-164. 10.1053/j.semvascsurg.2009.07.007.View ArticlePubMedGoogle Scholar
- Morasch MD, Peterson B: Subclavian artery transposition and bypass techniques for use with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg. 2006, 43 (Suppl A): 73A-77A. 10.1016/j.jvs.2005.10.060.View ArticlePubMedGoogle Scholar
- Cina CS, Safar HA, Lagana A, Arena G, Clase CM: Subclavian carotid transposition and bypass grafting: consecutive cohort study and systematic review. J Vasc Surg. 2002, 35: 422-429. 10.1067/mva.2002.120035.View ArticlePubMedGoogle Scholar
- Berguer R, Morasch MD, Kline RA, Kazmers A, Friedland MS: Cervical reconstruction of the supra-aortic trunks: a 16-year experience. J Vasc Surg. 1999, 29: 239-246. 10.1016/S0741-5214(99)70377-0. discussion 246-238View ArticlePubMedGoogle Scholar
- Hillerdal G: Chylothorax and pseudochylothorax. Eur Respir J. 1997, 10: 1157-1162. 10.1183/09031936.97.10051157.View ArticlePubMedGoogle Scholar
- Valentine VG, Raffin TA: The management of chylothorax. Chest. 1992, 102: 586-591. 10.1378/chest.102.2.586.View ArticlePubMedGoogle Scholar
- Doerr CH, Allen MS, Nichols FC, Ryu JH: Etiology of chylothorax in 203 patients. Mayo Clin Proc. 2005, 80: 867-870. 10.4065/80.7.867.View ArticlePubMedGoogle Scholar
- Shimada K, Sato I: Morphological and histological analysis of the thoracic duct at the jugulo-subclavian junction in Japanese cadavers. Clin Anat. 1997, 10: 163-172. 10.1002/(SICI)1098-2353(1997)10:3<163::AID-CA2>3.0.CO;2-V.View ArticlePubMedGoogle Scholar
- Van Pernis PA: Variations of the thoracic duct. Surgery. 1949, 26: 806-809.PubMedGoogle Scholar
- Langford RJ, Daudia AT, Malins TJ: A morphological study of the thoracic duct at the jugulo-subclavian junction. J Craniomaxillofac Surg. 1999, 27: 100-104. 10.1016/S1010-5182(99)80021-3.View ArticlePubMedGoogle Scholar
- Maldonado F, Cartin-Ceba R, Hawkins FJ, Ryu JH: Medical and surgical management of chylothorax and associated outcomes. Am J Med Sci. 2010, 339: 314-318.View ArticlePubMedGoogle Scholar
- Zabeck H, Muley T, Dienemann H, Hoffmann H: Management of chylothorax in adults: when is surgery indicated?. Thorac Cardiovasc Surg. 2011, 59: 243-246. 10.1055/s-0030-1250374.View ArticlePubMedGoogle Scholar
- Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC: Postoperative chylothorax. J Thorac Cardiovasc Surg. 1996, 112: 1361-1365. 10.1016/S0022-5223(96)70152-6. discussion 1365-1366View ArticlePubMedGoogle Scholar
- Shimizu K, Yoshida J, Nishimura M, Takamochi K, Nakahara R, Nagai K: Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer. J Thorac Cardiovasc Surg. 2002, 124: 499-502. 10.1067/mtc.2002.124386.View ArticlePubMedGoogle Scholar
- Fahimi H, Casselman FP, Mariani MA, van Boven WJ, Knaepen PJ, van Swieten HA: Current management of postoperative chylothorax. Ann Thorac Surg. 2001, 71: 448-450. 10.1016/S0003-4975(00)02033-6. discussion 450-441View ArticlePubMedGoogle Scholar
- Huggins JT: Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med. 2010, 31: 743-750. 10.1055/s-0030-1269834.View ArticlePubMedGoogle Scholar
- Kumar S, Kumar A, Pawar DK: Thoracoscopic management of thoracic duct injury: Is there a place for conservatism?. J Postgrad Med. 2004, 50: 57-59.PubMedGoogle Scholar
- Inderbitzi RG, Krebs T, Stirneman T, Ulrich A: Treatment of postoperative chylothorax by fibrin glue application under thoracoscopic view with use of local anesthesia. J Thorac Cardiovasc Surg. 1992, 104: 209-210.PubMedGoogle Scholar
- Wurnig PN, Hollaus PH, Ohtsuka T, Flege JB, Wolf RK: Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax. Ann Thorac Surg. 2000, 70: 1662-1665. 10.1016/S0003-4975(00)01921-4.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.