Central Lymphatic Imaging in Adults with Spontaneous Chyluria.

Purpose: Chyluria is a rare condition primarily prevalent in developing countries in tropical regions. In chyluria, there exists the communication between lymphatic vessels and the urinary tract, but the specific mechanism of this communication remains undocumented. The objective of this study was to assess the morphology of the main lymphatic vessels including the uro-lymphatic fistula, the thoracic duct using Magnetic Resonance Lymphangiography (MRL) and Intranodal Lymphangiography (IL). Materials and Methods: A retrospective study spanning five years, from January 2020 to January 2024, included 43 patients diagnosed with chyluria through cystoscopy and quantitative urine testing for triglycerides. These patients underwent MRL and then IL for uro-lymphatic fistula embolization. Results: The study involved 43 patients with an average age of 66.1 ± 19.5 years, with a male-to-female ratio of 1:2. Uro-lymphatic fistula occurred predominantly in the left kidney (72.1%), followed by the right kidney (20.9%), and both sides (7%). MRL imaging showed the thoracic duct in 100% of cases but visualized only 84.5% of the uro-lymphatic fistulas. In contrast, IL imaging showed the thoracic duct in 51.5% of patients but visualized uro-lymphatic fistulas in 100% of cases. In the procedure of IL, the average visualization time of the thoracic duct was 45 minutes, with a range of 35 to 69 minutes. Conclusion: MRL and IL complement each other in diagnosing the main lymphatic vessels in chyluria patients. The observed circulatory stasis in the thoracic duct supports the hypothesis that it contributes to increased pressure in the thoracic duct and the formation uro-lymphatic fistula as collateral circulations.

Minimally Invasive Treatment of Chyle Leak After Thyroidectomy and Cervical Lymph Node Dissection in Patients with Thyroid Carcinoma: Results of a Study Involving 36 Patients.

Objective: Chyle leak (CL) after head and neck surgery is a rare but well-known complication. In patients with high-output leakage, the treatment can be complicated. This study aims to report on a recent innovation in lymphatic intervention for treating such patients. Materials and Methods: A retrospective review of 36 patients with chyle leak after neck surgery for thyroid cancer was conducted to assess the efficacy of percutaneous lymphatic embolization and thoracic duct (TD) disruption. Results: Antegrade catheterization of the thoracic duct was achieved in 31 of 36 patients (86.1%). Therefore, embolization of the thoracic duct and thoracic duct branches was performed in 26 and 5 patients, respectively. In 5 cases of unsuccessful antegrade catheterization into the thoracic duct, transcervical access embolization was performed in 2 patients, and TD disruption (TDD) was performed in 3 patients. The pooled overall technical success rate of lymphatic embolization was 33/36 patients (91.7%). One patient who underwent thoracic duct embolization (TDE) with technical success (1/33 patients) but clinical failure had additional treatment directly sclerosing the TD under computed tomography scan. Cervical fluid collection sclerotherapy was done in 7 patients as an additional treatment. Resolution of the chyle leak after procedures was observed in all patients (100%). The mean time to resolution was 3 days (1-7 days). There was no complication intra and after procedures. Conclusion: TDE, selective TD branches embolization and TDD are safe and effective minimally invasive treatments for CL post-surgery for thyroid carcinoma. Sclerosing cervical fluid collection contributes to clinical success.

Occlusion of thoracic duct stent resulting in recurrent chyluria: role of renal-lymphatic fistula embolization.

BACKGROUND: Thoracic duct (TD) stenting is considered a treatment option for certain pathological conditions caused by TD obstruction, such as chyluria. Several studies have reported on the efficacy of TD stent treatment for both obstructive and leakage condition of TD, but few have evaluated the stent patency. This report aims to describe the patency of TD stent and the effectiveness of renal-lymphatic fistula embolization in the treatment of chyluria. CASE PRESENTATION: We report a case of chyluria treated by TD stent previously, stent was placed at the TD venous junction four months before the symptoms recurred. At the second intervention we found the stent was obstructed by debris. We recanalized the stent and successfully catheterised the microcatheter through the stent retrograde into the TD then into the renal-lymphatic fistula branch. After embolization of that abnormal branch, the recurrent chyluria was treated and no further episode of chyluria was occurred during 12 months follow up. CONCLUSION: Stent in the TD may be occluded by debris. Embolization of renal-lymphatic fistula might be the most important treatment for spontaneous chyluria.

Thoracic duct stent treatment for chyle leak after nephrectomy.

Chyle leak is a rare and serious condition caused by damaged lymphatic vessels. It can occur after retroperitoneal surgery involving extensive lymphadenectomy for kidney cancer. Besides lymphatic channel damage, the obstruction of the thoracic duct worsens the leakage. Managing patients with thoracic duct obstruction and postsurgical chyle leakage is challenging due to limited data on how to handle this condition. In this case report, a 28-year-old female patient underwent left nephrectomy for left kidney cancer. Three days after the surgery, milky fluid drained from the left renal fossa. Conservative treatment failed, and further examination through magnetic resonance lymphangiography revealed the absence of the thoracic duct and contrast extravasation at the left renal fossa. Lymphangiography confirmed distal thoracic duct obstruction. The patient's condition was successfully managed by using thoracic duct stenting. This report contributes to the understanding that thoracic duct obstruction can lead to lymphatic collateral circulation within the abdomen, thereby increasing the risk of postoperative chylous leak.

A 44-Year-Old Man With Chronic Lower Chest Pain.

CASE PRESENTATION: A 44-year-old man was admitted to the hospital because of chest pain located around his lower thoracic spine with deep inspiration for 6 months. He denied having any cough, dyspnea, fever, or weight loss. He had no history of trauma. He was a nonsmoker, without any other personal or familial medical history. He had been examined at some hospitals, but the cause had not been determined.

Chylous ascites after donor nephrectomy: MR lymphangiography and lymphatic embolization treatment.

Chylous ascites results from the leakage of lipid-rich lymphatic fluid into the peritoneal cavity. Most postsurgical chylous ascites occurs following abdominal aortic surgeries. However, rarely, it is a complication after laparoscopic donor nephrectomy. Postsurgical chylous ascites are often managed with conservative treatment or surgery, but lymphatic embolization may be required. Here, we presented a 45-year-old male patient who was referred for abdominal distension for 1 week after left donor nephrectomy. The drain fluid was milky and fluid analysis revealed high concentrations of triglycerides and chylomicron, confirming diagnosis of chylous ascites. The patient was treated with conservative therapy including a low-fat diet and fluid drainage but continued to have high draining output (up to 1500-2000 mL/24 h). He underwent magnetic resonance lymphangiography and intranodal lymphangiography, revealing extravasation of contrast into the abdomen and the left renal fossa. We embolized the interstitial lymphatic of the left retroperitoneal and lymphatic vessels leak. The patient was discharged from hospital at the fifth day after intervention. In this article, we demonstrate lymphatic lesions, the safety, and success of this technique.

Management of chyluria using percutaneous thoracic duct stenting.

BACKGROUND: Thoracic duct stenosis or obstruction is one of the causes of chyluria. Although the diagnosis of chyluria is not difficult, treatment is still challenging. Although there have been no standard guidelines for the treatment of chyluria, interventional techniques now offer minimally invasive treatment options for chyluria such as interstitial lymphatic embolization, ductoplasty with balloon, or thoracic duct stenting. CASE PRESENTATION : Here, we report a case of chyluria due to obstruction of the junction between the thoracic duct and subclavian vein in a 64 -year- old female patient. The patient was treated with balloon plasty for lymphovenous junction obstruction and interstitial lymphatic embolization for chyluria. However, chyluria was recurrent after 6 months so intranodal lymphangiography was performed. Anterograde thoracic duct was accessed through a transabdominal to the cisterna chyli which showed that the thoracic venous junction was re-obstruction. The patient was successfully treated by placing a uncovered drug-eluting stent with the size of 2.5 mm x 15 mm in length for resolving the thoracic occlusion. CONCLUSION: This report demonstrates the feasibility of using thoracic duct stenting in the treatment chyluria due to lymphovenous junction obstruction.

A case report of primary pulmonary artery intimal sarcoma.

Primary pulmonary artery sarcoma is a rare tumor that mimics pulmonary embolism. Patients may present with cough, dyspnea, chest pain, and weight loss. The diagnosis is challenging. Herein, we report a case of 29-year-old female patient who had presented with dyspnea, fatigue for 2 weeks. Computed tomography pulmonary angiography scan suggests pulmonary embolism. We decided to perform surgical embolectomy. The histopathological results, however demonstrated primary pulmonary artery intimal sarcoma. The patient died 1-month post-surgery because of respiratory and circulatory failure.

A 32-Year-Old Man With Dyspnea and Stridor.

CASE PRESENTATION: A 32-year-old man was admitted to the hospital because of dyspnea on exertion for 2 months. Dyspnea occurred in both inspiration and expiration with an associated wheeze that was more pronounced with exertion. He had no other medical history or allergies. The patient was a current one-pack-a-day smoker for the past 5 years. He denied any close personal contact or recent exposure to any patients with active TB. He denied any current symptoms of chest pain, cough, fever, or changes in weight. On a prior admission for similar symptoms, the patient had been diagnosed with asthma and treated with an inhaled corticosteroid/long-acting beta-agonist with no change or improvement in symptoms.

Combination of Lymph Node Embolization and Musculocutaneous Flap Operation for Managing Groin Lymphorrhea.

Lymphorrhea complications are common following femoral exposure for endovascular procedures. In patients unresponsive to either non-operative or operative therapy, treatment can be complicated. A 86-year-old male patient experienced lymphorrhea after stent graft to treat an abdominal aortic aneurysm, and five operative debridement attempts failed. Intranodal lymphangiography revealed leakage points from two lymph nodes directly into the wound, which were resolved by lymph node embolization using glue. Because the wound was large, a pedicled anterolateral thigh flap (ALT) operation was indicated. Percutaneous lymph node embolization combined with ALT operation may be effective for patients with large wounds and high-flow lymphatic leaks.

Percutaneous sclerosing injection to the thoracic duct under CT guidance for cervical chylous leakage post thyroidectomy: A case report.

Chylous leakage after thyroidectomy is rare, and almost all patients with this complication can be treated conservatively. However, in patients with high-flow leakage, treatments can be complicated. In this study, we report a case that was successfully treated by disrupting the thoracic duct using two sessions of percutaneous interventions. The first intervention was a thoracic duct embolization, and the second intervention was a sclerosing injection to the thoracic duct under computed tomography guidance.

A 69-Year-Old Man With Chronic Cough and Recurrent Pneumonia.

CASE PRESENTATION: A 69-year-old man consulted for a 3-day history of fever, wet cough, and yellow-green phlegm. He denied having any dyspnea, chest pain, hemoptysis, swallowing disorders, choke, chills, asthenia, anorexia, or weight loss. He reported a continuous dry cough and three episodes of pneumonia in the past 4 years. He was a nonsmoker, without any other personal or familial medical history. He had no known professional exposure. He was born and lived in Vietnam but had no known contact with TB in his family or workplace. He was never imprisoned or homeless and did never travel abroad.

Flow diverter stent for treatment of cerebral aneurysms: A report of 130 patients with 134 aneurysms.

BACKGROUND: This study aims to report our experience with cerebral aneurysms, which may improve in the treatment with the flow-diverter stent and follow up. METHODS: This study was conducted in a consecutive series of 130 patients. 134 procedures were performed for treating these patients in Hanoi Medical University Hospital and Bach Mai Hospital from January 2012 to April 2017. 143 flow diverter stents (Pipeline, FRED and SILK) were used. Aneurysm morphology, stent patency and cerebral parenchyma before and after intervention were analyzed on images of digital subtraction angiography (DSA), computed tomography (CT) and magnetic resonance (MR). The follow-up data after 3-6 months and 12 months were recorded. RESULTS: In 130 patients (31 men, 99 women), aneurysms of internal carotid artery were mostly common (92.6%), especially in cavernous (35.1%) and in para-ophthalmic (40.3%) segments. 83 cases (61.9%) had wide-neck aneurysms, and 16 cases (11.9%) had multiple aneurysms, and only 5 cases (3.7%) had blister-liked aneurysms. Endovascular treatment was successfully performed at rate of 94.8%. In 3 patients, the stent could not be delivered. Mortality and morbidity rates were 1.5% and 3.7%, respectively. MRI and MSCT follow-up at 3 months showed complete or incomplete occlusions of aneurysms was 7.4% or 17.5%, respectively. 3 patients experienced a thromboembolic event (4.3%). CONCLUSIONS: Intracranial aneurysms of cavernous and para-ophthalmic segments of internal carotid artery are mostly common with wide-neck and multi aneurysms. Deployment of flow diverter stent is safe and effective with high rate of successful and low procedural complications.

A 24-Year-Old Man With Recurrent Hemoptysis.

CASE PRESENTATION: A 24-year-old man was admitted for a new episode of hemoptysis. He reported 3 episodes of hemoptysis in the past 2 years. He had no other medical history and was a nonsmoker. As a Vietnamese person born and living in Vietnam, he was at risk for TB, but had not had contact with those having TB in his family or workplace, was never imprisoned nor homeless, and never traveled abroad. He never experienced pneumonia. He coughed up a small amount of fresh with air red blood (around 5 mL each time) several time for 3 days. He had no dyspnea, no chest pain, no fever, no asthenia, and no anorexia.

Value of Diffusion Weighted MRI with Quantitative ADC Map in Diagnosis of Malignant Thyroid Disease.

Thyroid nodule is a common disease in clinical practice. The diagnosis of malignant thyroid tumors determines the treatment strategy. Among a number of methods have claimed to help evaluating thyroid nodules, ultrasound is a usable one in spite of several disadvantages (dependent on the physician/technician, incomparable, etc.) and magnetic resonance imaging (MRI) accompanied by quantitative apparent diffusion coefficient (ADC) is a promising diagnostic tool. This study was designed to investigate the usefulness of ADC cut-off values and the protocol of thyroid MRI derived from quantitative diffusion weighted imaging (DWI) in differentiating benign and malignant thyroid nodules. The study was conducted on 93 patients with 128 thyroid nodules, diagnosed and underwent surgery at Hanoi Medical University Hospital. All the patients took thyroid MRI with different b levels (from 200 to 800). ADC value was calculated to each b level, and the statistical tests were conducted with the Statistical Package for Social Sciences (SPSS-Windows and Mac version 20) and STATA 12. The mean ADC with all the b ranging from 200 to 800 of malignant groups was significantly higher than the group of benign lesions (p from <0.001 to 0.01). We chose b = 500 as a standard b-value in the protocol of thyroid MRI. The ADC cut-off point for distinguishing malignant from benign thyroid lesions: 1.7 × 10-3 mm2/s with high accuracy (87.1%, 95% CI: 79.59-92.07%). The study revealed that quantitative diffusion weighted MRI with ADC measurement could potentially quantitatively differentiate between benign and malignant thyroid nodules.

Interventional Treatment of Lymphatic Leakage Post Appendectomy: Case Report.

BACKGROUND: Postoperative lymphatic complications are not common, and lymphatic leakage complication post appendectomy (LLCPC) is even rarer. However, the number of this operation is high so LLCPC can occur. CASE REPORT: Here, we report a female patient post appendectomy with severe chylous ascites. This patient underwent six operations. A leakage point at the right iliac-fossa, which was embolized successfully after two sessions, was spotted during intranodal lymphangiography. After 6 months, the ascites were significantly reduced while some lymphatic aneurysms still existed in the lumbar-retroperitoneal region. CONCLUSIONS: Basing the knowledge of this clinical case and literature, we have concluded that lymphatic leakage can be diagnosed and embolized by percutaneous intervention.

Conventional digital subtractional vs non-invasive MR angiography in the assessment of brain arteriovenous malformation.

OBJECTIVES: Digital subtractional angiography (DSA) is the standard method for diagnosis, assessment and management of arteriovenous malformation in the brain. Conventional DSA (cDSA) is an invasive imaging modality that is often indicated before interventional treatments (embolization, open surgery, gamma knife). Here, we aimed to compare this technique with a non-invasive MR angiography (MRI DSA) for brain arteriovenous malformation (bAVM). PATIENTS AND METHODS: Fourteen patients with ruptured brain AVM underwent embolization treatment pre-operation. Imaging was performed for all patients using MRI (1.5 T). After injecting contrast Gadolinium, dynamic MRI was performed with 40 phases, each phase of a duration of 1.2 s and having 70 images. The MRI results were independently assessed by experienced radiologist blinded to the cDSA. RESULTS: The AVM nidus was depicted in all patients using cDSA and MRI DSA; there was an excellent correlation between these techniques in terms of the maximum diameter and Spetzler Martin grading. Of the fourteen patients, the drainage vein was depicted in 13 by both cDSA and MRI DSA showing excellent correlation between the techniques used. CONCLUSION: MRI DSA is a non-invasive imaging modality that can give the images in dynamic view. It can be considered as an adjunctive method with cDSA to plan the strategy treatment for bAVM.