Treatment of malignant inferior vena cava obstruction with Gianturco-Rosch-Z stents: a single center 13-year experience.

RATIONALE AND OBJECTIVES: Malignant obstruction of the IVC can cause severe morbidity and impairment of quality of life in end-stage oncology patients. However, medical literature regarding minimally-invasive palliation using large diameter percutaneous stents, particularly the Gianturco-Rosch-Z (GRZ) stent is limited. MATERIALS & METHODS: A retrospective review from January 2004 to February 2017, revealed 17 subjects with malignant obstruction of the IVC who were treated with a total of 34 GRZ stents. Pre- and post-stent pressure gradients were measured in 10. Available data regarding clinical presentation and follow-up were recorded. RESULTS: Technical success for stent deployment was 100%. A median of 2 stents (range 1 to 5) were deployed per patient, with median stent diameter 20 mm (range 15 to 30 mm). The median pre-treatment pressure gradient of 17.5 mmHg (range 9-31 mmHg) decreased to a median of 4.5 mmHg (range 0-21 mmHg, p < .0004) after stent placement. One subject developed recurrent stent occlusion due to disease progression requiring additional intervention, for a primary patency rate of 94%. Lower extremity edema improved or resolved in 58% of those for whom follow-up data was recorded. Median survival after treatment was only 28 days (range 5 to 607 days). There were no procedural complications. CONCLUSION: Endovascular treatment of malignant IVC obstruction can be safely performed with GRZ stents. Although overall survival is poor, this technique can effectively palliate lower extremity edema symptoms.

Lymphatic interventions for isolated, iatrogenic chylous ascites: A multi-institution experience.

OBJECTIVES: Lymphangiography and thoracic duct embolization are established treatments for post-surgical chylothorax. There is only limited experience in their application to treat post-surgical chylous ascites. A multi-center analysis of the technical and clinical success of lymphangiography and lymphatic interventions in the treatment of isolated, iatrogenic chylous ascites is reported. METHODS: 21 patients (14 males; 7 females) aged 3-84 years (mean 56.9 years; median 63 years) were treated for isolated, iatrogenic chylous ascites between August 2012 and January 2018. Initial referrals occurred between 5-330 days (mean 72.7 days; median 40 days) after failing conservative therapy. Daily leak volumes ranged from 100 to 3000 mL. Lymphangiographic findings, techniques, clinical outcomes, and complications were recorded. RESULTS: 21 patients underwent 29 procedures. Seven patients underwent multiple procedures after chylous ascites persisted. Bilateral nodal lymphangiography (NL) was technically successful in all (100%) patients. Lymphangiography identified a leak in 14/21 (67%) patients and in 16/29 procedures (55%). Ten procedures (34%) consisted of NL alone and one (3.4%) consisted of NL combined with lymphatic disruption (LD). Six procedures (21%) consisted of nodal glue embolization (NGE) while nine procedures (31%) were catheter-based lymphatic embolization. Three separate patients underwent three procedures (10%) consisting of balloon-occluded retrograde abdominal lymphatic embolization. Clinical success, defined as no additional drainage of chylous ascites at 15 days, was ultimately achieved in 18/21 patients (86%). There were no major or minor complications. CONCLUSION: Lymphatic interventions can successfully treat post-surgical chylous ascites. Given the low risk of procedural complication, early intervention is encouraged.

The thoracic duct: clinical importance, anatomic variation, imaging, and embolization.

UNLABELLED: The thoracic duct is the body's largest lymphatic conduit, draining upwards of 75 % of lymphatic fluid and extending from the cisterna chyli to the left jugulovenous angle. While a typical course has been described, it is estimated that it is present in only 40-60% of patients, often complicating already challenging interventional procedures. The lengthy course predisposes the thoracic duct to injury from a variety of iatrogenic disruptions, as well as spontaneous benign and malignant lymphatic obstructions and idiopathic causes. Disruption of the thoracic duct frequently results in chylothoraces, which subsequently cause an immunocompromised state, contribute to nutritional depletion, and impair respiratory function. Although conservative dietary treatments exist, the majority of thoracic duct disruptions require embolization in the interventional suite. This article provides a comprehensive review of the clinical importance of the thoracic duct, relevant anatomic variants, imaging, and embolization techniques for both diagnostic and interventional radiologists as well as for the general medical practitioner. KEY POINTS: • Describe clinical importance, embryologic origin, and typical course of the thoracic duct. • Depict common/lesser-known thoracic duct anatomic variants and discuss their clinical significance. • Outline the common causes of thoracic duct injury and indications for embolization. • Review the thoracic duct embolization procedure including both pedal and intranodal approaches. • Present and illustrate the success rates and complications associated with the procedure.

Thoracic duct embolization and disruption for treatment of chylous effusions: experience with 105 patients.

PURPOSE: To review the indications, technical approach, and clinical outcomes of thoracic duct embolization (TDE) and thoracic duct disruption (TDD) in patients with symptomatic chylous effusions. MATERIALS AND METHODS: A total of 105 patients who underwent 120 consecutive TDE/TDD procedures were retrospectively reviewed. Data including cause of effusion, procedural technique, and pre- and postprocedural effusion volume were analyzed. Technical and clinical success were evaluated for each procedure, with technical success defined as successful interruption of the thoracic duct by embolization or needle disruption and clinical success defined as resolution of effusion without surgical intervention. RESULTS: The technical success rate was 79% (95 of 120); 53 TDEs were performed, resulting in a 72% clinical success rate (n = 38), whereas 42 TDDs showed a 55% clinical success rate (n = 23; P = .13). Procedures to treat postpneumonectomy chylous effusions had a success rate of 82% (14 of 17), compared with 47% (nine of 19) in postpleurectomy subjects (P < .05). Clinically successful cases had lower 24-, 48-, and 72-hour postprocedural effusion volumes versus clinically unsuccessful cases (P < .05), as well as greater rates of reduction in effusion volume at these time points (P < .05). Clinical success rate in subjects with traumatic effusions was higher than in subjects with nontraumatic effusions (62% [60 of 97] vs 13% [one of eight]; P < .05), and 6.7% of subjects (n = 7) experienced minor complications. CONCLUSIONS: TDE and TDD are safe and effective minimally invasive treatments for traumatic thoracic duct injuries. In the present series, factors affecting procedural success included etiology of effusion, postprocedural effusion volume, and rate of postprocedural effusion volume reduction.

Leiomyosarcoma of the popliteal vein.

Primary vascular leiomyosarcomas are rare tumors arising from the media of vessel walls, involving the extremities in about one third of reported cases, and the popliteal vein even less frequently. We report a case of popliteal vein leiomyosarcoma in a 62-year old man who presented with leg pain and edema 4 weeks following spine surgery. Findings on ultrasound, MRI and CT angiography are reviewed, with particular emphasis on the value of CT angiography in fully evaluating the extent of the mass and in assisting percutaneous biopsy.