Teaching Case

A 75-year-old female admitted with a left supraclavicular mass. One month earlier, the patient had undergone a replacement of the ascending thoracic aortic aneurysm with the E-vita open plus stent graft.

Physical examination revealed a 6 cm fluctuant mass in the left supraclavicular fossa without erythema or tenderness.

Ultrasonography and CT showed a large, 7×6cm lobulated cystic mass in the left supraclavicular region. (Fig 1a,1b). Percutaneous needle aspiration was performed and analysis of the fluid revealed a lymph origin (Fig 2), which was drained percutaneously. Two days later the patient returned with refill of the cystic mass.

We performed an intranodal lymphangiogram [1] using Lipiodol® via bilateral US-guided puncture of the hilum of inguinal lymph nodes. After 15ml of lipiodol had been injected, a fluoroscopic image showed accumulation of the lipiodol into the lymph vessels and filled of the cervical cystic cavity.

After identifying the level of chyle leak, we performed a transabdominal puncture of the chyli cistern (Fig 3) and catheterisation of thoracic duct to the level of the leak. (Fig 4). A successful embolisation with 3 and 4mm microcoils and N-Butyl Cyanoacrylate diluted 1:1 with Lipiodol® was performed proximal to the point of the chyle leak (Fig 5).

Lymphatic leakage is a severe complication after surgical procedures. Depending on the operative procedure this complication may occur in approximately 2.7% to 3.8%.

Conservative treatment including adequate fluid and electrolyte replacement, diet and different medications (octreotide/somatostatin). For persisting leakage refractory to conservative management, a lymphangiography and direct puncture of the lipiodol-filled cisterna chyli should be attempted. This will potentially stop further chylous leakage (needle disruption technique) or allow thoracic duct embolisation [2].

In cases where the site of lymphatic leakage cannot be accessed, Lipiodol® itself might help to occlude the leak due to undergoes an inflammatory and granulomatous reaction during its extravasation and its high viscosity that can result in closure of the leak [3].

We present a case of a postoperative cervical chylous lymphocele that was not reduced or improved despite conservative management and drainage. Therefore, we performed an intranodal lymphangiogram with lipiodol that allowed the identification of lymphatic injury level and thoracic duct embolisation with micro coils and glue with technical and clinical success.

Ultrasound-guided inguinal intranodal lymphangiography is a minimally invasive procedure with an important diagnostic and therapeutic value. In cases where chylous leakage persists after lymphangiography, a subsequent thoracic duct embolisation should be performed as an alternative of treatment in patients with traumatic and nontraumatic chylous leaks with few complications, no associated mortality and a high success rate.