Percutaneous Extra-Anatomic Lymphovenous Bypass Creation: Toward Treatment of Central Conducting Lymphatic Obstructions
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CASE REPORT
Percutaneous Extra-Anatomic Lymphovenous Bypass Creation: Toward Treatment of Central Conducting Lymphatic Obstructions Jacob J. Bundy1 • David S. Shin2 • Jeffrey Forris Beecham Chick2 • Wayne L. Monsky2 • Sean T. Jones2 • Jeb List2 • Anthony N. Hage3 Sandeep S. Vaidya2
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Received: 19 January 2020 / Accepted: 12 March 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
Abstract Introduction Protein-losing enteropathy manifests as a loss of serum proteins through the gastrointestinal tract, resulting in hypoproteinemia, extravascular fluid retention, and edema. Management consists of nutritional maintenance in conjunction with interventions targeted at treating the underlying etiology. Materials and Methods This report describes a patient with protein-losing enteropathy from a central conducting lymphatic obstruction who was treated with percutaneous extra-anatomic lymphovenous bypass creation. Results A modified gun-sight technique was used to create a lymphovenous bypass between an occluded terminal thoracic duct and the left internal jugular vein. Conclusion A percutaneous technique to reconstruct the terminal thoracic duct via lymphovenous bypass creation was feasible. Keywords Lymphovenous bypass Percutaneous extra-anatomic Gun-sight technique Protein-losing enteropathy Lymphatics Thoracic duct Interventional radiology
Abbreviation PLE Protein-losing enteropathy
Introduction Lymphatic disorders including protein-losing enteropathy (PLE), chylous ascites, and chylothorax have been treated with lymphatic embolization, thoracic duct embolization, and endolymphatic balloon-occluded retrograde abdominal lymphangiography and embolization [1–4]. The surgical creation of lymphovenous bypasses has been described as well [5, 6]. This report describes percutaneous creation of an extraanatomic lymphovenous bypass in a patient with chronic PLE secondary to radiation fibrosis. A modified gun-sight technique was used to create a lymphovenous bypass between an occluded terminal thoracic duct and the left internal jugular vein.
Clinical Case & Jeffrey Forris Beecham Chick [email protected] 1
Division of Interventional Radiology, Wake Forest Baptist HealthOne Medical Center Boulevard, Winston-Salem, NC, USA
2
Division of Interventional Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
3
Division of Interventional Radiology, Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA, USA
Institutional review board approval was not required for preparation of this report. A 35-year-old male with testicular rhabdomyosarcoma status post-orchiectomy with radiation to the chest, abdomen, and pelvis presented with anasarca for 5 years. Initial weight was 63.0 kg. Evaluation demonstrated malnutrition with a total protein of 3 g/dL (normal range 6.0–8.3 g/dL). Magnetic resonance enterography showed thickening of the small bowel. Deep en
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