CHD Interventions Featured Articles of February 2016

1. Percutaneous Lymphatic Embolization of Abnormal Pulmonary Lymphatic Flow as Treatment of Plastic Bronchitis in Patients with Congenital Heart Disease.

Dori Y, Keller MS, Rome JJ, Gillespie MJ, Glatz AC, Dodds K, Goldberg DJ, Goldfarb S, Rychik J, Itkin M.

Circulation. 2016 Feb 10. pii: CIRCULATIONAHA.115.019710. [Epub ahead of print]

PMID: 26864093

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Select item 26790106

bouddjemlineMehul Patel photoComment from Pr. Younes Boudjemline (Paris) and co-editor Dr. Mehul Patel (Detroit, MI), editors of congenital heart disease interventions Journal Watch: Plastic bronchitis (PB) is a relatively uncommon but potentially fatal condition in which airway casts develop in the tracheobronchial tree causing airway obstruction. The mechanism of cast formation in PB is thought due to abnormal perfusion of the bronchial submucosa with lymph and slow seepage of lymph proteins into the bronchial lumen, this eventually dries and denatures leaving a cast. The exact pathophysiology is still not well understood and hence the therapeutic targets continue to vary. The authors retrospectively studied 18 surgically corrected congenital heart disease patients with plastic bronchitis using bilateral intranodal lymphangiogram and CMR using respiratory navigated and cardiac- gated 3-dimensional turbo spin echo sequence with volume rendering.

Embolization of venovenous collaterals or in patients with a fenestration, temporary balloon occlusion of the fenestration was performed before Lipiodol injection to prevent paradoxical embolism. Using the Nadolski and Itkin method,  ultrasound guided intranodal lymphangiogram was performed using 25-gauge spinal needles attached to a short connector tubing and after identification of the target vessel (larger lumbar lymphatics or cisterna chyli), access to this vessel was performed by using the transabdominal approach using a 21- to 22-gauge Chiba needle (Cook Medical Inc, Bloomington, IN). A V18 control guide wire (Boston Scientific, Natick, MA) was then advanced into the TD and manipulated cephalad. Over the wire, a 60-cm 2.3F Rapid Transit microcatheter (Cordis Corp, Warren, NJ) was advanced further into the TD with enough access to perform any intervention.

Both, CMR or lymphangiogram demonstrated retrograde lymphatic flow from the thoracic duct (TD) toward lung parenchyma. Conventional antegrade thoracic duct catheterization was successful in all and 15 of 17(88%) patients who underwent an intervention had significant symptomatic improvement at a median follow-up of 315 days. The most common complication observed was nonspecific transient abdominal pain and transient hypotension. There have been prior reports on retrograde TD cannulation at the genu of the left subclavian vein and IJV, which could be useful in those with failure of conventional percutaneous direct cisterna chyli cannulation. A variety of embolization materials such as fibered endovascular coils, gelatin sponge, and doxycycline may be used along with covered stents to exclude some TD branches.

Take Home points:

 

  1. Abnormal pulmonary lymphatic perfusion exists in most patients with plastic bronchitis.
  2. Interruption of the lymphatic flow results in significant improvement of symptoms in these patients and, in some cases, at least temporary resolution of cast formation.
  3. Due care should be taken in those with right to left shunts as it could lead to paradoxical embolisation.
  4. Retrograde cannulation and interventions on the thoracic duct may be useful in those with failure of conventional antegrade approach.

References:

  1. Pediatric plastic bronchitis: case report and retrospective comparative analysis of epidemiology and pathology.

Kunder R, Kunder C, Sun HY, Berry G, Messner A, Frankovich J, Roth S, Mark J.

Case Rep Pulmonol. 2013;2013:649365. doi: 10.1155/2013/649365. Epub 2013 Apr 11.

PMID: 23662235 Free PMC Article

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  1. Retrograde Thoracic Duct Embolization in a Pediatric Patient with Total Cavopulmonary Connection and Plastic Bronchitis.

Chung A, Gill AE, Rahman FN, Hawkins CM.

J Vasc Interv Radiol. 2015 Nov;26(11):1743-6. doi: 10.1016/j.jvir.2015.07.023. No abstract available.

PMID: 26505943

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  1. Pediatric plastic bronchitis: A case report and literature review

Angelos P C, MacArthur

International journal of Pediatric Otolaryngology,  March 2010 Volume 5, Issue 2, Pages 66–69

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