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Updated: Nov 5, 2025

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction
Published on: March 25, 2022
Development of intractable ascites due to thoracic duct hypertension
Asad A Usman1, Jiri Horak1, Grace Wang2
1Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pa.
Abstract:
We describe a 69-year-old dialysis-dependent patient who developed intractable ascites after zone 2 aortic reconstruction for a type IA thoracic endovascular aneurysm repair endoleak. Investigation as to the cause of ascites revealed a unique set of clinical circumstances leading to intractable bloody ascites. Investigation included imaging and invasive testing to diagnose the culprit mechanism. Ultimately, interventional catherization of the left subclavian vein illustrated an abnormally elevated pressure in the left subclavian vein. It was thus determined that, owing to the combination of a left brachiocephalic (innominate) vein occlusion after surgical ligation and in situ left brachiobasilic arteriovenous dialysis graft, there was overcirculation through the thoracic duct. Retrograde flow through the pop-off thoracic duct led to hematogenous ascites. Ligation of the left brachiobasilic arteriovenous dialysis graft resulted in near instantaneous and complete resolution of the ascites.
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