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Thoracic Duct-to-Azygous Vein Lymphovenous Anastomosis for Lymphatic Decompression: Initial Experience and Early
Benjamin Smood1, Katsuhide Maeda1,2, Rosa Hwang3
1Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Background:
Thoracic duct obstruction can cause devastating lymphatic complications, and definitive treatments remain lacking. This investigation evaluated our initial experience and early outcomes using a surgically created thoracic duct-to-azygous vein lymphovenous anastomosis (TDA-LVA) to provide lymphatic decompression in critically ill neonates and infants with thoracic duct obstruction.
Methods:
All children who underwent TDA-LVA creation at the Children's Hospital of Philadelphia between December 2019 and January 2024 were retrospectively reviewed. Preoperative and postoperative clinical characteristics were compared among all patients. Primary end points of analysis included survival to discharge and at last follow-up.
Results:
Eight children (median weight, 4.5 kg; interquartile range [IQR], 3.5-5.0 kg) underwent successful TDA-LVA creation. All procedures were tolerated very well. One patient (1 of 8 [12.5%]) required chest washout on postoperative day (POD) 7, and 1 TDA-LVA was unsuccessfully revised on POD 21. The median hospital length of stay after TDA-LVA creation was 138 days (IQR, 64-241 days). Overall, 6 of 8 patients (75.0%) survived to hospital discharge, all of which (6 of 6 [100.0%]) remained alive at a median follow-up of 165 days (IQR, 18-521 days) after discharge. Postoperative TDA-LVA patency was confirmed with conventional lymphangiography in 5 of 8 patients (62.5%), and up to POD 70.
Conclusions:
A TDA-LVA can restore lymphatic fluid drainage into the systemic venous circulation and remain patent for >2 months in carefully selected patients with thoracic duct obstruction. Further investigations are needed to determine the long-term durability and potential impact on overall quality of life and survival in children with complex lymphatic disorders.
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