Intravascular Ultrasound-Guided Transcaval Cisterna Chyli Access for Lymphatic Intervention: A Proof-of-Concept Study...

Central lymphatic interventions are an emerging frontier for Interventional Radiology. Conventional lymphatic access relies on transabdominal puncture of the cisterna chyli following secondary opacification from groin or pedal contrast injection. These techniques are time-consuming and risk injury to multiple structures. This study evaluated the feasibility of direct transcaval cisterna chyli access using intravascular ultrasound with an intracardiac echocardiography probe (IVUS-ICE), motivated by the close proximity of the IVC and cisterna chyli in the retroperitoneum.

IVUS-ICE guidance was used to attempt cisterna chyli cannulation from the IVC in six swine. In the first cohort (n = 2), nodal lymphangiography was performed to co-localize the cisterna chyli prior to ultrasound guided cannulation. In the second cohort (n = 4), de novo access of the cisterna was attempted; rescue nodal lymphangiography was only performed if the cisterna could not be definitively identified sonographically. After central lymphatic cannulation, thoracic duct embolization was performed with coils and/or glue.

Transcaval cisterna chyli cannulation and subsequent thoracic duct embolization was successful in all animals (n=6). In the second cohort where primary IVUS-ICE access was attempted, de novo cannulation without preceding lymphangiography was successful in 75% of subjects. Success depended on the sonographic visibility and proximity of lymphatics to the IVC.

This study demonstrates that IVUS-ICE-guided transcaval access is technically feasible. This approach may improve procedural safety and efficiency by eliminating transgression of abdominal structures inherent to transabdominal access and the often-time-consuming process for central lymphatic opacification for a subset of patients.