Interactive Cardiovascular and Thoracic Surgery 3:423-425(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Chylothorax and re-expansion pulmonary edema following myocardial re-vascularization: role of lymph vessel insufficiency
Marc Riqueta,*,
Jalal Assouada,
Nicola D'Attellisa and
Iradj Gandjbakhchb
a Departments of Thoracic Surgery and Anesthesiology, Georges Pompidou European hospital, 20 rue Leblanc, 75908 Paris cedex 15, France
b Department of Cardiothoracic Surgery, La Pitié Salpétrière Hospital, Paris, France
* Corresponding author. Tel.: +33-1-56-09-34-50; fax: +33-1-56-09-33-80
marc.riquet{at}hop.egp.ap-hop-paris.fr
Received December 23, 2003;
received in revised form February 15, 2004;
accepted March 1, 2004
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Abstract
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Chylothorax is a rare complication following coronary artery bypass graft surgery. In the following case, we report a chylothorax complicating left internal mammary artery harvesting due to injury of the left anterior mediastinal lymph node chain (LAMLNC) at the level of the proximal pedicle of the mammary artery. Re-expansion pulmonary edema occurred during re-operation for chylothorax following suturing of this lymph node chain. This observation demonstrates the role of the LAMLNC in both complications when injured or interrupted.
Key Words: Cardiac surgery; Left internal mammary artery; Re-expansion pulmonary edema; Chylothorax
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1. Introduction
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Chylothorax is an uncommon complication following cardiac surgery and particularly rare after myocardial re-vascularization [1]. Re-expansion pulmonary edema infrequently occurs when a collapsed lung is rapidly re-expanded [2]. In the following case, we report the observation of both events in the same patient and comment on the physiopathology of their occurrence.
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2. Case report
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A 59-year-old diabetic female underwent triple coronary artery bypass grafting in December 2001. The procedure consisted of a left internal mammary artery (LIMA) to left anterior descending and reversed saphenous vein grafts to the marginal branches. The postoperative course was complicated by a left chylothorax (cholesterol 1.35 mmol/l and triglycerides 17.10 mmol/l). Treatment consisted of chest tube drainage, and replacement of long-chain triglycerides by medium-chain triglycerides in the diet. The pleural effusion progressively disappeared over the following 5 days (total amount 1860 ml) but re-appeared a few days later and the patient was referred to our department. Iterative drainage was performed and the patient was placed on total parenteral nutrition. The chylous effusion persisting (4500 ml over 20 days) with a collapsed lung due to partial loculations, a thoracoscopic procedure was planned. Pedal lymphangiography was performed before surgery, demonstrating reflux within the left anterior mediastinal lymph node chain (LAMLNC) from the thoracic duct (TD) arch (Fig. 1) with an upper chylous leak. Thoracoscopy following a cream meal was performed, and fibrin clots with 1800 ml of chyle were evacuated. The left lung was partially adherent to the thoracic wall and mediastinum. Due to chyle leaking from the upper thoracic sulcus and the need for further exploration involving risk of LIMA injury, a thoracotomy was performed to free the lung. The LAMLNC appeared distended and the upper leak was sutured. An additional leak at the level of subaortic lymph nodes, probably induced by mediastinal decortication, was also sutured. The pleural space was washed with warm saline solution and the left lung re-inflated. Immediately following this procedure, fluid mimicking plasma appeared from the left endobronchial tube. This fluid proved to contain no chyle (cholesterol 1.15 mmol/l and triglyceride 0.39 mmol/l). The amount of fluid was abundant over the first 2 h (total amount 1200 ml) and progressively decreased during mechanical ventilation which was continued in the intensive care unit. The pleural effusion ceased over the following 3 days (395 ml over 3 days) and mechanical ventilation was discontinued. The patient recovered and is faring well without sequel 24 months later.
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Fig. 1 Lymphangiogram demonstrating injected subclavicular and cervical nodes and injected left anterior mediastinal nodes indicating reflux (*). The leak originates at the top of the mediastinum (arrow) and encircles the aortic arch (two arrows). Contrast medium is visible in the lower part of the pleural cavity (circles).
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3. Comment
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Chylothorax is a rare complication following myocardial re-vascularization. Chaiyaroj et al. [1] described only six case reports in 1993: the cause of chylothorax was not identified and conservative management usually successfully controlled the leak. However, in one patient Chaiyaroj et al. [1] observed at re-operation a leak from a lymphatic vessel 1.5 mm in diameter located near the proximal LIMA pedicle at the level of the first rib. The authors suggested that lymphatic injury occurred at the time of dissection to maximize mammary artery length. In an anatomical study [3], it was reported that the LAMLNC normally connects with the left jugulo subclavian venous confluent after having crossed the LIMA near its origin at the apex of the thorax and sometimes with the arch of the TD near its termination (Fig. 2). Normally, lymph vessels are valved and lymph back flow is impossible. Chyle valve insufficiency may allow back flow from the TD within the LAMLNC as in our observation. Injury of such a backflowing LAMLNC is more likely to explain chylothorax complicating LIMA harvest, than injury of the TD itself, the TD being more deeply located in this region. The rarity of chylothorax following LIMA harvest is explained by usual lymph vessel valve competency of LAMLNC which in addition are not always connected with the TD itself (Fig. 2).
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Fig. 2 Left anterior mediastinal lymph node chain and its relation with the origin of the left internal mammary artery at the superior part of the thorax. Subpleural lymph vessels from the left lung joining the left anterior mediastinal lymph node chain. (1) Left pulmonary artery; (2) arch of TD entering the venous confluent; and (3) left upper pulmonary vein.
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The occurrence of RPE during surgery is extremely uncommon and rarely reported [4,5]. RPE occurred twice within 1 h after the start of mechanical ventilation on a collapsed lung [5] and once 1 h after re-inflation following video-assisted thoracic surgery [4]. In the three cases, the amount of RPE was small, not exceeding 20 ml.
The pathophysiology of RPE remains undefined. Several potential mechanisms have been suggested including enhanced endothelial permeability (due to membrane disruption and ischema—reperfusion—mediated injury), decrease in perivascular pressure, application of a high negative pleural pressure, decreased surfactant [2,4] and/or decreased lymph flow [4,6]. Decreased lymph flow has been suggested to play an important role in cases of RPE following evacuation of malignant pleural effusions, because they compromise lymphatic drainage [6]. In our observation, the lung was collapsed for a long period and all mechanisms were potentially present. The LAMLNC is an important pathway for left lung lymph drainage [7]. Valve insufficiency may have been favored by a preponderant left LAMLNC lung lymph drainage in this patient (Fig. 2). We suggest that suturing the LAMLNC interrupted the increased lymph flow produced by left lung reventilation and may have led lymph to transudate within the alveoli. RPE was controlled and treated by continuous positive airway pressure which has also been reported by Iqbal et al. [6].
Chylothorax and RPE are extremely rare. Simultaneous occurrence is coincidental. However, both events are not independent and appear related to a dominant LAMLNC draining the left lung lymph, with compromised valve continence. This observation illustrates the role insufficient LAMLNC may play in chylothorax following LIMA harvest and the role lung lymph drainage may have in RPE.
doi:10.1016/j.icvts.2004.03.001
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References
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- Chaiyaroj S, Mullerworth MH, Tatoulis J. Surgery in the management of chylothorax after coronary artery bypass with left internal mammary artery. J Thor Cardiovasc Surg. 1993;106:754–756[Medline]
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- Yamagidate F, Dohi S, Hamaya Y, Tjujito T. Reexpansion pulmonary edema after thoracoscopic mediastinal tumor resection. Anesth Analg. 2001;92:1416–1417[Free Full Text]
- Suzuki S, Niikawa H, Shibuya J, Hosaka T, Maeda S, Suzuki T, Handa M. Analysis of edema fluids and histologic features of the lung in rexpansion pulmonary edema during video-assisted thoracoscopic surgery. J Thorac Cardiovasc Sur. 2002;123:387–389[Free Full Text]
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- Rouviere H. Les vaisseaux lymphatiques des poumons et les ganglions viscéraux intrathoraciques. Ann Anat Pathol. 1929;6:113–158
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Abstract
1. Introduction