Direct Percutaneous Retrograde Thoracic Duct Access for Embolization Using a Modified Sheath Technique for the Treatment of Chyloptysis and Plastic Bronchitis.

Thoracic duct embolization is an established minimally invasive treatment for thoracic lymphatic disorders refractory to conservative therapy. We report the case of a 58-year-old man with chyloptysis and plastic bronchitis who presented with persistent respiratory symptoms despite conservative management. Intranodal lymphangiography demonstrated opacification of the thoracic duct. However, antegrade access via the cisterna chyli was not feasible because of its challenging location, and retrograde transvenous access was unsuccessful because of ductal tortuosity. Ultrasound demonstrated a dilated upper thoracic duct in the left lower neck, which was accessed percutaneously using a micropuncture set adapted as a modified sheath, followed by successful navigation of the microcatheter into the cisterna chyli. Successful embolization was performed using a mixture of n-butyl cyanoacrylate and ethiodized oil, resulting in immediate symptomatic improvement and resolution of the patient's supplemental oxygen requirement. This case demonstrates that direct percutaneous retrograde thoracic duct access using a modified sheath technique is a feasible alternative when conventional approaches are technically challenging.