a 65-year - old female visited korea university anam hospital complaining of chest pain , palpitation , and dyspnea . on the basis of computed tomography , she was diagnosed with takayasu s arteritis including a large aneurysm ( 58 mm ) on the aortic distal arch ( fig .
because the patient strongly refused surgery , we performed thoracic endovascular aortic repair ( tevar ) with left subclavian artery ( lsca ) to left common carotid arterial transposition ( fig .
after tevar , the patient s symptoms improved , and she was discharged on postoperative day 10 with a normal chest x - ray ( fig .
the patient returned to the hospital complaining of moderate dyspnea on postoperative day 19 , and the follow - up chest x - ray showed a severe left pleural effusion ( fig .
after the insertion of a chest tube , postoperative chylothorax was confirmed by a pleural fluid analysis .
conservative management with a fat - free diet and nil per os was attempted for 2 weeks , but there was no remarkable improvement .
therefore , we administered a subcutaneous injection of octreotide ( 0.1 mg ) every 8 hours for 2 weeks ; however , even these injections had no effect .
surgical treatment was also considered , but given the possibility of unsuccessful repair due to the uncertainty of the exact site of the thoracic duct leakage and the patient s strong refusal , it could not be our next option .
therefore , we performed an intranodal lymphangiogram using lipiodol ( poppy seed oil used as a radio - opaque contrast agent to outline structures in radiological investigations ) on postoperative day 46 .
a total volume of 3 to 6 ml of lipiodol was injected into each lymph node at the inguinal area under the guidance of ultrasonography . during the fluoroscopy
, the lipiodol had migrated to the retroperitoneal lymphatics but did not advance beyond the l3 level .
however , the chest x - ray taken 3 days after the thoracic duct embolization ( tde ) revealed that the lipiodol had migrated up to the subclavian lymphatics ( fig .
the chest tube drainage suddenly decreased on the 3rd day after tde , and we were finally able to remove the chest tube on the 13th day after tde ( fig .
postoperative chylothorax is a rare but serious complication of the thoracic and esophageal surgical procedure .
further , a significant loss of immunoglobulins , t lymphocytes , and proteins into the pleural cavity results in immunosuppression .
conservative treatments include drainage of the pleural effusion , a diet including medium - chain triglycerides ( mcts ) , total parenteral nutrition ( tpn ) , and injection of somatostatin analogs like octreotide . an mct diet and tpn reduce the chyle s flow , and somatostatin analogs reduce the intestinal chyle production . in case
the high - output chylothorax responds poorly to conservative management , surgical treatment such as thoracic duct ligation , pleuroperitoneal shunt , pleurodesis , or pleurectomy is required .
lymphangiography has also been considered a treatment of chylothorax , being less invasive than surgery and having a success rate of about 80% ( table 1 ) [ 36 ] .
the mechanism is thought to be caused by lipiodol , which produces an inflammatory process and occludes the chyle leak .
complications of lymphangiography are pulmonary oil embolism , hypersensitivity , and lymphatic obstruction , but these are rare and usually minor . in our case , postoperative chyle leakage was not reduced or improved despite the trial of conservative management and octreotide injection . therefore , we performed an intranodal lymphangiogram and tde with lipiodol . through this case
, we verified that tde with lipiodol could be considered an alternative for the treatment of postoperative chylothorax , if conservative medical treatment is unsuccessful and surgical treatment is not possible .
 chylothorax is a rare postoperative complication of a thoracic surgical procedure . here 
 , we report a case of chylothorax after thoracic endovascular aortic repair with debranching for the distal arch aneurysm of the aorta . 
 first , the patient was treated by a medical method ( nil per os , fat - free diet , and octreotide ) , but this method failed . 
 the patient strongly refused surgical treatment . 
 therefore , we tried to occlude the thoracic duct by lymphangiography lipiodol , and this line of treatment was successful . 
CASE REPORT
DISCUSSION