Management of Chylothorax

Variant: 1 Adult. Chylothorax of any etiology. Initial therapy.

Procedure	Appropriateness Category
Medical therapy and dietary modification	Usually Appropriate
Thoracic duct embolization	May Be Appropriate
Surgery	May Be Appropriate
Pleurodesis	Usually Not Appropriate

Variant: 2 Adult. Chylothorax refractory to medical and dietary management. Next therapy.

Procedure	Appropriateness Category
Thoracic duct embolization	Usually Appropriate
Pleurodesis	Usually Appropriate
Surgery	May Be Appropriate

Variant: 3 Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.

Procedure	Appropriateness Category
Thoracic duct embolization	May Be Appropriate
Catheter directed mechanical thrombectomy thoracic central vein	May Be Appropriate
Intraabdominal lymphatic embolization	May Be Appropriate
Medical therapy and dietary modification	May Be Appropriate (Disagreement)
Thoracic central vein recanalization	May Be Appropriate
Pleurodesis	May Be Appropriate
Surgery	May Be Appropriate
Surgical thrombectomy thoracic central vein	May Be Appropriate

Variant: 4 Adult. Chylothorax with concurrent chylous ascites. Initial therapy.

Procedure	Appropriateness Category
Medical therapy and dietary modification	May Be Appropriate (Disagreement)
Portal vein recanalization	May Be Appropriate
TIPS	May Be Appropriate
Surgery	May Be Appropriate
Pleurodesis	Usually Not Appropriate
Thoracic duct embolization	Usually Not Appropriate

Panel Members

Eric J. Monroe, MD^a, Charles Y. Kim, MD^b, Osmanuddin Ahmed, MD^c, Brendan Cline, MD^d, Irmina A. Elliott, MD^e, Ken Hirasaki, MD^f, Amber Liles, MD^g, Mina S. Makary, MD^h, Daniela Molena, MDⁱ, Roger T. Tomihama, MD^j, Raul N. Uppot, MD^k, Nicholas Fidelman, MD^l

Summary of Literature Review

Introduction/Background

Initial Therapy Definition

Initial therapy is defined as a first-line treatment option for the medical condition defined by the variant. More than one option can be considered usually appropriate as the initial therapy when:

There are equivalent alternatives (ie, only one option will be planned to effectively manage the patient’s care).

There are complementary therapies (ie, more than one treatment option is planned to be performed simultaneously or in sequence during the same setting, wherein the therapies provide synergistic or complementary benefits to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1:Adult. Chylothorax of any etiology. Initial therapy.

Variant 1:Adult. Chylothorax of any etiology. Initial therapy.
A. Medical therapy and dietary modification

Variant 1:Adult. Chylothorax of any etiology. Initial therapy.
B. Pleurodesis

Variant 1:Adult. Chylothorax of any etiology. Initial therapy.
C. Surgery

Variant 1:Adult. Chylothorax of any etiology. Initial therapy.
D. Thoracic duct embolization

Variant 2:Adult. Chylothorax refractory to medical and dietary management. Next therapy.

Variant 2:Adult. Chylothorax refractory to medical and dietary management. Next therapy.
A. Pleurodesis

Variant 2:Adult. Chylothorax refractory to medical and dietary management. Next therapy.
B. Surgery

Variant 2:Adult. Chylothorax refractory to medical and dietary management. Next therapy.
C. Thoracic duct embolization

Variant 3:Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.

Variant 3:Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.
A. Catheter directed mechanical thrombectomy thoracic central vein

Variant 3:Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.
B. Intraabdominal lymphatic embolization

Variant 3:Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.
C. Medical therapy and dietary modification

Variant 3:Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.
D. Pleurodesis

Variant 3:Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.
E. Surgery

Variant 3:Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.
F. Surgical thrombectomy thoracic central vein

Variant 3:Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.
G. Thoracic central vein recanalization

Variant 3:Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.
H. Thoracic duct embolization

Variant 4:Adult. Chylothorax with concurrent chylous ascites. Initial therapy.

Variant 4:Adult. Chylothorax with concurrent chylous ascites. Initial therapy.
A. Medical therapy and dietary modification

Variant 4:Adult. Chylothorax with concurrent chylous ascites. Initial therapy.
B. Pleurodesis

Variant 4:Adult. Chylothorax with concurrent chylous ascites. Initial therapy.
C. Portal vein recanalization

Variant 4:Adult. Chylothorax with concurrent chylous ascites. Initial therapy.
D. Surgery

Variant 4:Adult. Chylothorax with concurrent chylous ascites. Initial therapy.
E. Thoracic duct embolization

Variant 4:Adult. Chylothorax with concurrent chylous ascites. Initial therapy.
F. TIPS

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.