A combined intrahepatic (IH) and periduodenal (PD) embolization strategy results in higher initial response rates and longer duration of remission compared with IH embolization alone in congenital heart disease (CHD) patients with protein-losing enteropathy (PLE), a study has shown.
“These findings support a more comprehensive embolization approach as a promising interventional therapy for this high-risk population,” the researchers said.
Seventy-one CHD patients who underwent percutaneous lymphatic embolization for medically refractory PLE were included in this single-centre retrospective review. Multicompartment magnetic resonance lymphangiography (MRL) was conducted, followed by IH or combined IH plus PD embolization.
Duration of remission (serum albumin ≥3.0 g/dL without intravenous albumin supplementation or repeat percutaneous PLE intervention) was the primary endpoint. Secondary analyses included the following: initial response (albumin ≥3.0 g/dL within 30 days without intravenous albumin supplementation), impact of thoracic duct obstruction, and transplant-free survival.
Of the patients, 17 underwent IH and 54 IH plus PD embolization. All patients who went through multicomponent MRL had duodenal leaks. [J Am Coll Cardiol 2026;88:1473-1494]
IH plus PD embolization correlated with higher initial response rates (87 percent vs 41 percent; p<0.0004), and median serum albumin levels increased from 2.3 to 4.2 g/dL after the procedure in the IH plus PD group (p<0.0001). Furthermore, fewer IH plus PD patients had PLE recurrence than those on IH alone during follow-up (45 percent vs 100 percent; p=0.005).
Notably, patients with thoracic duct obstruction had shorter remission duration than those without obstruction (p=0.0005). Sustained remission rate was higher in the IH plus PH group than the IH only group (40 percent vs 11 percent; p=0.04).
Secondary analysis among initial responders revealed an association between greater cumulative time in PLE remission and a lower risk of death or transplantation (hazard ratio, 0.45 per additional year of remission, 95 percent confidence interval, 0.22‒0.94; p=0.035).
Safety
Adverse events (AEs) occurred frequently in this high-risk population. The most common AEs were transient pancreatitis (75 percent) and hyperbilirubinemia (40 percent), most of which were self-limiting or managed conservatively. The odds of developing serious and catastrophic AEs postprocedurally did not significantly differ between the two groups (level 3c/4/5: 43 percent vs 44 percent; p>0.99; level 4/5: 8.7 percent vs 3.5 percent; p=0.57).
“Our findings demonstrate that a combined IH and PD embolization was associated with a higher rate of initial response and more durable remission with fewer interventions,” said the researchers, who noted two considerations when interpreting these findings.
“First, there were era-related changes in our programme, including the evolution of embolization technique, advances in MRL, refinements in esophagogastroduodenoscopy protocols using water/saline mixtures to localize intestinal lymphatic leaks, and possible shifts in patient referral and selection patterns,” they said.
Temporal changes in imaging and procedural practice, as well as increasing operator experience, could result in lead-time bias and era-related confounding. Thus, the association between IH plus PD embolization and improved PLE outcomes may not be solely attributable to the strategy itself. Furthermore, radiation and procedure time depend on similar confounders.
“Second, these gains must be considered in the context of procedure-related AEs and the absolute rates of sustained remission and transplant-free survival, underscoring that lymphatic embolization entails a meaningful risk–benefit trade-off even in experienced centres,” the researchers said.
“Future studies are needed to define optimal patient selection, assess the benefit of adjunctive medical therapies such as midodrine or steroid tapering, and determine the role of repeat or staged embolization in high-risk populations,” they said. “Advances in lymphatic imaging and access techniques may further improve the safety, precision, and scalability of this approach across institutions.”