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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3627_Библиотеки_им_академика_М_И_Перельмана
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82
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A) Selected axial image from a contrast-enhanced CT scan with pulmonary embolism protocol at the level of the pulmonary artery bifurcation. The image
shows bilateral large emboli in the main right and left pulmonary arteries (arrows). (B) Axial image of the same study at the level of the ventricles. The
right-to-left ventricular (RV/LV) ratio has been measured. The diameter of the RV (black line) is larger than the diameter of the LV (white line). The ratio in
this case is . 1.0.
■ Dierential Diagnosis
• Massive pulmonary embolism (PE) with right
ventricular strain: The images show large bilateral
emboli in the main pulmonary arteries. The right-to-left
ventricular (RV/LV) ratio is . 1.0.
• Pulmonary embolism: This diagnosis is incomplete. The
complete diagnosis needs to describe the RV/LV ratio.
■ Essential Facts
Pearls and Pitfalls
ü The RV diameter is measured in the section that shows
the tricuspid valve at its widest.
ü The LV diameter is measured in the section that shows
the mitral valve at its widest.
ü Ventricles are measured from inner wall to inner wall.
ü A properly measured RV/LV ratio . 1, indicates right
ventricular strain and is associated with an increased
risk of adverse outcome and may be used as a
parameter to dictate more aggressive treatment.
B
ü Failure to report RV/LV ratio in a CT scan PE protocol
• Careful evaluation of CT scans with PE protocol is
essential.
• Emboli location needs to be described (main, lobar,
segmental).
• The RV/LV ratio needs to be specied in the summary of
the radiology report.
constitutes an incomplete report.
ü Failure to report RV/LV ratio may delay patient
treatment and result in a poor outcome.
Case 42
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83
A
■ Clinical Presentation
A 28-year-old man who is infertile underwent a venographic procedure.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B C D
(A) Spot lm obtained during a selective venogram of the left spermatic vein. There is reux to the spermatic veins distally, within the scrotal area. Note
that there are multiple small venules. (B) Venogram after coil embolization of one of the main spermatic venous branches. Note that there is still a large,
patent venous branch that has not been embolized. (C) Spot lm obtained during alcohol injection into the spermatic veins, with the intent to sclerose the
venous branches. (D) Spot lm obtained after deployment of an Amplatzer plug (St. Jude Medical, St. Paul, MN) into the main trunk of the spermatic vein
(arrow), completely sealing this venous system.
■ Dierential Diagnosis
• Left varicocele: Venogram shows reux of contrast via
incompetent spermatic veins.
• Incompetent ovarian vein causing pelvic congestion: This
is a male patient. This condition is similar in women but
causes dierent symptoms.
■ Essential Facts
• Incompetent gonadal veins cause symptoms in men
and women. In men, it can cause testicular pain and
infertility. In women, it mainly causes symptoms of
pain and dyspareunia, the so-called “pelvic congestion”
syndrome.
• The left gonadal vein is usually more frequently aected
because of its anatomy. It drains directly into the left
renal vein. The right spermatic vein drains directly into
the inferior vena cava (IVC).
Pearls and Pitfalls
ü Distally, in the pelvis, the gonadal veins are multiple
small venous channels. These channels fuse into a single
trunk that drains directly into the renal vein on the left
side and directly into the IVC on the right side.
ü There is a small valve at the junction of the left
spermatic vein and the left renal vein. When this valve
is incompetent, reux occurs and causes varicocele in
men and pelvic varices in women.
ü Symptomatic patients can be treated surgically or with
direct transcatheter sclerotherapy and coils.
ü Sclerosing agents include alcohol, sodium tetradecyl
sulfate (Sotradecol; Mylan, Canonsburg, PA), and boiling
contrast.
ü Injection of sclerosing agents should be conducted
with extreme care. Orchitis with severe testicular pain
can occur if the sclerosing agent leaks into the venous
channels in the scrotum.
Case 43
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85
A
■ Clinical Presentation
A 67-year-old man with head and neck cancer presents to the emergency department with massive bleeding from the
mouth.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Spot lm from digital subtraction angiography (DSA) of the right carotid artery. There is a small pseudoaneurysm in the medial aspect of the right
common carotid artery with contrast extravasation (arrow). (B) Spot lm from a DSA obtained after stent graft placement. The extravasation is no longer
identied.
■ Dierential Diagnosis
• Carotid blowout syndrome (CBS) in a patient with
head and neck cancer: Image (A) shows an area of active
extravasation into the soft tissues. This patient had a
history of head and neck cancer.
• Carotid artery trauma: There was no history of trauma in
the present case. Images can be quite similar in a case of
trauma.
• Ulcerated atherosclerotic plaque: Other ndings of
atherosclerosis should be identied.
■ Essential Facts
• CBS is considered a complication of tumor radiotherapy.
• Bleeding may be massive. Patients may die secondary to
choking with blood products.
• More frequent in patients with a history of tumor
radiotherapy.
Pearls and Pitfalls
ü Careful evaluation of imaging studies is important.
Bleeding site may be subtle.
ü Surgical and endovascular techniques are available to
treat this complication.
ü These patients have extremely poor prognosis. Bleeding
may persist even after endovascular correction.
Case 44
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87
A
■ Clinical Presentation
A 73-year-old man with a nonhealing ulcer in the right foot presents; he underwent an arteriogram with intervention for
limb salvage.
■ Further Work-up
B
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A) Spot lm from a digital subtraction angiogram (DSA) of the right lower extremity. The anterior tibial artery shows a severe stenosis in the proximal and
mid-segment. (B) Spot lm from a DSA after angioplasty of the anterior tibial artery. Contrast extravasation is identied, indicating arterial perforation.
(C) Spot lm obtained during retrograde anterior tibial artery pedal access. A 0.018-inch wire has been advanced retrograde. (D) Spot lm from a DSA
obtained after retrograde recanalization of the anterior tibial artery and angioplasty. The result is excellent, with , 30% residual stenosis, and contrast
extravasation is no longer identied.
■ Dierential Diagnosis
• Arterial rupture during recanalization procedure:
There is no good dierential diagnosis.
B C
Pearls and Pitfalls
ü Careful technique is essential to success. Buckling of the
wire or diculty advancing wires or catheters indicates
extraluminal location.
D
ü Always consider a pedal approach in these cases. It may
■ Essential Facts
be easier.
ü The use of drug-eluting balloons for angioplasty has not
• Endovascular management of distal peripheral vascular
disease has progressed immensely.
• The high technical and clinical success rates have made
the endovascular approach the option of choice for limb
salvage procedures.
• Primary and secondary patency rates at 1 year can be as
high as 80 and 87%, respectively.
• The challenge is to thread a guidewire through the
occlusion without vessel damage.
resulted in better outcomes.
ü The operator performing these cases should be
prepared to solve unexpected complications.
ü Arterial perforation, bleeding, hematoma, and arterial
thrombosis are common complications.
Case 45
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A B
■ Clinical Presentation
A 65-year-old woman presents with acute onset of lower extremity pain.
89
■ Further Work-up
C
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
C
(A) Selected image from a contrast-enhanced CT scan of the abdomen and pelvis. No contrast is identied in either internal iliac artery (arrows). (B) Axial
image on the same patient at the level of the femoral heads. Note lack of opacication of the left femoral artery. (C) Reconstruction of the left arterial iliac
system. Note the lling defects within the common femoral artery and the internal iliac artery (arrows).
■ Dierential Diagnosis
• Acute embolic occlusion of the left supercial femoral
artery and internal iliac arteries.
• Acute dissection: Images not consistent with this option.
Aorta and iliac arteries are normal.
• Chronic arterial occlusion: Images show large lling
defects within the internal iliac arteries and left common
femoral artery.
■ Essential Facts
• Acute embolic occlusion occurs more frequently in
elderly patients.
• Atrial brillation is a risk factor.
• The presence of ulcerated plaque in the thoracic or
abdominal aorta is a risk factor.
Pearls and Pitfalls
ü Look at the electrocardiogram.
ü Request images of the thoracic aorta if not available.
ü If pressed for “unusual” causes, think “shaggy aorta” or
“paradoxical embolism.”
ü The ndings need to be promptly identied and
reported.
ü Look for emboli in other arteries (branches of the
superior mesenteric artery, renals).
Case 46
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■ Clinical Presentation
A
B
A 70-year-old patient with pancreatic cancer presents with massive upper gastrointestinal bleeding.
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