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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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RadCases.thieme.com RadCases Interventional Radiology
https://t.me/med1917
92
■
Imaging Findings
A B C
(A) Selected spot lm obtained during digital subtraction angiography (DSA) of the celiac trunk. The gastroduodenal artery (GDA) is not opacied.
(B) Selected image from a superselective injection into the GDA via a microcatheter. A small pseudoaneurysm of the GDA is identied. Active extravasation
into the duodenal lumen is noted (arrow). (C) Selected spot lm from a DSA completion angiogram. Coils identied within the GDA. Patient stabilized.
■ Dierential Diagnosis
• Pseudoaneurysm of the gastroduodenal artery (GDA)
with active bleed.
• Duodenal ulcer: Good possibility, but imaging clearly
shows the pseudoaneurysm.
• Hemobilia: Patient also has a biliary stent, and this is
another good possibility.
■ Essential Facts
• Patients with pancreatic cancer survive longer mainly
because of more aggressive therapies.
• Rare complications are now identied in patients with
pancreatic cancer with longer survival.
• Self-expandable, metallic duodenal and biliary stents are
often seen in these patients.
• Endovascular embolization is technically successful in 90
to 95% of patients.
• Approximately 65 to 70% respond clinically with no
recurrent bleeding.
Pearls and Pitfalls
ü Vessel erosion is possible in patients with long-term
indwelling metallic stents.
ü Clinical suspicion is paramount to identify the problem.
ü Pseudoaneurysms are treatable by coil embolization.
ü These patients are, for the most part, not good surgical
candidates.
ü Recurrent bleeding after embolization will occur 48
to 72 hours after the rst procedure. Second-look
angiography is indicated in these cases because new
sources may be identied.
Case 47
https://t.me/med1917
■ Clinical Presentation
93
A
A 65-year-old patient who underwent an angiographic procedure presents 48 hours after angiography with acute right
lower extremity pain.
■ Further Work-up
B
94
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Selected axial image of a contrast-enhanced CT angiogram of the abdomen, pelvis, and lower extremities. Both femoral arteries are opacied and
appear intact. There is no hematoma or pseudoaneurysm on the right groin. (B) Selected spot lm obtained during selective right lower extremity diag-
nostic digital subtraction angiography. Note a lling defect in the distal popliteal artery.
■ Dierential Diagnosis
• Acute popliteal artery occlusion secondary to AngioSeal footplate migration: Notice the perfectly square-
shaped embolus. The patient had arterial closure with
Angio-Seal (Terumo, Somerset, NJ).
• Plaque embolization after angiography: Possible; however,
the lling defects associated with this problem are
irregularly shaped.
• Groin complication (hematoma, pseudoaneurysm): CT scan
shows normal femoral arteries.
■ Essential Facts
• Complications with closure devices are uncommon.
However, when present, they are dicult to treat.
• The risk of a complication after use of a closure device is
1 to 3%.
• Angio-Seal has a footplate that anchors the collagen plug
to the anterior wall of the artery.
• Faulty closure device placement may result in footplate
migration, which is a very unusual complication.
Pearls and Pitfalls
ü In cases of post-angiography complications, always ask
if a closure device was used.
ü Clean the arterial puncture site with sterile solution
before deploying a closure device.
ü Obesity and age older than 70 are risk factors associated
with device failure.
ü Groin infection with abscess formation is one of the
worst complications of closure devices.
Case 48
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A B
■ Clinical Presentation
95
A 67-year-old man with hematuria presents.
96
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A) Selected axial image of a noncontrast CT scan of the abdomen. A rounded, hyperdense mass is identied in the medial aspect of the right kidney.
(B) Selected image obtained during cryoablation of the right kidney mass. The needle is identied in proper position. (C) Noncontrast CT scan obtained
immediately after ablation. The hypodense area corresponds to the “ice ball” (arrow).
■ Dierential Diagnosis
• Renal cell carcinoma (RCC): Management with
cryoablation. Biopsy was performed immediately before
ablation.
• Other renal tumors: Oncocytoma.
• Pyelonephritis: No clinical or imaging ndings to support
this possibility.
B
Pearls and Pitfalls
ü Cryoablation is essentially painless and, for this reason,
an excellent option for the management of renal
tumors. Procedures can be done under sedation.
ü High-temperature ablation procedures (microwave and
radiofrequency) are painful and require either deep
sedation or general anesthesia.
ü Ideal system for lesions , 3 cm in diameter.
ü Results with larger lesions (. 3 cm) are suboptimal.
■ Essential Facts
• RCC is the most common tumor in the kidney.
• Any renal tumor in an elderly patient is highly suspicious
of RCC and should be addressed.
• These lesions could be asymptomatic and discovered
incidentally.
ü Larger lesions (. 3 cm) require more than one
treatment needle, and long-term results are not as
good.
C
Case 49
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97
A
■ Clinical Presentation
A 70-year-old patient who had a spontaneous right pneumothorax presents. The patient underwent a chest tube placement
in the emergency department. The patient presents with persistent shortness of breath.
■ Further Work-up
B
RadCases.thieme.com RadCases Interventional Radiology
https://t.me/med1917
98
■
Imaging Findings
A B C
(A) Spot lm chest x-ray obtained at presentation in the emergency department. There is a right-sided pneumothorax. (B) Selected image from a contrast-
enhanced CT scan of the chest showing bilateral pneumothorax. A chest tube is seen to cross from the right to the left side through the midline (arrow).
(C) Spot lm after right-sided chest tube insertion. The left-to-right chest tube was removed shortly after this lm was obtained.
■ Dierential Diagnosis
• Iatrogenic left-sided pneumothorax after attempted
right chest tube placement: No good dierential in this
case. This case illustrates an uncommon complication
during a blind procedure.
■ Essential Facts
• Blind chest tube placement to treat pneumothorax is
often performed in the emergency department (ED).
• Complications do occur after these procedures.
• The interventional radiologist will be responsible for
1) identifying the complication and 2) solving the
complication.
• This case illustrates an uncommon complication after a
blind procedure in the ED.
Pearls and Pitfalls
ü In complicated cases, evaluation of previous lms is
essential.
ü Careful evaluation of the case is essential.
ü Image-guided chest tube placement should be oered
in complex cases.
ü Bilateral pneumothorax can be a fatal complication in
an elderly, labile patient.
Case 50
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A B
■ Clinical Presentation
99
A 42-year-old woman presents with menorrhagia.
■ Further Work-up
C D
100
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
C D
(A, B) Selected images from a contrast-enhanced MRI scan of the pelvis showing a hypervascular, irregular uterine mass arising from the muscular layer.
(C) Spot lm obtained from a pelvic digital subtraction angiogram during a broid embolization procedure. (D) Spot lm obtained during a superselective
catheterization of the left uterine artery during an embolization procedure.
■ Dierential Diagnosis
• Uterine broids: Uterine broid embolization procedure.
• Uterine leiomyosarcoma: Unusual tumor, rarely described,
but it is a possibility.
• Adenomyosis: Another relatively common pathology;
however, the appearance of the current case does not
support this possibility.
Pearls and Pitfalls
ü Patient selection and work-up is essential for a good
clinical outcome.
ü Superselective catheterization of the uterine artery
with microcatheter is recommended.
ü Embospheres (Merit Medical, South Jordan, UT) of 500
to 700 microns are frequently used for embolization.
ü Most of these patients require a 23-hour observation
admission.
■ Essential Facts
• Uterine broids are common benign tumors.
• Heavy menstrual bleeding is a common clinical
presentation.
• Other symptoms include urinary frequency, constipation,
and dyspareunia.
• Uterine broid embolization is an accepted therapeutic
option with a very good clinical outcome.
ü Patients should be followed clinically. An MRI scan at
6 months should be part of the follow up and will show
shrinkage of the broids.
ü Endometritis is a rare but major complication that may
require hysterectomy.
Case 51
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101
A
■ Clinical Presentation
A 7-year-old boy presents with a long history of swelling of the left axilla.
B
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