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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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122
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A, B
(A) Aortogram shows enlarged, tortuous uterine (arrows) and ovarian (arrowheads) arteries. (B) Selection of the anterior division of the internal iliac artery
shows the right uterine arterial branch (arrow) supplying tumor vascularity. This uterine artery is smaller than expected for a broid uterus because the
bulk of the supply is from the ovarian arteries in this case. (C) Selective arteriography of the right ovarian artery (arrow) shows extensive supply to the
uterine tumor vascularity. (D) Embolization of the right ovarian artery (arrow), both uterine arteries, and the left ovarian artery was performed by selective
injection of particles.
■ Dierential Diagnosis
• Fibroid uterus: Supplied by both uterine and ovarian
arteries.
■ Essential Facts
• Approximately 30 to 40% women older than 35 years
of age have uterine broids, and approximately 25% are
symptomatic.
• Patients often seek treatment after a known history of
broids and menorrhagia, occasionally with anemia,
and bulk symptoms such as abdominal pain, distention,
urinary frequency, and constipation.
• Diagnostic considerations:
◦ Clinical consultation begins with a history and physical
examination. Endometrial biopsy may be ordered to
rule out uterine malignancy.
◦ Ultrasound is a common screening modality and
often the only imaging required before uterine artery
embolization (UAE). Fibroids can be hypoechoic or have
mixed echogenicity in a heterogeneous uterus.
◦ MRI is used as a primary and sole screening tool by
many practitioners, but others use MRI only when
ultrasound is equivocal for alternative diagnoses,
particularly malignancy.
◦ MRI better demonstrates malignant features that
may indicate the need for hysterectomy and better
demonstrates pedunculated, subserosal broids.
Fibroids are usually low signal intensity on T1 and T2
and enhanced images. On follow-up MRI immediately
after UAE, broid enhancement may suggest clinical
failure.
◦ CT is not routinely used to screen patients for UAE
but is excellent for assessing possible postprocedure
complications such as abscess. Fibroids often have
retained contrast and air in the rst week after UAE.
• Treatment considerations:
◦ Medical therapy is limited to pain control medications
and leuprolide to shrink broids prior to surgery.
◦ Endovascular therapy with UAE treats all broids
permanently. Embolic agents used include permanent
particles for broids and temporary Gelfoam (Pzer,
New York, NY) for postpartum hemorrhage. Typical
recovery consists of an overnight admission for pain
control. Clinical success rates are high (85–96%).
Complications include postembolization syndrome,
infection (endometritis, abscess), sloughing of mucosal
broids, nontarget embolization, vasospasm, and
infertility from ovarian embolization.
◦ Surgical treatment consists of two options.
Hysterectomy cures the patient of broids but is
associated with weeks of recovery and morbidity in
up to 20% of patients. In addition to the denite loss
of fertility, major complications include injury to the
urinary tract, bowel perforation, wound infections,
and adhesions. Myomectomy maintains fertility but
removes the dominant broids without treating all
broids. Thus, it has a high late failure rate (40%).
Pearls and Pitfalls
UAE is often avoided in patients who desire pregnancy,
but in such patients, pregnancy is achieved after UAE at
rates approaching those of the general population.
Leuprolide reduces gonadotropin secretion and creates
a low-estrogen state (drug-induced menopause) but is
only transient in most cases, reversing 3 months after
cessation of therapy.
Failure of UAE is more common in cases of
pedunculated broids, unilateral artery embolization,
and ovarian artery supply.
Studies have demonstrated increased rates of
miscarriage after UAE.
C, D
Case 62
https://t.me/med1917
A B
■ Clinical Presentation
An 84-year-old woman with a history of chronic interstitial lung disease presents for routine CT scans for staging.
123
■ Further Work-up
C
124
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A CB D
(A) Arterial-phase, contrast-enhanced CT scan shows an aneurysm (arrowhead) anterior to the descending thoracic aorta at the level of proximal main
stem bronchi accompanied by enlarged arterial branches (arrow). (B) Conventional selective arteriogram shows markedly enlarged bronchial arteries
(arrow) and an aneurysm (arrowhead) involving the proximal segment of a bronchial artery. (C) Cone-beam CT scan during conventional selective arteriogram through a 5-Fr catheter (short arrow) shows a short neck (long arrows) between the aorta and the aneurysm (arrowhead). (D) The aneurysm was
embolized by packing with coils (arrowhead).
■ Dierential Diagnosis
• Bronchial artery aneurysm.
■ Essential Facts
• Bronchial artery embolization (BAE) is usually performed
for massive hemoptysis (. 300 mL/d), which is caused by
the bronchial arteries (BAs) in 90%, pulmonary arteries in
5%, and systemic arteries in 5% of cases.
• Bronchial artery aneurysms (BAAs) represent , 1% of
cases referred for BAE. More common indications include
recurrent or massive hemoptysis from tuberculosis,
fungal and bacterial infections, chronic bronchitis,
sarcoidosis, cystic brosis, bronchogenic carcinoma, and
bronchial adenoma.
• BAAs are usually singular and result from chronic, benign
lung diseases listed above, although idiopathic cases have
been described. Other causes include Behçet’s disease,
pulmonary sequestration, trauma, systemic connective
tissue disease, and autoimmune vasculitis such as
polyarteritis nodosa, Hughes–Stovin syndrome, and
hyperimmunoglobulinemia E syndrome.
• Aneurysms of the BAs are believed to have a high risk
of life-threatening rupture. For intraparenchymal BAAs,
rupture or erosion into the adjacent bronchial tree causes
hemoptysis. For mediastinal BAAs such as the one in
this case, a mediastinal hematoma results and presents
with pain or mass eect on the esophagus, airway, and
central veins.
• BAE considerations:
◦ The most common BA variations are either two left
BAs and one right intercostobronchial trunk (ICBT)
(40%) or one left BA and one right ICBT (21%). BAs arise
near left mainstem bronchus in 94% of cases (T5 to T6).
◦ Aberrant BAs parallel the bronchi but may arise from
atypical sites such as the aortic arch (most common),
internal mammary arteries, subclavian artery, and the
costovertebral trunk.
◦ CT angiography or MR angiography is critical for
planning BAE for BAAs to determine arterial source,
neck length and diameter, and BA tortuosity. Bronchial
angiography is performed with the intent to embolize.
◦ BAAs are embolized with coils, although preliminary
adjunctive embolization of the more distal (eerent)
bronchial artery branches with permanent particles
may be performed rst to treat chronic lung disease.
◦ The most common complications of BAE are chest
pain, dysphagia, and dissection. Tissue necrosis (lung,
bronchi, and esophagus), transient cortical blindness,
and paralysis due to spinal artery embolization or
injury occur in , 1% of cases.
Pearls and Pitfalls
ü Unlike BAAs, aneurysms of the pulmonary arteries are
almost always mycotic and have a high risk of rupture.
Tuberculosis is the most common cause (Rasmussen’s
aneurysms).
ü Care should be taken to identify spinal arteries during
BAE and avoid selective catheterization, embolization,
or injury of these vessels. “Hairpin-shaped” anterior
medullary arteries arise from ICBT in 10% of cases. The
artery of Adamkiewicz arises from the aorta at the T9
to T12 level in 75% of cases.
ü Surgery may be required when BAE fails or is infeasible.
Case 63
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125
A
■ Clinical Presentation
A 47-year-old man with a history of bilateral femoral deep vein thrombosis that is worsening despite anticoagulation pres-
ents to interventional radiology for inferior vena cava lter placement.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Digital subtraction inferior vena cava (IVC) venography shows two communicating left renal veins forming a loop (arrow). (B) An IVC lter (arrow) has
been placed below the caudal-most renal vein.
■ Dierential Diagnosis
• Duplicated left renal veins: An obvious rst choice.
Cross-sectional imaging would verify that these veins are
circumaortic (one anterior, one posterior).
• Enlarged left lumbar vein: Unlikely, because both veins
join to drain the kidney.
■ Essential Facts
• Anomalies of the renal veins (RVs) and inferior vena cava
(IVC) have been observed by selective renal venography
in 20 to 37% of the general population. Similar ndings
have been observed by cross-sectional imaging and
autopsy studies. The most common anomalies include:
◦ Duplicated (with or without circumaortic) left RV
◦ Retroaortic left RV
◦ Duplicated right RVs
◦ Duplication of the IVC
◦ Azygous continuation of the IVC
◦ Congenital megacava
• Clinical signicance of anomalies of the RVs and IVC
includes:
◦ In patients with multiple RVs, placement of a lter
between the outows of consecutive RVs leaves the
patient vulnerable to future pulmonary embolism (PE)
because a collateral pathway through the RV circulation
remains open and may increase in size over time. As in
this case, the lter is placed below the lowest RV outow.
◦ In the case of duplication of the IVC, the left IVC usually
drains into the left RV. Unilateral infrarenal lter
placement protects the patient from PE originating from
only a single lower extremity. Options for bilateral deep
vein thrombosis or bilateral presurgical prophylaxis
include bilateral lter placement or placement of a
suprarenal lter.
◦ In the case of congenital megacava, placement of a
conventional IVC lter can lead to life-threatening
lter migration to the right atrium. Most lters are
rated for placement in IVCs up to a diameter of 28 mm.
Bird’s nest lters can be placed in IVCs up to 40 mm
in diameter. Alternatively, bilateral common iliac vein
lters can be placed in patients with megacava.
◦ Knowledge of venous anomalies may aect the
technique, success, and safety of major operations such
as renal transplantation or aortoiliac surgery, diagnostic
procedures such as adrenal and renal vein sampling,
and therapeutic procedures such as spermatic vein
embolization for the treatment of varicoceles.
Pearls and Pitfalls
ü Selective injection of the RVs is indicated if anomalies
are suspected.
ü Venography for lter placement usually relies on
detection of RV outow and may miss anomalies.
ü Lumbar veins can be confused for duplicated RVs.
Case 64
https://t.me/med1917
127
A
■ Clinical Presentation
A 54-year-old man presents with cholangiocarcinoma. The plan is for surgical resection.
■ Further Work-up
B C
128
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A) Venous-phase CT scan shows a large, hypovascular right hepatic lobe mass (large arrow) measuring 11 cm in diameter. No cirrhosis is evident, and the
left hepatic lobe is free of tumor and is of normal size (small arrow). (B) Transhepatic portal venography was performed using a contralateral approach by
puncturing the segment 3 portal branch. The right lobe (large arrow) is signicantly larger than the left (small arrow) and demonstrates hypoperfusion
in the region of the tumor. (C) Repeat portal venography after embolization (particles, coils) (arrow) of the branches of the right portal vein. (D) Repeat
CT scan after right lobe resection (large arrow). The left lobe (small arrow) is signicantly larger as a result of preliminary embolization of the portal vein.
■ Dierential Diagnosis
• Right lobe cholangiocarcinoma requiring left lobe
hypertrophy via right portal vein embolization (PVE).
■ Essential Facts
• PVE is performed to facilitate the option for curative
resection in patients with large liver tumors by enlarging
the portion of the liver that will remain after resection
(future liver remnant: FLR).
• Candidates for PVE:
◦ PVE increases FLR so that the volume of resected liver
will not result in perioperative liver dysfunction.
◦ Most patients undergo right PVE for right lobe
hepatectomy in order to hypertrophy the left lobe.
Extended hepatectomy includes both the right lobe and
segment 4 of the left lobe.
◦ The right lobe provides adequate liver function after left
lobe hepatectomy in nearly all cases.
◦ In patients with normal liver function, an FLR of . 20%
is recommended.
◦ In patients with hepatic steatosis or exposure to
hepatotoxic chemotherapy, an FLR of . 30% is
recommended.
◦ In patients with Child–Pugh class A cirrhosis and
preserved liver function, an FLR of . 40% is recommended.
◦ Absolute contraindications to PVE include extensive
ipsilateral tumor thrombus, clinically evident portal
hypertension (contraindication to hepatectomy), and
Child–Pugh class B or C cirrhosis (not candidates for
major resection).
• PVE procedure:
◦ Current liver function is estimated by the indocyanine
green (ICG) test. ICG is cleared exclusively by biliary
excretion. Higher ICG percentage in the blood
15 minutes after intravenous injection indicates poor
hepatic reserve.
B C D
◦ Multiphase contrast-enhanced CT is obtained
for preoperative planning and measurement of
standardized FLR (sFLR: calculated FLR standardized
relative to patient size as a ratio of FLR to total
functional liver volume).
◦ PVE is performed to achieve complete portal occlusion
of targeted segments using embolic agents—usually
glue, coils, and permanent particles. All segments
intended for resection should undergo PVE.
◦ Transhepatic access routes include ipsilateral (portal
vein [PV] of the tumor-bearing liver) and contralateral.
Ipsilateral minimizes the risk of injury to the FLR but is
more challenging.
◦ Periodic portography and portal pressure
measurements are obtained. Portal hypertension is a
contraindication for resection.
Pearls and Pitfalls
ü Hypertrophy of the FLR takes 2 to 4 weeks in otherwise
normal livers and . 4 weeks in cirrhotic livers.
ü Extended right hepatectomy typically leaves an sFLR
, 20%.
ü PVE typically does not cause postembolization
syndrome.
ü Mortality after PVE has not been reported.
ü Major complications are uncommon (, 3%) and
include nontarget embolization of the contralateral PVs
(which excludes the patient from resection), bleeding,
pneumothorax, and cholangitis.
Case 65
https://t.me/med1917
A B
129
■ Clinical Presentation
A 38-year-old man presents with a long history of abdominal pain and a sudden onset of dizziness and palpitations.
■ Further Work-up
C D
130
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A, B C, D
(A) Venous-phase, contrast-enhanced CT scan shows stranding of fat (arrow) surrounding the pancreatic head, suggestive of inammation, infection, or
hemorrhage. (B) CT angiography scan with 3D reformatting shows marked narrowing of the origin of the celiac artery (arrowhead) with post-stenotic
dilatation. No evidence of atherosclerotic change is seen in the aorta or superior mesenteric artery, and the appearance of the celiac artery suggests extrinsic
compression. (C) Selective superior mesenteric arteriogram shows retrograde opacication of the celiac artery and its branches via enlarged anterior and
posterior pancreaticoduodenal arteries (PDAs) (arrowheads). A PDA branch aneurysm is seen (arrow). (D) Superselective arteriogram shows the aneurysm
(arrow) originating from a duodenal artery The aneurysmal duodenal artery was embolized with coils.
■ Dierential Diagnosis
• Median arcuate ligament syndrome (MALS) resulting in
a ruptured pancreaticoduodenal aneurysm: Indicated
by the combination of these two entities on CT scanning
and angiography.
• Pancreatitis with resultant aneurysm formation: A possibility,
given the fat stranding surrounding the pancreatic head.
■ Essential Facts
• MALS is compression of the celiac artery by the median
arcuate ligament of the diaphragm. MALS is far more
common in females and has a wide age range—from
adolescence to elderly patients (median, 35 years).
• In addition to celiac artery compression, chronic
irritation/inammation of the celiac ganglion/plexus
is postulated as a cause for MALS. Disruption of the
ganglion improves outcomes after surgery.
• In addition to a congenital cause, MALS has been
observed after abdominal surgery (e.g., liver
transplantation), pancreatitis, and trauma.
• Clinical presentation is mild to severe abdominal pain,
particularly during exercise and after eating, chronic
intermittent nausea and diarrhea, and signicant weight
loss (. 20 pounds). An epigastric bruit may be detected
during exhalation.
• Untreated, MALS can cause xed stenoses, aneurysms, or
complete occlusion of the celiac artery with enlargement
of pancreaticoduodenal collateral pathways to supply the
celiac distribution. Aneurysms of PDAs may result, which
carry a high risk of rupture.
• Physical exam and imaging studies are performed, both
stressed (exhalation) and unstressed (inhalation).
• Imaging considerations:
◦ Doppler sonography is a useful screening tool as well
as a follow-up imaging test after treatment. Look for
velocity . 200 cm/s, respiratory variation in velocity
measurements, and grayscale imaging showing stenosis
and post-stenotic dilatation.
◦ CT/CT angiography (CTA) veries MALS and excludes
inammatory and neoplastic causes of mesenteric
ischemia.
◦ MRI/MR angiography (MRA) is an alternative to CT/CTA.
◦ Conventional angiography best demonstrates xed
versus transient stenosis (varying with respiration),
aneurysms, and the direction and pathway of collateral
circulation.
◦ Conventional angiography, CTA, and MRA images
typically show compression of the cranial aspect of
the celiac trunk, often slightly distal to the origin. A “J”
conguration of the celiac artery may result.
• Treatment considerations:
◦ Surgical release of the median arcuate ligament with
disruption of the celiac ganglion is the rst-line
treatment.
◦ Endovascular revascularization with angioplasty or
stent placement is contraindicated prior to median
arcuate ligament release to prevent further arterial
injury, early recurrence (angioplasty), and deformation
and fracture of balloon-expandable stents.
◦ Angioplasty and stent placement are options for
residual stenosis of the celiac artery after median
arcuate ligament release.
◦ Embolization should be performed for aneurysms
of collateral arteries (most commonly, the PDAs and
branches) because the rate of life-threatening rupture
associated with visceral artery aneurysms is high. Coil
embolization is standard.
Pearls and Pitfalls
ü With strict patient selection, 65 to 75% describe
symptom relief after surgical release of the median
arcuate ligament.
ü Compression occurs in 5 to 20% of asymptomatic
people; clinical correlation is vital.
ü Absence of rigorous patient screening can lead to an
overdiagnosis of MALS, contributing to a lowered
success rate for surgical decompression
Case 66
https://t.me/med1917
131
A
■ Clinical Presentation
A 65-year-old man presents with swelling and persistent bleeding at the stomal site of a gastrostomy tube 1 day after
placement.
■ Further Work-up
B
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