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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
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■
Imaging Findings
A, B C, D
(A) Conventional left renal venography performed from a femoral approach shows retrograde ow of contrast into the left ovarian vein (arrow). The vein
exceeds a diameter of 6 mm, indicating abnormal enlargement. (B) Selective catheterization of the left ovarian vein shows retrograde ow into the more
caudal engorged ovarian venous plexus (arrow) and pelvic veins. (C) Contrast injection of the left pelvic veins results in opacication of the right ovarian
vein via enlarged pelvic vein collaterals (arrow). (D) Image obtained during venous sclerotherapy and embolization. Sclerotherapy of pelvic collaterals and
ovarian veins was performed with sodium tetradecyl sulfate, and coils (arrow) were continued to the distal ovarian vein.
■ Dierential Diagnosis
• Pelvic congestion syndrome.
■ Essential Facts
• Pelvic congestion syndrome (PCS) refers to chronic pelvic
pain from ovarian and pelvic varicosities resulting in
engorgement, thrombosis, and mass eect on regional
nerves. Typical patient age is 20 to 45 years.
• Risk factors include multiparity, retroaortic renal vein,
nutcracker syndrome, and May–Thurner syndrome.
• Presentation varies, but PCS is suspected when pain
accompanies vulvar enlargement and varices of the
perineum, rectum, buttocks, and legs. Pain is often a
chronic (. 6 months), severe, dull, noncyclical ache.
Other symptoms include lethargy, vaginal discharge,
dysmenorrhea, lumbosacral neuropathy, rectal
discomfort, and urinary frequency.
• Multidisciplinary evaluation is required to distinguish
PCS from neoplastic, inammatory, infectious, and other
benign conditions of the gastrointestinal, genitourinary,
orthopedic, and neurologic systems.
• Imaging considerations:
◦ Supine positioning underestimates venous distention.
◦ Pelvic ultrasound is rst-line for uterine and adnexal
pathology and initial identication of varices. Positive
study shows dilated ovarian veins (. 4 mm), dilated
arcuate veins in the myometrium, bilateral varicose
veins in the pelvis, and slow ow (, 3 cm/s) and
reversed ow, particularly in the ovarian vein.
◦ Cross-sectional imaging rules out other pathologic
causes of pelvic pain and diagnoses venous compression
syndromes described above. Venous phase and coronal
images demonstrate varicosities.
◦ MRI/MR venography is the most sensitive study for
pelvic varices, which have ow voids on T1 images, high
signal on T2 images, and enhancement with gadolinium.
◦ Pelvic and ovarian vein venography is performed at the
time of treatment and can be performed from a jugular or
femoral vein approach. Positive ndings include dilated
ovarian vein (. 6 mm), retrograde ow in the ovarian
veins, enlarged collateral veins, and delayed clearance.
• Treatment considerations:
◦ Medical options suppress ovarian function, reduce
inammation, and increase venous contraction.
◦ Hysterectomy for PCS results in recurrent or residual
pain in 20 to 33% of cases.
◦ Laparoscopic bilateral vein ligation is more invasive
than embolization, and studies are limited. Varicosities
are missed by laparoscopy in the majority of cases
because of supine positioning and technical limitations.
◦ Pelvic and ovarian vein embolization and sclerotherapy
is the preferred treatment for PCS and results in a
clinical success rate of 70 to 85%.
• Embolization and sclerotherapy:
◦ Liquid sclerosing and embolizing agents as well as
Gelfoam slurry have been used for venous obliteration.
Coils are commonly used adjunctively.
◦ No change in menstrual cycle or fertility is observed.
◦ Complications occur in 0 to 8% of cases and include vein
perforation, nontarget embolization, embolic migration
to the pulmonary arteries, cardiac arrhythmia, and
thrombophlebitis.
Pearls and Pitfalls
ü Chronic pelvic pain is the primary complaint in 10 to
15% of gynecologic visits, and PCS is a rare cause.
ü PCS is a diagnosis of exclusion.
ü PCS is associated with polycystic ovaries in 50% of cases.
Case 72
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A
■ Clinical Presentation
A 72-year-old man with esophageal carcinoma presents with a markedly painful right chest wall mass.
CB
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■
Imaging Findings
AA
(A) Noninfused CT scan shows a large right chest wall mass (arrow). (B) Two microwave ablation antennae have been inserted (arrows). (C) After 2 months,
there is persistence of a largely cystic mass (arrow), although evidence of tumor progression is seen at the posterolateral aspect of the tumor.
■ Dierential Diagnosis
B C
short treatment times (10 minutes). Disadvantages
compared to the other options include the need for
• Microwave ablation of metastatic chest wall mass for
palliation of symptoms.
grounding pads, the greater risk of skin burns, and the
heat-sink eect—dissipation of thermal energy from
the target lesion caused by adjacent blood vessel and
airways.
■ Essential Facts
◦ Microwave ablation (MA) may be a better option. MA
uses microwave energy to increase kinetic energy of
• Image-guided ablation of lung tumors is a minimally
invasive method to treat both primary and secondary
lung neoplasms. Goals and benets of ablation include
cure of early lung cancer, palliation of metastatic cancer,
and enhancement of the ecacy of chemotherapy or
external-beam radiation.
• Common applications:
◦ Poor surgical candidate because of comorbidities such
as cardiopulmonary disease with early-stage, singular,
malignant lung cancer without hilar, mediastinal, or
extrathoracic involvement (attempt at cure).
◦ Few small nodular metastases without hilar,
mediastinal, or extrathoracic involvement.
◦ Select patients requiring palliation for tumor-related
symptoms.
◦ Poor candidates for lung resection secondary to poor
pulmonary function.
• Severe respiratory disease and underlying interstitial
lung disease such as pulmonary brosis are considered
contraindications. Some patients with apical,
paramediastinal, or mediastinal tumors may be poor
candidates because of the proximity to major vascular
structures.
• Procedures are performed using CT guidance, typically
with IV sedation and analgesia, local anesthesia, and,
occasionally, paravertebral nerve block.
• Ablation options:
◦ Radiofrequency ablation (RFA) is the most commonly
described modality for lung ablation. Oscillating
electrical current between an active and reference
electrode causes electron collisions with the adjacent
molecules, resulting in frictional heating to 60 to
100°C and subsequent necrosis. An advantage is
surrounding water molecules and then transfer heat
energy to the surrounding tissues, causing coagulation
necrosis. Advantages include larger zones of active
heating, higher intratumoral temperatures than RFA,
comparable short treatment times, greater eect on
cystic masses, and the absence of the heat-sink eect.
◦ Cryoablation distributes pressurized argon gas to
an area of lower pressure, causing an ice ball with
temperatures as low as negative 140°C. At negative
40°C, ischemia, protein denaturation, and cell rupture
results. A disadvantage includes longer treatment times
caused by the need for multiple freeze–thaw cycles.
Advantages include less pain and easier assessment of
the ablation zone margin that results from the well-
dened ice ball and surrounding edema.
• After ablation, patients undergo immediate repeat CT
scanning to gauge success and complications, chest
radiograph to rule out pneumothorax, and inpatient
observation for 24 hours to detect and treat developing
complications.
• Outcomes are most reliable for RFA because of larger
published studies with longer follow-up. RFA of stage I
non–small cell lung cancer results in a reported median
survival time of 29 months. Tumors , 3 cm have
statistically lower time to progression compared to larger
lesions.
• Complications include post-ablation syndrome (fever,
malaise, anorexia) caused by circulating tumor necrosis
factor, pain, acute respiratory distress syndrome,
pulmonary or mediastinal hemorrhage, hemoptysis, and
injury to surrounding structures that may result in chest
wall necrosis, pneumothorax, abscess, skin burn, and
bronchopleural stula. Serious complications are rare.
Case 73
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A
■ Clinical Presentation
A 17-year-old girl presents with increasing forearm pain and swelling.
B
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■
Imaging Findings
C
(A) Gadolinium-infused, fat-saturation T1-weighted MRI scan shows innumerable intramuscular channels in the forearm. MR angiography image shows
no arterial supply to the abnormality. (B) Doppler ultrasound shows ow within the channels and no arterial signal. Images A, B shown on previous page.
(C) Conventional venography shows slow ow through the channels (arrows). (D) Sclerotherapy was performed by initially slowing ow with coils (arrow-
head) and then injecting Sotradecol (sodium tetradecyl sulfate; Mylan, Canonsburg, PA) foam into the vascular channels (arrow).
■ Dierential Diagnosis
• Intramuscular venous malformation.
■ Essential Facts
• Venous malformations (VMs) are classied as simple,
low-ow vascular malformations by the International
Society for the Study of Vascular Anomalies. This
category includes capillary malformations (CMs) and
lymphatic malformations (LMs).
• VMs, like other vascular malformations, are present at
birth (often unnoticed), grow during childhood without
involuting, and consist of vascular spaces lined with mature
endothelium. The vascular components have reduced
elastic lamina and smooth muscle leading to ectasia.
Coagulopathy may result in thrombosis, phleboliths, and
Masson’s endothelial hyperplasia (papillary fronds).
• Imaging considerations:
◦ Ultrasound screens for the presence and size of vascular
malformations and measures ow rate by Doppler to
distinguish low ow from high ow.
◦ MRI and MR angiography determine the extent of vascular
lesion and relationship to adjacent structures. Dynamic
gradient pulse sequences evaluate lesion type: high-ow
arteriovenous malformations (AVMs) show signal void
and low-ow AVMs show high signal on T2.
◦ Conventional venography is performed with the intent
to treat in most cases.
• Treatment considerations:
◦ Reassurance may be sucient for asymptomatic or
mildly symptomatic VMs.
◦ Conservative management often involves pressure
garments to slow progression and control symptoms.
Daily low-dose aspirin can minimize pain associated
with regular thrombotic events.
◦ Indications for treatment include hemorrhage, ulceration,
gross deformity, disabling pain, and loss of function.
◦ Percutaneous sclerotherapy is reserved for moderate to
severe symptoms.
◦ Surgical resection may be an option for failed or
incomplete treatment by sclerotherapy and embolization.
• Embolization and sclerotherapy:
◦ Tourniquet application, pressure cu ination, coil
embolization, or balloon occlusion of the venous
outow may be used to make VMs more conspicuous
and slow ow for treatment.
◦ The VM is accessed with a buttery needle equipped
with injection tubing. Contrast is usually hand injected
to obtain a digital subtraction venogram.
◦ Lesion volume, extent, ow rate, and type of venous
drainage are determined.
◦ Sclerosant is injected using a digital subtraction
technique to observe displacement of contrast
previously injected for venography and to prevent
nontarget injection. Common agents include ethanol,
sodium tetradecyl sulfate, polidocanol, and bleomycin.
◦ Compressive garments are often used after sclerotherapy.
◦ Minor complications include swelling, pain, erythema,
blistering, and hyperpigmentation. Major complications
of ethanol include skin necrosis (, 2%), permanent
nerve injury (, 1%), deep venous thrombosis (, 2%),
pulmonary embolism, and muscle contracture
(1%). Other agents have lower rates of these major
complications and rare cardiac complications such as
arrhythmia and cardiopulmonary collapse.
Pearls and Pitfalls
Informed consent for percutaneous treatment of
vascular malformations should include the possibility
that the lesion may require multiple treatment sessions,
may never be fully eradicated, and may recur.
Ethanol is the most eective sclerosant but is the most
likely agent to cause major complications.
Sodium tetradecyl sulfate and polidocanol are slightly
less eective and may result in incomplete treatment
or recurrence, but they have a lower risk of systemic
toxicity, skin necrosis, and nerve injury than ethanol.
Bleomycin is a newer addition to sclerotherapy options.
D
Case 74
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■ Clinical Presentation
A 6-month-old boy with lower-limb hypertrophy presents to interventional radiology clinic for treatment evaluation.
■ Further Work-up
C D
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■
Imaging Findings
C,DA, B
(A, B) Coronal (A) and sagittal (B) T2-weighted MRI images show marked enlargement of the left leg with diuse soft tissue edema (arrow), venous vari-
cosities (large arrowhead), and a network of venous channels suspicious for a venous malformation (VM) (small arrowheads). (C) Conventional venography
performed by injection of a posterior tibial vein shows no opacication of the left femoral vein and instead shows opacication of a markedly enlarged lateral thigh vein (arrow) as well as multiple collateral veins (arrowhead). (D) Repeat conventional venography with a tourniquet in place again demonstrates
no opacication of the left femoral vein and instead shows further opacication of multiple collateral veins suggestive of a VM (arrows).
■ Dierential Diagnosis
• Klippel–Trénaunay syndrome (KTS): Indicated by soft
tissue hemihypertrophy aecting the left leg, venous
varicosities, and absence of the femoral vein.
• Lymphedema: May cause hemihypertrophy, but the
vascular ndings are suspicious for KTS.
• Deep venous thrombosis: Can cause unilateral edema with
absence of femoral vein opacication.
■ Essential Facts
• KTS is most likely a congenital disorder of improper
vascular development diagnosed if at least three of the
following are present: venous malformations (VMs),
varicose veins, capillary malformations, and hypertrophy
of bone or soft tissue.
• Varicose veins and VMs vary in size from small to
markedly dilated, tortuous veins commonly occurring
in the deep and supercial circulations of the limbs,
the scrotum, the mesentery, the bowel, and the solid
intraperitoneal and retroperitoneal organs. Normal
venous pathways may be absent (as in this case), and
persistent embryologic pathways may be present. Venous
thrombosis and thromboembolism may complicate KTS.
• Hypertrophy of soft tissue can result in increased limb
length and diameter.
• Capillary malformations (most common nding) can occur
anywhere, including the walls of the gastrointestinal and
genitourinary tracts, but typically involve the skin of the leg.
Rarely, Kasabach–Merritt syndrome may result, indicated
by thrombocytopenia and consumptive coagulopathy.
• Parkes–Weber syndrome or Klippel–Trénaunay–Weber
syndrome (KTWS) are equivalent terms to describe
KTS with the addition of arteriovenous malformations
(AVMs). Severe cases can result in paradoxical embolus or
congestive heart failure.
• Imaging ndings:
◦ Multiphase contrast-enhanced CT scans, MRI scans,
and Doppler ultrasound images may show capillary
malformations, VMs, varicose veins, and phleboliths.
◦ Cases of KTWS are distinguishable by evidence of high-
ow AVMs, including a nidus with early draining veins
on multiphase contrast-enhanced CT scans associated
with ow voids on MRI scans and arterial waveforms on
Doppler ultrasound images.
◦ The popliteal and femoral veins are the most
commonly aected veins of the lower extremities, and
abnormalities include aplasia, hypoplasia, compression,
and fenestration.
◦ Common collateral pathways of KTS include ascending
lumbar veins, anterior abdominal veins, and the
internal paravertebral venous plexus. A persistent,
embryologic sciatic vein and lateral veins of the lower
extremity also serve as common, collateral pathways.
• Treatment depends on presentation and organ
involvement:
◦ Lower extremity varicosities may be manageable with
sclerosing agents, venous thermal ablation techniques,
and surgical stripping.
◦ AVMs are usually managed by embolization, most
commonly of the venous outow using coils.
◦ Venous thrombosis and pulmonary embolism may
require either anticoagulation or caval ltration.
Pearls and Pitfalls
ü Abnormalities of the iliac veins and inferior vena cava
are rare in KTS.
ü Absence of femoral venous drainage may contraindicate
or limit options for endovascular treatment of venous
varicosities and malformations associated with KTS
because ectatic veins may be the principal drainage of
the leg.
Case 75
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A
■ Clinical Presentation
A 42-year-old man is referred to interventional radiology after a syncopal episode and found to have “cold” ngers.
B
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■
Imaging Findings
C D
(A) Selected arteriogram shows abrupt occlusion of the brachial artery and reconstitution by a large collateral artery. (B) Hand arteriogram shows absence of
perfusion to all proper digital arteries. Images A, B shown on previous page. (C) Following surgical thrombectomy, the brachial artery is patent and a non–
ow-limiting dissection is present (arrow). (D) Following overnight infusion of a thrombolytic agent, ow is restored to most proper digital arteries. The radial
(arrow) and ulnar (arrowhead) arteries are newly thrombosed, likely caused by thromboembolism during thrombolysis, but the hand is supplied by collaterals.
■ Dierential Diagnosis
• Thromboembolism to the digital arteries: Complicating
upstream thromboembolic occlusion of the brachial artery.
• Secondary Raynaud’s (Raynaud’s phenomenon): May
accompany this acute ischemia caused by more proximal
brachial artery obstruction; this option is suggested by
diuse hypoperfusion of all digital arteries rather than
select abruptly occluded arteries.
■ Essential Facts
• Acute occlusion of mid-sized arteries such as the brachial,
femoral, or popliteal arteries most commonly results
from thromboembolism.
• Cardiac sources account for the majority of thromboemboli.
Causes include arrhythmia (most commonly, atrial
brillation), bacterial or fungal endocarditis, valvular
disease, and upstream arterial lesions such as plaque,
aneurysm, dissection, and post-stenotic dilatation.
• In situ thrombosis can complicate other arterial conditions
such as atherosclerosis (typically, ulcerated), vasculitis,
trauma, and iatrogenic injury (e.g., brachial artery puncture).
• Raynaud’s is reversible diminished distal perfusion caused
by vasospasm of the arterioles. Clinical presentation may
include pallor, cyanosis, numbness, and pain brought
on by factors such as traumatic injury, cold, stress, and
ischemia and aggravated by risk factors such as alcohol
and tobacco use. Diagnosis is made by careful history
and physical exam. Imaging studies can be supportive in
equivocal cases, but no imaging study is denitive.
• Imaging considerations:
◦ Echocardiogram and electrocardiogram are performed in
cases of suspected thromboembolism of unknown etiology
in order to rule out cardiac and proximal arterial sources.
◦ Doppler ultrasound is the rst-line screening tool to
diagnose extremity thromboembolism.
◦ CT angiography and MR angiography are used to verify
thrombosis, establish extent and location, and plan
revascularization.
◦ Conventional angiography is the gold standard
to establish the diagnosis and to guide therapy.
Arteriography should include an aortic arch and proximal
upper extremity to look for sources of thromboembolism.
◦ Angiography of the hand is often performed before
and after injection of a vasodilator such as papaverine
to determine the extent of reversible vasospasm
(Raynaud’s) versus xed obstruction.
• Treatment considerations:
◦ Symptomatic brachial artery thromboembolism is
managed by surgical or endovascular thrombectomy/
thrombolysis.
◦ Success rates for thrombolysis of the medium-sized
arteries of the upper extremity are comparable to those
of open surgical embolectomy.
◦ Distal embolization may necessitate overnight
thrombolysis.
Pearls and Pitfalls
ü Raynaud’s phenomenon and Raynaud’s disease are
separate entities:
Raynaud’s phenomenon, or secondary Raynaud’s, is
vasospasm superimposed on another condition—
most commonly scleroderma and mixed connective
tissue disease, and less commonly a broad list
of causes (autoimmune, infectious, neoplastic,
metabolic, hematologic, pharmacologic, frostbite,
and environmental exposure to vibrating tools or
polyvinyl chloride).
Raynaud’s disease, or primary Raynaud’s, is vasospasm
without an underlying disorder. Prevalence is 4 to
5% of the general population, typically presenting in
the second or third decade, rarely causing tissue loss,
and associated with a good prognosis.
ü Thrombosis of mid-sized arterial branches can be
complicated by more distal thromboembolism
(e.g., “trash foot” or “trash hand”), either spontaneously
or during attempts at surgical or endovascular
revascularization.
Case 76
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A
■ Clinical Presentation
A 75-year-old man presents with lower gastrointestinal bleeding.
■ Further Work-up
B C
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