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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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152
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A) Arterial-phase contrast-enhanced CT scan shows active extravasation (arrow) into the cecum. (B) Early arterial-phase angiogram of the ileocolic artery
shows an abnormal tuft of tortuous vessels (arrow) and an early draining vein (arrowhead). (C) Capillary-phase image better demonstrates ow through
this tuft (arrow) and shows early drainage into a mesenteric vein branch (arrowhead). (D) No further opacication of the tuft is seen after coil placement
(arrow) into the feeding ileocolic branches.
B
C
■ Dierential Diagnosis
treatment.
• Angiodysplasia: Suggested by an early draining vein in
the arterial phase of angiography.
• Arteriovenous malformation: Would be suggested by an
abnormal nidus of more prominent arterial branches
draining into an early draining vein.
• Neoplasm or infection: Can cause arteriovenous shunting.
■ Essential Facts
• Angiodysplasia is an abnormal tuft of vessels in the bowel
wall associated with an early draining vein. This entity
typically occurs in older adults.
• This is most likely an acquired condition, most commonly
occurring in the cecum but described from the stomach
to the rectum, likely resulting from the development
of abnormal vascularity (veins, venules, and enlarged
capillaries) over time in areas of mural stress.
• A more unusual dierential possibility is a Dieulafoy lesion,
which is bleeding caused by an abnormally large (1–5 mm
diameter) artery just below the mucosa. This entity has
been described from the esophagus to the colon and is
treatable by transarterial embolization (TAE) or endoscopy.
• Heyde’s syndrome (HS) is aortic valvular stenosis combined
with gastrointestinal (GI) bleeding from angiodysplasia.
HS is thought to result from proteolysis of von Willebrand
factor because of turbid ow. Loss of this clotting factor
results in bleeding from preexisting angiodysplasia.
• Imaging considerations:
◦ CT angiography may be used instead of the technetium-
99m tagged red blood cell study to detect subtle causes
◦ CT requires the absence of oral contrast agents, a carefully
timed arterial-phase study, and multiphase imaging.
◦ Conventional angiography often provides better
visualization of angiodysplasia than CT, particularly in
the absence of active extravasation.
• Treatment considerations:
◦ Endoscopy with cautery, laser treatment, or injection of
the tuft with sclerosing agents tends to be the rst-line
treatment because angiodysplasia has a tendency to
recur after TAE.
◦ Surgical resection is considered a better second-line
treatment than endoscopy by many clinicians because
of the high rates of recurrence reported with TAE.
◦ TAE is associated with high rates of recurrence but
is commonly performed in patients with severe
bleeding that obscures endoscopic visualization. When
angiodysplasia is discovered by conventional angiography,
concurrent embolization is attempted. Superselective
particle injection may be added to microcoil embolization
to decrease the likelihood of recurrence.
Pearls and Pitfalls
ü In the left colon, diverticulosis predominates as the
most common source, and TAE is a more denitive
treatment for this entity.
ü The higher ratio of angiodysplasia to diverticula in
the right colon compared to the left is responsible for
a higher rate of recurrence after TAE or endoscopic
treatment of right colonic bleeding.
D
Case 77
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A
■ Clinical Presentation
A 65-year-old man with a history of cirrhosis and hepatocellular carcinoma presents with recurrent upper gastrointestinal
hemorrhage despite two attempts at endoscopic management. No esophageal varices were noted by the endoscopist.
■ Further Work-up
B C
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■
Imaging Findings
A
(A) Coronal reformatted, venous-phase, contrast-enhanced CT shows gastric varices (arrow) and a large, exophytic hepatic mass (arrowhead) involving
the right lobe of a nodular liver consistent with a history of hepatocellular carcinoma and cirrhosis. (B) From a transfemoral approach, a large gastric varix
(arrow) was catheterized at the junction of the left renal vein and left adrenophrenic trunk. (C) Coil-assisted retrograde transvenous obliteration (CARTO):
the caudal-most portion of this branch was embolized to stasis with coils (arrowhead); the varices were then injected with a slurry of Gelfoam (Pzer, New
York, NY) particles and dilute contrast material. No further bleeding was noted during his hospital stay, and the patient was discharged.
■ Dierential Diagnosis
• Bleeding isolated gastric varices (IGVs).
■ Essential Facts
• IGVs result most commonly from cirrhosis or splenic vein
(SV) thrombosis and drain via physiologic portosystemic
shunts—most commonly the gastrorenal pathway (as in this
case). Alternative or adjunctive eerent drainage includes
phrenic, pericardiac, ileocolic, and azygo-esophageal veins.
• Upper gastrointestinal endoscopy is the rst-line
method of diagnosis and treatment of bleeding IGVs. For
refractory cases, treatment options depend on patency
of the SV and portal vein (PV). Therefore, Doppler
ultrasound is a useful tool for screening patients.
• If the SV is patent, options include transjugular
intrahepatic portosystemic shunt (TIPS) versus balloonoccluded retrograde transvenous obliteration (BRTO).
◦ BRTO involves occluding the physiologic shunt and
injecting an embolic or sclerosing agent into the entire
variceal system to cause occlusion.
◦ TIPS involves endovascular shunt creation from the
portal to the systemic veins.
• In the setting of PV thrombosis or chronic occlusion:
◦ If the PV is completely occluded, BRTO may result in
mesenteric venous thrombosis, ischemia, and increased
bleeding from untreated varices.
◦ If the PV is partially thrombosed, BRTO may improve
spontaneous recanalization by improving PV ow.
◦ Options include surgical shunts and PV recanalization
with TIPS.
• In the setting of SV occlusion:
◦ BRTO may result in mesenteric venous thrombosis,
ischemia, and increased bleeding from untreated varices.
◦ Options include surgical splenectomy and partial
splenic embolization.
• BRTO considerations:
◦ Pre-procedural planning using contrast-enhanced CT or
MR venography is essential.
◦ Alternatives to balloon occlusion (BRTO) of the eerent
outow avoid prolonged balloon access and ination.
These include plug-assisted (PARTO) and coil-assisted
(CARTO) occlusion, as in this case.
◦ Injection of an embolic agent (e.g., Gelfoam slurry, as in
this case) or a sclerosing agent (typically a mixture of
lipiodol, Sotradecol [Mylan, Canonsburg, PA], and air to
create a foam).
◦ After a period of hours, the balloon is deated and
removed. For PARTO and CARTO, no balloon is required,
and sheaths and catheters are removed immediately
after the procedure.
◦ Success rates for terminating active bleeding exceed
90%. Recurrence rates range from 0 to 10%.
◦ Possible major complications include cardiac
arrhythmia, pulmonary embolism, PV or renal vein
thrombosis, as well as aggravation of ascites, eusions,
and other varices (esophageal, stomal, and duodenal).
Pearls and Pitfalls
ü BRTO may actually improve liver function and
encephalopathy.
ü TIPS has been shown to be less eective than BRTO for
IGVs but may be an option in the setting of concurrent
bleeding esophageal varices.
ü BRTO increases portal hypertension and may exacerbate
or cause ascites or bleeding esophageal varices.
ü TIPS bypasses intrahepatic ow and exacerbates liver
failure and encephalopathy; it may be contraindicated
when these conditions preexist.
B, C
Case 78
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A
■ Clinical Presentation
• A 66-year-old man presents to interventional radiology for treatment of refractory ascites.
■ Further Work-up
B, C D
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■
Imaging Findings
B–DA
(A) Noninfused CT shows massive ascites. (B) Chest radiograph shows interval placement of a peritoneovenous catheter (arrow) tunneling along the an-
terior chest wall and entering the right internal jugular vein. (C) CT shows a port reservoir (arrow) placed within the right lower chest wall. (D) A catheter
enters the abdominal cavity (arrow). The ascites is markedly reduced.
■ Dierential Diagnosis
• Refractory ascites resulting from cirrhosis treated with
peritoneovenous shunt placement.
■ Essential Facts
• Refractory ascites (RA) refers to a condition in
which ascites continues to accumulate despite
the administration of maximum doses of diuretic
medications.
• The most common causes of RA presenting for
management in interventional radiology are cirrhosis
and malignancy. When associated with cirrhosis, RA is
associated with a median survival rate of 50% at 1 year.
• Treatment options:
◦ Frequent large-volume paracentesis (LVP) with albumin
infusion has been the standard treatment of RA, but
limitations include the need for frequent hospital visits
and the risk of peritoneal infections from frequent
interventions.
◦ Permanent peritoneal catheters tunneled under
the skin and inserted into the peritoneal cavity are
commonly placed for malignant RA. Risks include
peritoneal infection and adhesions, but the incidence of
these complications is low because of the short survival
associated with malignant RA.
◦ Peritoneovenous shunts have been used for benign and
malignant causes of RA and require regular pumping
of the port reservoir by the patient to return ascitic
uid to the venous circulation. Patients with cirrhosis
who are poor candidates for transjugular intrahepatic
portosystemic shunts (TIPS) may benet from
peritoneovenous shunts.
◦ TIPS is performed for RA related to cirrhosis and results
in a marked improvement in transplant-free survival
compared to LVP (93% compared to 52%). Long patency
rates of covered stents have resulted in the preferential
use of TIPS over LVP for TIPS candidates with RA.
◦ Liver transplantation is the ultimate cure for RA,
but only 20% of patients achieve this goal because of
limitations in graft availability and patient candidacy.
• Complications of peritoneovenous shunts include shunt
occlusion, infection, post-shunt coagulopathy, deep
venous thrombosis, catheter breakage, and leaks.
Pearls and Pitfalls
Peritoneovenous shunts are totally implanted and
therefore have a lower risk of peritoneal infection
compared to external permanent peritoneal drains.
Advantages of peritoneovenous shunts include their
applicability to patients who are not TIPS candidates
(e.g., with hepatic encephalopathy) and their
applicability to a variety of benign and malignant
causes of RA.
A disadvantage of peritoneovenous shunts compared to
external permanent drains is the need for an incision to
clear, reposition, or replace the shunt catheter.
A disadvantage of peritoneovenous shunts over TIPS
in patients with cirrhosis is the need for continued
pumping of the ascites by the patient and the failure of
peritoneovenous shunts to reduce portal hypertension.
Case 79
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A
■ Clinical Presentation
A 65-year-old man presents with intermittent claudication of the right leg.
B C
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■
Imaging Findings
B, CA
(A) Pelvic digital subtraction angiography shows bilateral stenoses of the common (large arrows) and external (small arrows) iliac arteries. (B) Repeat pelvic
digital subtraction angiography centered on the right iliac arteries after successful stent placement in the common (large arrow) and external (small arrow)
iliac arteries. (C) Unsubtracted angiogram shows placement of both stents (arrows), sparing the origin of the internal iliac artery between them.
■ Dierential Diagnosis
• Atherosclerotic stenosis of the iliac arteries.
■ Essential Facts
• Chronic aortoiliac peripheral atherosclerotic disease
(PAD) is less common than femoropopliteal PAD but is
more commonly symptomatic due to the greater number
of muscle groups subjected to reduced perfusion.
• Aortoiliac PAD tends to occur in younger patients
compared to femoropopliteal PAD. Risk factors include
cigarette smoking, hypercholesterolemia, high blood
pressure, and diabetes.
• Noninvasive work-up:
◦ History and physical exam immediately distinguish
chronic from acute aortoiliac disease. Patients with
chronic aortoiliac PAD often have diminished femoral
pulses. Other evaluations include capillary rell, skin
quality, color (pallor), and qualitative temperature, as
well as the presence of tissue loss.
◦ Ankle-brachial indices (ABIs) and lower extremity Doppler
ultrasound should be performed in all patients with
chronic limb ischemia. A normal ABI of 1.0 indicates that
the blood pressure is equivalent in the arms and legs. An
ABI of 0.3 to 0.5 corresponds to severe claudication, and
an index of , 0.3 corresponds to rest pain and tissue loss.
◦ Abnormal resting or post-exercise ABIs in candidates
for intervention should prompt MR angiography or CT
angiography; these tests have replaced conventional
angiography, which is usually reserved for guiding
treatment.
• Medical management options:
◦ Risk modication in all patients: smoking cessation and
control of hyperlipidemia, diabetes, and hypertension.
◦ Supervised exercise program and antiplatelet regimens
apply to select patients. Supervised exercise may result
in better treadmill walking performance after 6 months
compared to primary stent placement.
◦ Unlike patients with infrainguinal PAD, patients with
aortoiliac PAD may be considered for intervention
without undergoing extensive medical therapy.
• Surgical treatment options:
◦ Aortofemoral bypass is the gold standard and has a
. 85% 5-year patency with a 2% perioperative mortality.
◦ Other bypass options: iliofemoral, femorofemoral,
axillofemoral, and descending thoracic aorta-tofemoral.
• Endovascular treatment options:
◦ Percutaneous transarterial angioplasty (PTA):
First-line option for patients with symptomatic
aortoiliac PAD and short, concentric, stenosis in larger
arteries with favorable outow.
Factors that portend a poorer long-term patency
include poor distal runo, long lesion length
(. 3 cm), small stent diameter (, 8 mm), and
complete occlusion of the target vessel.
◦ Stents:
For simpler lesions described previously, stents are
usually reserved for unfavorable results, ow-
limiting dissections, residual stenoses . 30%, and
residual systolic pressure gradient of . 10 mm Hg.
Stents are used for longer lesions, after recanalization
of occluded arteries, and for recurrent disease.
Pearls and Pitfalls
ü Heparin is controversial for aortoiliac interventions.
Some believe that the high ow makes anticoagulation
unnecessary.
ü In a meta-analysis of 14 studies with 2,116 patients
comparing PTA with PTA and stent placement for
aortoiliac PAD, stents resulted in higher technical
success (96% vs. 91%), higher immediate postprocedure
ABI (0.87 vs. 0.76), and higher 4-year primary patency
(77% vs. 65%).
ü Possible complications of endovascular therapy
include puncture site complications in , 5% (bleeding,
pseudoaneurysm, arteriovenous stula), lesion
site complications in 3 to 4% (dissection, rupture,
thrombosis), distal embolization in , 3%, and systemic
complications in , 1% (renal failure, myocardial
infarction, contrast reaction).
Case 80
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A
C
B
■ Clinical Presentation
A 38-year-old woman has a history of a Whipple procedure causing splenic and portal vein thrombosis. She presents with
gastric and esophageal varices refractory to endoscopic management.
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■
Imaging Findings
BA C
(A) Contrast-enhanced CT shows large gastric varices (arrow). Large esophageal varices were noted on endoscopy. The splenic and portal veins are occluded.
(B) Celiac digital subtraction angiography shows patency of all celiac branches. A gastric balloon (arrows) has been inated to tamponade bleeding varices.
(C) The middle branches of the spleen have been successfully embolized with coils (arrows), sparing the upper and lower poles. The gastric balloon was
removed within 24 hours of embolization without further bleeding.
■ Dierential Diagnosis
• Gastroesophageal varices caused by portal and splenic
vein occlusion.
■ Essential Facts
• In all cases of variceal bleeding resulting from either
chronic portal vein thrombosis (PVT) or chronic splenic
vein thrombosis (SVT), medical management is rst line,
including attempts at pharmacologic reduction of portal
pressure and endoscopic variceal ligation or sclerotherapy.
• In cases of SVT and PVT, when medical management
fails, standard endovascular options such as transjugular
intrahepatic portosystemic shunt (TIPS) and balloonoccluded retrograde transvenous obliteration (BRTO) are
limited.
• Chronic portal vein thrombosis (PVT):
◦ Commonly leads to cavernous transformation and
isolated gastric varices
◦ The combination of portal vein recanalization and TIPS
is an option to relieve symptoms of portal hypertension,
such as ascites and gastroesophageal variceal bleeding.
◦ BRTO risks mesenteric venous thrombosis by obliterating
large physiologic portosystemic shunts because cavernous
transformation is likely insucient to accommodate the
resultant increased portal venous ow.
◦ Direct puncture of an intraparenchymal branch of the
splenic vein may facilitate transsplenic portal vein
recanalization.
◦ Surgical portosystemic shunt creation is an alternative
option (mesocaval or splenorenal).
• Chronic splenic vein thrombosis (SVT):
◦ Commonly leads to isolated gastric varices
◦ Portal venous pressure is normal in the absence of
chronic liver disease, and TIPS is not an option.
◦ BRTO risks markedly increasing variceal bleeding by
obliterating large physiologic portosystemic shunts.
◦ Surgical splenectomy is a rst-line option.
◦ Alternatively, direct puncture of an intraparenchymal
branch of the portal vein facilitates trans-hepatic
splenic vein recanalization in some cases.
◦ If splenic vein recanalization fails, selective variceal
sclerosis rather than complete BRTO may be an option
for poor surgical candidates.
• In this case, the combination of SVT and PVT has resulted
in drainage of the splenic venous outow through
large bleeding gastric and esophageal varices. Medical
management has failed, and endovascular options such
as TIPS, BRTO, and venous recanalization do not apply.
• Partial splenic embolization (PSE) reduces splenic
arterial and venous ow and, as a result, reduces portal
hypertension. PSE has been applied to bleeding gastric
varices for which medical therapy has failed and other
endovascular methods have failed or are infeasible, as in
this case.
Pearls and Pitfalls
ü PSE has been described using a variety of embolic
agents, including particles, coils, and plugs.
ü Approximately 50% of splenic arterial distribution is
embolized.
ü Other indications for PSE include:
Splenic laceration
Portal hypertension in a poor TIPS candidate because
of hepatic encephalopathy
Hypersplenism (thrombocytopenia, leukopenia,
anemia, splenomegaly, particularly in patients with
cirrhosis)
Portal hyperperfusion syndrome in patients with
small-for-patient-size liver transplant grafts
resulting in excessive portal venous ow. These
patients are at risk for hepatic artery thrombosis
and graft loss.
Case 81
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A
■ Clinical Presentation
A 45-year-old woman presents with gross hematuria and a history of diabetic nephropathy.
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