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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
172
■
Imaging Findings
A, B, C D, E
(A) Selective left renal vein venography shows a vertical indentation (arrow) suggestive of extrinsic compression of the medial aspect of the vein, limiting
ow. The pressure gradient across this narrowing measured 11 mm Hg. (B) The left ovarian vein is surgically occluded (large arrow) but reconstituted by a
large collateral vein (arrowhead). Flow spontaneously reuxes caudally across a rich ovarian venous plexus (small arrow) to the pelvic veins. (C) Cross-pelvic
varices (arrow) ll spontaneously with continued injection. (D) The ovarian vein and collateral veins were obliterated by a combination of embolization
using coils (arrow) and sclerotherapy using an injection of sodium tetradecyl sulfate. (E) The renal vein was successfully stented (arrow).
■ Dierential Diagnosis
• Nutcracker syndrome causing pelvic congestion
syndrome.
■ Essential Facts
• Nutcracker syndrome (NS) is compression of the left
renal vein (RV) between the superior mesenteric artery
(SMA) and the aorta causing increased RV pressure and
dilation of the gonadal and pelvic veins.
• Presentation is usually in thin younger women, but NS
has been described in children and men. Symptoms
may include gross hematuria caused by distention
of periureteral venous collaterals, proteinuria, pelvic
congestion syndrome (PCS) in women, and varicocele in
men.
• PCS is chronic pelvic pain in the setting of dilated
ovarian (left . right) and periuterine veins, dyspareunia,
labial and perineal varices, and the absence of an
alternative explanation such as endometriosis, broids,
adenomyosis, or pelvic infection.
• Imaging options:
◦ Ultrasound screens for RV obstruction and venous
abnormalities described below.
◦ Contrast-enhanced CT or MRI is obtained prior to
conventional venography to determine the cause of RV
obstruction. Contrast-enhanced CT scans may show
a diminished angle between the SMA and the aorta,
extrinsic compression of the RV between the SMA and
aorta, dilated pelvic veins, and absence of additional
pathology to explain the patient’s symptoms.
◦ Conventional venography is the diagnostic imaging tool
of choice and typically shows compression of the left
RV, perirenal varices, retrograde lling of a dilated left
gonadal vein (. 5 mm), and an elevated pressure gradient
between the RV and inferior vena cava (. 2 mm Hg).
• Treatment options:
◦ Stent placement in the left RV is the most common
treatment, but its utility is not well established by
published studies.
◦ Embolization and sclerotherapy of the gonadal venous
plexus may be required in addition to the RV stent
when venous congestion is marked or persistently
symptomatic (varicocele or PCS). This rich plexus
results in recurrence after focal coil embolization or
surgical ligation. More complete obliteration with coils
and sclerosing agents reduces this risk.
◦ In cases of PCS without NS, endovascular gonadal vein
obliteration, laparoscopic gonadal vein ligation, and
hysterectomy have been reported.
Pearls and Pitfalls
Most cases of PCS occur in the absence of NS and are
caused by retrograde reux of blood from the RVs
through the gonadal veins and into the pelvic veins due
to valvular incompetence.
Ultrasound, MRI, and conventional venography should
be performed with the patient upright or reverse.
Trendelenburg if possible, because supine positioning
can underestimate gonadal and pelvic venous dilation
in cases of PCS.
Gross hematuria can have multiple causes identiable
on renal arteriography, including arteriovenous
malformation, arteriovenous stula, pseudoaneurysm
(e.g., from trauma, biopsy, percutaneous catheter
placement), and hypervascular masses.
RV obstruction can have multiple causes, including
intraluminal thrombus, intrinsic abnormalities
(stenoses, webs), or extrinsic compression
(retroperitoneal lymphadenopathy, masses, aneurysm,
or brosis).
Case 87
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A B
■ Clinical Presentation
A 54-year-old man presents with bleeding esophageal varices that failed to resolve with endoscopic therapy.
173
■ Further Work-up
C
174
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
CA B D
(A) Coronal reformatted contrast-enhanced CT images in the venous phase show multiple tortuous vessels in the porta hepatis (large arrow) and absence
of the portal vein bifurcation. The spleen (small arrow) is markedly enlarged. (B) More posterior image shows large varices (arrow) adjacent to the spleen
and gastric fundus. (C) Conventional mesenteric and portal venography obtained from a transjugular approach again shows multiple tortuous vessels
(large arrows) and occlusion of the bifurcation of the main portal vein, although the remainder (small arrow) is patent. (D) Venogram after transjugular
intrahepatic portosystemic shunt (arrow) shows decompression of the periportal collaterals.
■ Dierential Diagnosis
• Cavernous transformation requiring transjugular
intrahepatic portosystemic shunt (TIPS) placement.
■ Essential Facts
• Cavernous transformation refers to the development of
multiple tortuous periportal collaterals resulting from
obstruction of the portal vein. The mass-like tangle of
collateral veins is also called a cavernoma.
• Collateral vein enlargement begins within weeks of portal
venous obstruction. Collateral veins drain the mesenteric
veins into the right and left portal veins, the intrahepatic
portal branches, and the pericholecystic veins.
• Cavernous transformation is identied initially by
screening Doppler ultrasound (. 95% negative predictive
value for portal occlusion) and conrmed by multiphase
contrast-enhanced CT or, less commonly, by MR
venography. Coronal images help to identify the remnant
portal vein and the extent of occlusion to determine the
feasibility of subsequent interventions such as portal vein
recanalization, TIPS creation, or liver transplantation.
• Despite the rich collateral network, cavernous
transformation fails to relieve portal hypertension in 90%
of cases, particularly in patients with cirrhosis.
• TIPS indications in the setting of portal vein occlusion:
◦ To preserve the portal vein for future liver
transplantation
◦ To relieve symptoms of portal hypertension, such as
medically refractory ascites and variceal bleeding
◦ To preserve portal vein patency following portal
thrombectomy/thrombolysis in the setting of cirrhosis
• TIPS approaches in the setting of chronic portal vein
occlusion:
◦ The traditional transjugular approach is made dicult
by a number of possible anatomical limitations: limited
or absent intrahepatic portal vein branches, diculty
accessing the splenic or superior mesenteric veins
through the occluded portal vein, and the presence of
multiple intrahepatic portal collateral channels. These
obstacles decrease the technical success rate (40–66%)
and increase the complication rate of the transjugular
approach.
◦ A newer approach begins with transsplenic
recanalization of the extrahepatic portal vein to the
level of the portal bifurcation. From this approach, a
snare is placed at the portal bifurcation and targeted
for TIPS creation from the transjugular approach. The
portal vein is dilated with a balloon catheter and is
suitable for eventual liver transplantation if indicated.
In the initial series of 61 patients, technical success was
98% and major complications occurred in , 4% (splenic
laceration requiring only transfusions).
Pearls and Pitfalls
ü Portal vein occlusion—either acute or chronic—is not a
contraindication to TIPS.
ü Transsplenic technique markedly improves technical
success.
ü TIPS using standard technique is technically successful
in 50% of cases.
Case 88
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175
A
C
■ Clinical Presentation
An 83-year-old woman presents for treatment of chronic severe back pain. A biopsy of her L2 and L3 vertebrae revealed no
evidence of malignancy.
B
D
176
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
EC, DA, B
(A) Sagittal T1-weighted MRI scan shows a mild compression fracture of the L3 (small arrow) and a 40% compression fracture of the L2 (large arrow)
vertebral bodies. Low signal on T1 corresponded with increased signal on T2 and enhancement (not shown) consistent with recent compression fracture.
No evidence of malignancy was seen. (B) Sagittal short T1 inversion recovery MRI scan showed increased signal (small arrow) in the L3 vertebral body
suspicious for edema resulting from recent fracture. This was not apparent in the L2 vertebral body (large arrow). (C) Lateral uoroscopic image shows
kyphoplasty balloon ination (arrow) in the L3 vertebral body. (D) Lateral uoroscopic image shows kyphoplasty balloon ination (arrow) in the L2 vertebral
body. (E) Lateral uoroscopic image shows successful cement injection in both vertebral bodies (arrows).
■ Dierential Diagnosis
• Osteoporotic compression fractures treated with
kyphoplasty.
■ Essential Facts
• Vertebral body compression fractures most commonly
occur as a result of osteoporosis but also result from
benign and malignant tumors. 16% of women and 5%
of men will suer a compression fracture during their
lifetime. Most occur from T8 to L2.
• Risk factors include postmenopausal state, sedentary
lifestyle, low calcium intake, smoking and alcohol,
advanced age, and the use of corticosteroids.
• Clinical presentation is usually sudden severe pain in the
acute setting, and constant pain, reduced mobility, loss
of height, and potential spinal column instability in the
chronic setting.
• Imaging considerations:
◦ MRI prior to vertebroplasty or kyphoplasty evaluates
for malignancy and additional fractures.
◦ Biplane uoroscopic guidance and monitoring of cement
injection reduces the risk of complications of vertebroplasty,
such as leakage of cement into the spinal canal.
◦ Interosseus venography shows the direction of ow of
cement to maximize benet and prevent complications.
• Treatment options:
◦ Conservative management is rst-line and includes
bed rest, brace, pain control, calcium supplementation,
hormone replacement, calcitonin, and bisphosphonates.
For prolonged pain (. 3 months) refractory to conservative
management and limiting the patient to a wheelchair or
indenite bed rest, vertebroplasty should be considered.
◦ Vertebroplasty and kyphoplasty are performed for
painful vertebral body fracture, impending fracture
due to tumor (hemangioma, metastasis, myeloma),
painful vertebral body fracture due to osteonecrosis (as
in Kummell’s disease), unstable compression fracture,
multiple compression fractures that may compromise
pulmonary or gastrointestinal function, and chronic,
nonhealing traumatic fractures of normal bones.
◦ 90% of patients report pain relief that begins soon after
the procedure and lasts well over 1 year.
◦ Surgical decompression and fusion may become
necessary when other options fail or are contraindicated.
• Technique:
◦ Patients are positioned prone under uoroscopy with
conscious sedation.
◦ Lidocaine is injected into the periosteum.
◦ A 10- to 15-gauge needle is gently tapped with a
hammer to the junction of the middle and anterior
one third of the vertebral body via a transpedicular
(bilateral or unilateral) or paraspinal approach.
◦ Interosseus venography conrms positioning.
◦ Vertebroplasty: cement (polymethylmethacrylate) is
injected mixed with sterile barium under uoroscopic
(biplane) monitoring until the cement reaches the
posterior one fourth of the vertebral body or enters a
nontarget location such as the epidural or paravertebral
veins or the disk space through an end-plate fracture.
◦ Kyphoplasty: a balloon is inated in the vertebral body,
resulting in a cavity that is then lled with cement.
Lower pressure is required during injection, which
reduces leakage from the vertebral body.
Pearls and Pitfalls
8 Contraindications to vertebroplasty and kyphoplasty
include response to conventional therapy,
asymptomatic fracture, osteomyelitis, acute traumatic
fracture, vertebral tumor extending into the epidural
space, vertebra plana . 90%, retropulsed fracture
fragment causing spinal stenosis, and fracture through
the posterior vertebral body cortex.
8 Acute complications (1–10%) include fractures of the
ribs or posterior elements, leakage of cement into the
spinal canal or nerve roots through an acute fracture
(more common with vertebroplasty), infection, and
bleeding. Injection of cement into the epidural venous
plexus can result in pulmonary cement embolism.
8 Delayed fracture of adjacent vertebral bodies is
controversial but is described in up to 10% of cases.
Case 89
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177
A
B
■ Clinical Presentation
A 73-year-old man presents with recurrent ulceration of the dorsum of his right foot.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A) Digital subtraction angiography shows a femoral-to-distal bypass graft with separate anastomoses to the tibioperoneal trunk and the anterior tibial
artery (ATA). A stenosis (arrow) involves the ATA anastomosis, distal graft, and proximal ATA. (B) Doppler ultrasound shows a ow rate of 40 cm/s within
the distal graft. (C) Angioplasty of the distal graft and proximal ATA was performed with a 3-mm balloon catheter (arrow). (D) After angioplasty, angiography shows restoration of the normal diameter (arrow) of the distal graft and proximal ATA.
■ Dierential Diagnosis
• Stenosis of a femoral to anterior tibial artery bypass
graft.
■ Essential Facts
• Infrapopliteal peripheral arterial disease (PAD) is often
associated with multilevel PAD but more often is isolated
in patients with diabetes.
• Intervention is indicated for infrapopliteal PAD with
critical limb ischemia (CLI) to achieve limb salvage in
cases of nonhealing ulcers and surgical wounds.
• The goal is obtaining patency for the duration of
the healing process; excellent long-term patency of
infrapopliteal obstruction is typically not possible after
endovascular revascularization.
• Imaging options:
◦ Doppler ultrasound is rst-line imaging to detect the
location, to predict the degree of arterial obstruction,
and to detect complications of distal bypass grafts.
◦ CT angiography (CTA) has largely replaced diagnostic
angiography of the lower extremities for evaluation of
PAD to plan revascularization.
◦ MR angiography (MRA) is an alternative to CTA in
patients with an allergy to iodinated contrast, and in
many institutions, MRA is a rst-line imaging test.
• Treatment options:
◦ Endovascular options include angioplasty (most
common), stent placement, and atherectomy. Three-year
limb salvage rates for CLI range from 75 to 85%, but 3-year
primary patency rates range from 30 to 50%.
◦ Endovascular options are rst-line for complications
of distal bypass grafts because repeated interventions
achieve high cumulative patency rates (. 80% for
3 years).
◦ Occlusions may be treated with stent placement or
atherectomy. Ongoing trials of drug-eluting stents and
atherectomy devices are promising; patency rates have
exceeded those of angioplasty and stents.
◦ Subintimal recanalization with stent placement is
another option for occlusions.
◦ Surgical management of infrapopliteal PAD usually
involves revascularization from the femoral artery
with autologous saphenous vein graft. Although
this option results in longer patency rates, patients
with infrapopliteal PAD and CLI are commonly poor
candidates, and endovascular options are considered
rst.
◦ To achieve long-term patency in cases of claudication,
infrapopliteal surgical bypass may be a better option for
appropriate candidates.
◦ Irrespective of treatment option, the best results occur
when straight-line ow to the foot is achieved.
Pearls and Pitfalls
An antegrade ipsilateral common femoral artery
puncture provides mechanical advantage for distal
arterial lesions.
Pedal access for infrapopliteal PAD has been used
adjunctively with antegrade femoral access and as
a back-up technique when obstructions cannot be
crossed from the femoral approach.
Heparin is mandatory for these procedures, and
intra-arterial nitroglycerin is used for periprocedural
vasospasm.
Antiplatelet therapy (clopidogrel and/or aspirin)
is typically used long term after endovascular
revascularization.
B
Case 90
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179
A B
■ Clinical Presentation
A 68-year-old man with a long history of prostate cancer presents with hematuria.
DC
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
C,D
(A, B) Conventional pelvic arteriogram in the arterial (A) and venous (B) phases shows rich arterial vascularity (arrow) in the expected location of the
prostate fed inferiorly by branches of the internal pudendal artery (arrowhead) and superiorly by branches arising from the superior vesical, rectal, gluteal,
and obturator arteries. (C, D) Two prostatic branches (arrow) arising from branches of the internal iliac artery were selectively catheterized and embolized
with 350- to 500-micron particles. (E) Postembolization arteriogram shows stasis (arrow). (F) Pelvic arteriogram after bilateral prostatic artery embolization shows minimal residual perfusion (arrow).
■ Dierential Diagnosis
• Prostate cancer: The most likely diagnosis given the
history and the marked diuse prostatic enlargement.
• Benign prostatic hypertrophy: Can cause a large
hypervascular prostate.
■ Essential Facts
• Prostate artery embolization (PAE) is a treatment option
for prostatic hematuria caused by prostate cancer or
benign prostatic hypertrophy (BPH), and for other lower
urinary tract symptoms (LUTS) caused by BPH.
• Management of prostatic hematuria:
◦ Prostatic hematuria is responsible for 10% of LUTS.
Causes include prostate cancer (as in this case), BPH,
iatrogenic complications, trauma, and radiation therapy.
◦ Prostatic hematuria usually resolves with medical and
conservative management.
◦ PAE is a standard treatment for medical-refractory cases.
◦ PAE is typically performed using permanent
particles ranging from 300 to 700 microns if selective
catheterization of the appropriate prostatic artery can
be achieved. Otherwise, embolization of the anterior
division of the internal iliac artery is an option, typically
with a combination of Gelfoam and coils.
• Management of BPH:
◦ BPH causes bladder outlet obstruction and irritation
resulting in urinary retention, frequency, urgency,
straining, and intermittency (stops and starts during
attempts at urination).
◦ Medical-refractory BPH requires surgical management,
but PAE is an investigational alternative.
◦ Open prostatectomy is rst-line treatment for severe
BPH but results in long hospital stays (mean, 9 days),
urethral stricture, bladder neck stenosis, bleeding,
urinary incontinence, and higher mortality rates than
alternatives.
◦ Transurethral resection of the prostate (TURP) is
rst-line for mild-to-moderate BPH. Mean hospital stay
is , 3 days. Complications include TURP syndrome
(electrolyte imbalance due to saline infusion),
urinary tract infection, acute urinary retention,
bladder neck stenosis, urethral stricture, retrograde
ejaculation, erectile dysfunction, bleeding, and urinary
incontinence.
◦ PAE is performed with a single overnight admission or
as an outpatient procedure. Preliminary randomized
controlled trials show that PAE is comparable to
TURP for improvements of the International Prostate
Symptom Score, quality of life, urinary peak ow rate,
and prostate volume.
◦ PAE is typically performed using permanent
particles ranging from 300 to 700 microns.
Reported complications of selective PAE have
been limited to minor access site hematomas,
postembolization syndrome (pelvic pain, fever, nausea,
and vomiting), and urinary tract infections.
Pearls and Pitfalls
ü Prostate artery anatomy is quite variable. In order
of frequency by CT angiography and conventional
arteriography, prostate arteries arise from the internal
pudendal artery, the superior vesical artery, the
gluteal–pudendal trunk, the obturator artery, and the
rectal arteries.
ü Fine surface branches may show a corkscrew pattern on
arteriography.
E,FA,B
Case 91
https://t.me/med1917
A B
181
■ Clinical Presentation
A 54-year-old man with a history of transjugular intrahepatic portosystemic shunt placement to treat bleeding esophageal
varices caused by alcoholic cirrhosis presents to the emergency department with disorientation.
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