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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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182
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Transjugular portogram shows a transjugular intrahepatic portosystemic shunt (TIPS) (arrow). (B) TIPS reduction by deployment of a small balloon-
expandable stent (arrow) parallel to a covered self-expanding stent within the preexisting TIPS.
■ Dierential Diagnosis
• Hepatic encephalopathy after transjugular intrahepatic
portosystemic shunt (TIPS).
■ Essential Facts
• TIPS-related hepatic encephalopathy likely results
when nitrogenous products from the intestine, such
as ammonia, bypass ltration by the liver and enter
the intracranial circulation. The incidence of hepatic
encephalopathy after TIPS is 20%.
• Clinical presentation is obtundation, disorientation, and
confusion.
• Predisposing factors include high dietary protein,
diuresis, sepsis, sedatives, hypokalemia, dehydration, and
preexisting hepatic dysfunction.
• With the appropriate clinical presentation after TIPS,
hepatic encephalopathy should be considered regardless
of the imaging appearance and sonographic features of
the TIPS.
• Treatment options:
◦ Medical treatment should be attempted rst, including
a protein-restricted, high-ber diet; nonabsorbable
disaccharides such as oral or rectal lactulose; oral
nonabsorbable antibiotics such as neomycin; and
colonic cleansing with mannitol solution or laxatives.
Approximately 5% of cases are refractory, and
endovascular treatment is necessary.
◦ Endovascular treatment options include reduction
of the diameter of the TIPS, coil embolization of
physiologic portosystemic shunts, or coil embolization
of the TIPS.
◦ Surgical treatment usually involves liver transplantation
and is reserved for severe cases.
• Endovascular reduction of TIPS may be accomplished by
two common methods:
◦ The rst involves deploying within the preexisting TIPS
a new covered stent, constricted in the middle by a loop
of suture.
◦ The second depicted in this case involves deploying two
new stents parallel to each other within the preexisting
TIPS: one covered self-expanding stent and one shorter
uncovered balloon-expandable stent. The short balloonexpandable stent narrows the lumen of the selfexpanding stent.
ü Pearls and û Pitfalls
8û Recurrent variceal bleeding after placement of a
constricted stent for encephalopathy may necessitate
balloon dilation of the constricted stent.
8û Recurrent variceal bleeding after coil embolization of
a TIPS stent may necessitate placement of a new TIPS
stent.
8û Nontarget embolization of coils during TIPS occlusion
results in embolization of a pulmonary arterial branch.
8û Death due to severe decrease in cardiac output,
metabolic acidosis, and hypotension has been reported
(extremely rare) due to abrupt shunt occlusion.
Case 92
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183
A
■ Clinical Presentation
A 35-year-old woman presents for evaluation of an incidental nding on a chest radiograph.
B C
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B C
D
(A) CT scan shows an enlarged pulmonary artery branch (arrow) supplying a pulmonary arteriovenous malformation (AVM). (B) Pulmonary angiogram in
the arterial-phase image shows the enlarged pulmonary artery (arrow) supplying a saccular venous component (arrowhead) of the AVM. (C) Venous-phase
image shows drainage of the AVM to a large pulmonary vein (arrow). (D) Postembolization image shows coils (arrowhead) and a vascular plug (arrow).
(E) Postembolization angiogram shows no ow in the arterial feeder at the level of the coils (arrow).
■ Dierential Diagnosis
• Pulmonary arteriovenous malformation (AVM):
Indicated by the enlarged pulmonary arterial branch with
immediate opacication of a large draining vein.
■ Essential Facts
• This patient may have hereditary hemorrhagic
telangiectasia (HHT), also known as Osler-Weber-Rendu
disease, because 60 to 90% of patients with pulmonary
AVMs have HHT. Conversely, 20% of patients with HHT
have pulmonary AVMs.
• HHT is autosomal dominant with a general incidence of
2 in 100,000, typically encountered in young patients.
Most patients have simple pulmonary AVMs—one or two
arteries drain to one or two veins.
• Paradoxical embolus may present with stroke, brain
abscess, myocardial infarction, mesenteric infarction, or
peripheral artery thromboembolus.
• Plain radiographs of patients with pulmonary AVMs
typically show well-circumscribed noncalcied nodules,
more commonly in the lower lobes.
• Multidetector CT angiography identies pulmonary
arterial supply, pulmonary venous drainage, and the
presence of pulmonary arterial thrombus to verify
diagnosis and plan treatment. Look for size (see below)
and number of arteries supplying the AVM and the
presence of additional AVMs.
• Treatment options and associated risks:
◦ Prophylactic antibiotics should be started to diminish
the risk of brain abscess.
◦ Anticoagulation should be considered to minimize
the possibility of pulmonary or paradoxical
thromboembolism.
◦ AVMs with arterial supply . 3 mm in diameter are
treated, but many radiologists embolize all visible AVMs
due to the risk of interval enlargement noted on serial
CT scan.
◦ Transcatheter arterial embolization (TAE) is the rst-
line intervention. Coils and vascular plugs are used;
particles and liquid embolic agents are avoided because
of the risk of iatrogenic paradoxical embolus.
◦ Complications of TAE to treat pulmonary AVM include
paradoxical coil embolus (, 1%) and air embolus to the
coronary arteries (, 5%).
Pearls and Pitfalls
Detachable coils and vascular plugs have greatly
reduced the risk of paradoxical embolization as a
complication of TAE.
E
Case 93
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185
A
B C
■ Clinical Presentation
An 11-month-old boy presents to interventional radiology for treatment of a left upper arm mass since birth.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
C D
(A) Doppler ultrasound image shows a mass with multiple vascular channels exhibiting an arterial waveform. (B) Brachial arteriogram shows innumerable tiny
arteries (arrow) supplying a dense vascular nidus (arrowhead). (C) Venous-phase images show large saccular venous channels (arrows) draining the nidus into
the brachial and cephalic veins. (D) Cyanoacrylate glue (arrow) has been injected into the venous channels. The arteriovenous malformation was then resected.
■ Dierential Diagnosis
• Peripheral arteriovenous malformation: The only
diagnosis, given the rapid arteriovenous shunting
through a nidus of vessels.
■ Essential Facts
• Arteriovenous malformations (AVMs) are classied as
combined high-ow vascular malformations by the
International Society for the Study of Vascular Anomalies.
This category includes arteriovenous stulas.
• AVMs, like other vascular malformations, are present at
birth (but often unnoticed) and grow with the patient
without involuting. Histology combines capillaries,
venules, and arterioles that hypertrophy within brous
or bromyxomatous tissue. Growth may be exacerbated
by pregnancy, puberty, or trauma.
• High-ow AVMs are dicult to treat and require a
multidisciplinary approach.
• Imaging considerations:
◦ Ultrasound screens for the presence and size of vascular
malformations, measures ow rate, and detects arterial
waveforms to distinguish high-ow from low-ow
malformations.
◦ MRI and MR angiography determine the size and
relationship to adjacent structures. Dynamic gradient
pulse sequences distinguish lesion types: high-ow AVMs
show signal void, and low-ow AVMs are high signal on T2.
◦ CT with CT angiography can demonstrate size, bone and
tissue involvement, calcications, and thrombus.
◦ Conventional angiography and direct puncture of the
nidus with contrast injection are performed with the
intent to treat.
• Treatment options:
◦ Indications for treatment include pain, bleeding,
ulceration, shunt-related cardiac failure, or gross
deformity such as limb length discrepancy (as in the
Parkes–Weber variant of Klippel–Trénaunay syndrome).
◦ Nidus elimination or venous outow obliteration by
direct puncture or selected catheterization is the most
common strategy for complicated high-ow AVMs.
◦ Liquid embolic agents: cyanoacrylate and ethylene
vinyl alcohol. Sclerosing agents: absolute ethanol and
polidocanol.
◦ Embolization using coils and other large embolic
devices is an adjunctive treatment for ow reduction.
◦ Complications of sclerotherapy and embolization
include tissue necrosis, nontarget embolization with
ischemia, infection, bleeding, and postembolization
syndrome (nausea, pain, fever, and leukocytosis).
◦ Surgical ligation of the feeding arteries for AVMs is
usually ineective due to rich collateral recruitment.
◦ Surgical resection is sometimes performed after
sclerotherapy and embolization.
Pearls and Pitfalls
Treatment of AVMs starts with direct puncture of the
nidus or venous outow under imaging guidance and
contrast opacication to demonstrate the ow rate,
ow direction, size, and venous drainage.
For AVMs with a large draining vein, sclerotherapy and
embolization are more safely performed with concurrent
venous occlusion using either balloon catheters,
application of a tourniquet, or coil embolization.
Vascular malformations commonly recur or partially
persist, and repeated treatment is often necessary.
B
Case 94
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A B
187
C D
■ Clinical Presentation
A 39-year-old woman presents to the emergency department with shortness of breath and sepsis after a throat infection.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
DC
(A, B) Contrast-enhanced CT of the neck shows complete thrombosis and distension of the right internal jugular vein (arrows) with adjacent low density
(arrowheads) extending into the surrounding soft tissues. (C, D) Chest CT shows bilateral nodules (arrows), many of them cavitated.
■ Dierential Diagnosis
• Lemierre’s syndrome.
■ Essential Facts
• Lemierre’s syndrome is a rare cause of septic
thrombophlebitis of the internal jugular vein (IJV)
caused by regional extension of oropharyngeal bacterial
infection to form a peritonsillar abscess. Anaerobic
gram-negative bacteria proliferate—most commonly
normal oropharyngeal ora such as Fusobacterium
necrophorum.
• Patients are often otherwise healthy adolescents or
young adults, but risk factors include oropharyngeal or
tonsillar infection as well as procedures such as tooth
extraction, lymphangioma treatment, jaw reconstruction,
and tumor resection.
• Hematogenous spread can cause serious complications
such as bacteremia and septic emboli to the pulmonary
arteries. Further extension to the systemic arteries can
occur from pulmonary abscesses. Reported complications
include hepatic, renal, and splenic abscesses, osteomyelitis,
septic arthritis, epidural abscess, meningitis, and sepsis.
• Presentation varies with sequelae, but most patients
have a progressive oropharyngeal infection, lethargy,
fevers, neck swelling, and lymphadenopathy. Pulmonary
sequelae may result in chest pain, cough, hemoptysis,
and shortness of breath. Peripheral arterial septic emboli
present with organ-specic signs and symptoms.
• Imaging considerations:
◦ Chest radiography may show sequelae of pulmonary
septic emboli, such as peripheral focal opacities that
may be uniform or cavitated. Other sequelae include
bronchial pneumonia, empyema, and pleural eusion.
◦ Neck ultrasound is the initial screening tool and shows
thrombosis and distension of the IJV.
◦ Neck CT shows thrombosis and distension of the IJV with
mural enhancement and surrounding edema.
• Treatment is intravenous antibiotics.
Pearls and Pitfalls
Lemierre’s syndrome is usually fatal if left untreated,
but mortality is still high (6–15%) with medical
management and antibiotic therapy to cover susceptible
anaerobic ora.
Case 95
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A B
■ Clinical Presentation
A 36-year-old man with nausea and mid-epigastric pain after recent hospitalization for pancreatitis is referred from an
outside hospital for drainage of a pseudocyst.
189
■ Further Work-up
C D
RadCases.thieme.com RadCases Interventional Radiology
https://t.me/med1917
190
■
Imaging Findings
A B C D
(A) Contrast-enhanced, arterial-phase CT shows a pseudocyst (arrowhead) in the region of the lesser sac with a large, enhancing component (arrow)
adjacent to the celiac trunk. (B) This enhancing component appears denser on this venous-phase CT, which raises the suspicion for a pseudoaneurysm.
(C) Selected celiac arteriogram shows the left gastric (arrow) and splenic arteries. No extravasation is visible. The hepatic arteries are not visible because
they arise from the superior mesenteric artery in this patient. (D) Selected left gastric (arrow) arteriogram shows a large pseudoaneurysm (arrowhead)
arising from a branch of this vessel. This branch was successfully embolized with coils.
■ Dierential Diagnosis
• Pseudoaneurysm in pseudocyst: Indicated by
extravasation into a large saccular outpouching.
• True aneurysm: Less likely, given the appearance and
etiology.
■ Essential Facts
• Contents of pseudocysts may erode into or weaken the
wall of an adjacent artery, causing an aneurysm (all layers
of wall intact) or pseudoaneurysm (PSA); both have a
high risk of rupture. Other complications of visceral
PSAs include pain, sepsis, peritonitis, organ failure, and
tissue necrosis due to extrinsic compression or vascular
compromise.
• The arteries aected are most commonly the
gastroduodenal (GDA), splenic and pancreaticoduodenal,
and less commonly, the gastric and gastroepiploic.
• Most PSAs caused by pseudocysts will eventually
rupture if left untreated; mortality rate with rupture is
10 to 40%.
• As in this case, large PSAs can mimic abscesses and be
referred for “drainage.” Recommend Doppler ultrasound
prior to considering percutaneous drainage of a uid
collection suspicious for a PSA.
• Imaging considerations:
◦ PSAs caused by pancreatic pseudocysts can range in
size from , 1 cm to . 10 cm.
◦ Doppler ultrasound of PSAs often demonstrates the
yin–yang pattern of color ow and the to-and-fro
spectral pattern by pulsed-wave Doppler.
◦ Multiphase contrast-enhanced CT is benecial to
identify PSAs because it shows internal enhancement
that changes over time.
• Treatment considerations:
◦ Coil embolization of the PSA or feeding artery is
recommended for stable patients.
◦ Percutaneous drainage of infected pseudocysts can
be oered after embolization. In addition, large,
sterile pseudocysts can be drained to minimize the
risk of superinfection or complications of extrinsic
compression.
◦ Percutaneous thrombin injection of PSAs has been
described. Thrombin at 300–1000 IU is injected into
the PSA in small increments (100 IU per 0.1 mL) under
sonographic monitoring using a 22-gauge needle.
• Recurrence rate is 25% after embolization of PSAs of
pancreatic pseudocysts due to continued erosion.
• Surgery is reserved for failed embolization, unstable
patients, and problems associated with extrinsic
compression by large PSAs. Open surgical drainage and
ligation of the feeding artery are typical.
Pearls and Pitfalls
Back door–front door coil embolization is the most
common strategy to treat aneurysms and PSAs to
ensure the absence of supply from collateral vessels.
This requires understanding of normal and variant
anatomy. For example:
The right gastric artery may require embolization
to prevent reconstitution of the left gastric artery
(not required in this case because the only branch
feeder was embolized); the right gastric has
multiple variants of origin, such as the proper
(most common), common, right, and left hepatic
arteries and the GDA.
The gastroepiploic arcade is supplied by the GDA
(right) as well as the splenic artery (left).
The pancreaticoduodenal arcades are supplied by
the GDA as well as the superior mesenteric artery.
The splenic artery is supplied by the celiac,
pancreatic, gastroepiploic, and gastric arteries.
Case 96
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A B
C D
■ Clinical Presentation
A 71-year-old man presents with severe abdominal pain progressing over the past week.
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