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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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12
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A spot lm obtained before an angiographic procedure in this woman. The image shows an Essure intratubal sterilization device (arrows).
■ Dierential Diagnosis
• Essure intratubal sterilization device: The current
case shows an Essure intratubal sterilization device
(Bayer, Whippany, NJ).
• Malpositioned intrauterine device: This is a possibility;
however, the location and appearance of the Essure
device is quite characteristic. No other intrauterine
device has this same appearance.
• Postsurgical foreign body: This is also a possibility;
however, as mentioned previously, the Essure device has
a characteristic appearance.
■ Essential Facts
• The Essure system was approved by the U.S. Food and
Drug Administration for permanent sterilization in 2002.
• It is a nitinol coil that is implanted in the oce, under
hysteroscopy. The procedure is an outpatient procedure.
The Essure device has a characteristic appearance on
plain lms.
Pearls and Pitfalls
ü The Essure system is designed to induce brosis and
tubal occlusion.
ü Eective and complete tubal occlusion by this device
needs to be conrmed by hysterosalpingogram
3 months after insertion.
ü Several complications have been described after Essure
insertion, including incomplete tubal occlusion, tubal
perforation, intractable pain, bleeding, and unintended
pregnancies.
Case 7
https://t.me/med1917
13
A B
■ Clinical Presentation
A 59-year-old diabetic man presents with lower back pain and fever.
14
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Selected sagittal image from a diagnostic, noncontrast MRI shows abnormal soft tissue bulging at the L5/S1 level. There is moderate compression of
the thecal sac. (B) Selected axial image of the L5/S1 space during disk aspiration. The image shows an 18-gauge needle within the abnormal area.
■ Dierential Diagnosis
• L5/S1 pyogenic diskitis: The abnormal bulging in the
L5/S1 space is suggestive of a disk infection. The cultures
were positive for Corynebacterium striatum. Disk
aspiration is important for diagnosis.
• Spinal tuberculosis or fungal infection: These are strong
possibilities. Dierential diagnosis is established with
cultures of the abnormal tissue.
■ Essential Facts
• The most common mechanism of vertebral osteomyelitis
and diskitis is hematogenous spread from a distant site.
Direct trauma and postsurgical complications could also
be causes of spinal infection.
• Symptoms can be nonspecic, but a leading symptom is
back pain.
• Cross-sectional imaging (CT or MRI) is useful to establish
the diagnosis.
Pearls and Pitfalls
ü The most accurate method to establish etiology is
image-guided needle aspiration (guidelines from the
Infectious Disease Society of America).
ü CT is recommended for diagnostic aspiration of the
lumbosacral area. Tilting the gantry is useful to guide
the needle tract in the optimal angle (see image A,
above).
ü Fluoroscopic guidance is useful for the thoracic spine
and upper lumbar spine.
ü Needle aspiration is 90 to 95% sensitive for diagnosis.
ü Fluoroscopic guidance of the lumbosacral area is
dicult and may result in a prolonged, unsuccessful
procedure or complications.
Case 8
https://t.me/med1917
15
A
■ Clinical Presentation
A 52-year-old woman presents with left leg swelling. Venogram was obtained in a prone position.
16
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B C
(A) A venous digital subtraction angiogram (DSA) obtained in the prone position—the left common iliac vein shows a 95% stenosis immediately caudal to
the junction with the inferior vena cava. (B) A selected image from a venous DSA obtained 24 hours after catheter-directed infusion of tissue plasminogen
activator. The appearance of the vein has improved, but there is a residual 60 to 70% stenosis. (C) A selected image from a venous DSA after iliac vein stent
placement. The left iliac vein is now widely patent.
■ Dierential Diagnosis
• May–Thurner syndrome: The case is diagnostic. The
stenosis within the left common iliac vein shows the
characteristic signs of May–Thurner syndrome. This
stenosis is caused by compression of the left common
iliac vein by the right common iliac artery.
• Venous brosis: This is a possible diagnosis but in
the absence of an underlying cause, this is low in the
dierential.
• Spontaneous venous thrombosis: Very rare in this location,
especially in the absence of an underlying cause.
■ Essential Facts
• May–Thurner anatomy is the compression of the left
common iliac vein by the right common iliac artery. This
anatomic relationship results in left lower extremity
swelling, pain, and venous thrombosis.
• The compression of the left iliac vein by the right iliac
artery and its clinical consequences were identied and
described by Virchow in 1851.
• Clinical presentation and history are essential
components for diagnosis.
Pearls and Pitfalls
ü Cross-sectional imaging is the key to diagnosis.
ü Endovascular stent placement has been accepted as the
treatment of choice for symptomatic patients who do
not respond to conservative therapy.
ü For patients presenting with extensive iliofemoral deep
venous thrombosis, catheter-directed thrombolysis
followed by stent placement is an accepted therapeutic
option.
ü Clinical suspicion is the key. Many patients with
May–Thurner syndrome go undiagnosed.
Case 9
https://t.me/med1917
17
A
■ Clinical Presentation
A 62-year-old woman presents with gross hematuria.
B
18
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B C
(A) A selected axial image of a contrast-enhanced CT scan of the abdomen. The CT scan shows a saccular structure arising from the left renal artery
(arrow). No extravasation is identied. (B) A selected image from a selective left renal artery digital subtraction angiogram (DSA). The image shows a
complex left renal artery aneurysm. The artery has a beaded appearance. (C) A selected image from a selective left renal artery DSA after coil embolization
of the aneurysm. Note preservation of ow to renal parenchyma.
■ Dierential Diagnosis
• Aneurysm of the left renal artery; patient with
bromuscular dysplasia: Characteristic appearance by
CT scan and arteriogram.
• Pseudoaneurysm of the renal artery: In the absence of a
traumatic or inammatory cause, this diagnosis is less
likely.
• Renal cell carcinoma: Renal cell carcinoma is identied as
a solid, hypervascular mass in the kidney parenchyma.
On occasion, more central aneurysms may appear as
solid masses.
■ Essential Facts
• Renal artery aneurysms are uncommon. The true
incidence in the general population is unknown.
• Association between bromuscular dysplasia (FMD) and
renal artery aneurysms has been described.
• Symptoms include pain, hematuria, and hypertension.
Pearls and Pitfalls
ü Indications for treatment include symptoms (pain or
hematuria), enlargement over time, or size larger than
2 cm.
ü Selective coil embolization is emerging as a suitable
minimally invasive option.
ü Careful selective embolization with preservation of
renal parenchyma is crucial.
ü Aneurysm should not be confused with a solid
tumor/mass.
Case 10
https://t.me/med1917
19
A
C
■ Clinical Presentation
A 48-year-old man, who underwent laparoscopic resection of a left renal cell carcinoma 3 weeks prior, presents with hematuria and back pain.
B
20
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A) A selected axial image of a contrast-enhanced CT scan of the abdomen. A large saccular structure with avid contrast enhancement is identied in the
mid-pole of the left kidney (arrow). (B) A selected digital subtraction angiography (DSA) image from a selective left renal arteriogram. The large saccular
structure arises from a segmental branch of the lower pole (arrow). (C) A selected DSA image from a selective left renal arteriogram after embolization
with direct injection of thrombin within the saccular structure and coil embolization of the supplying lower pole artery. Minimal parenchymal loss is noted.
■ Dierential Diagnosis
• Iatrogenic pseudoaneurysm of the left kidney: This
complication is increasingly reported in patients
undergoing laparoscopic partial nephrectomy.
• Mycotic aneurysm of the renal artery: A good option if this
patient did not have the surgical history. Spontaneous
lesions like the one presented here are very unusual.
• Postsurgical hematoma: A strong possibility; however, in
the absence of hemodynamic instability and perirenal
soft tissue stranding, this option is less likely.
■ Essential Facts
• This is a rare complication, recently described after
laparoscopic partial nephrectomy.
• Patients present with back pain, dysuria, and hematuria.
• Endovascular management of this complication is the
rst line of treatment.
• Coil placement on the end-artery should suce to
eliminate the lesion. Thrombin injection is optional and
should be performed with extreme care.
B C
Pearls and Pitfalls
ü Contrast-enhanced CT is the cross-sectional imaging
method of choice for diagnosis.
ü In patients with borderline renal function, a color
Doppler evaluation may be diagnostic.
ü High clinical suspicion is crucial.
ü Endovascular treatment may be associated with distal
embolization or arterial dissection.
ü If treated with thrombin, this needs to be administered
with extreme care and in increments of 100 units
per injection.
Case 11
https://t.me/med1917
A B
■ Clinical Presentation
A 58-year-old man underwent Whipple surgery for pancreatic cancer. Shortly after surgery, the patient presents with
hemodynamic decompensation.
21
■ Further Work-up
C
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