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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
22
■
Imaging Findings
A B C
(A) Selected axial image of a contrast-enhanced CT scan of the abdomen. The image shows extravasation of contrast anterior to the splenic artery
and portal vein. There is compression and irregularity of the portal vein lateral to the site of extravasation. (B) Arteriogram shows an actively bleeding
perforation of the splenic artery. (C) Digital subtraction angiogram obtained after successful coil embolization of the splenic artery. No further extravasation
is demonstrated.
■ Dierential Diagnosis
• Iatrogenic splenic artery laceration: This is
demonstrated by active extravasation of the splenic
artery on arteriogram. The CT angiogram was positive
for a bleed, but the source could not be determined.
Arteriogram demonstrated the injury to the splenic
artery.
• Iatrogenic portal vein injury: Denitely an option, and
the dierential diagnosis from a cross-sectional imaging
standpoint is extremely dicult. The arteriogram
provides the answer.
■ Essential Facts
• Bleeding after pancreaticoduodenectomy occurs in 4 to
16% of patients.
• Endovascular evaluation of a patient with bleeding after
pancreaticoduodenectomy is usually recommended
if the patient is stable. If unstable, surgical revision is
recommended.
Pearls and Pitfalls
ü Endovascular methods are useful in the evaluation and
management of patients with bleeding after pancreatic
surgery.
ü Stent graft placement is discouraged in patients with an
active source of infection.
ü A vascular injury of the midsegment of the splenic
artery can be treated with coil embolization. Flow to
the spleen is provided by short gastric collaterals or
collaterals from the gastroepiploic artery.
ü Even if the patient is stable, if CT ndings are diagnostic
of a vascular injury, an invasive evaluation should not
be delayed.
ü Precise identication of the bleeding source may be
dicult by cross-sectional imaging.
Case 12
https://t.me/med1917
A
■ Clinical Presentation
A 46-year-old woman with Crohn’s disease presents with fever, elevated white blood cell count, and pain.
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■ Further Work-up
A transvaginal drain was performed. After drain removal, the patient had a massive transvaginal bleed. An arteriogram was
performed.
B
C
RadCases.thieme.com RadCases Interventional Radiology
https://t.me/med1917
24
■
Imaging Findings
A B C
(A) Transvaginal ultrasound image obtained during drainage procedure shows a bright echogenic image consistent with an acute bleed (arrow). The bleed
was controlled by the drainage catheter. (B) Arteriogram after catheter removal shows a discrete irregularity within the left uterine artery consistent with
a uterine artery laceration (arrow). (C) Arteriogram after coil embolization of the mid-uterine artery. Complete control of the acute bleed was achieved
after embolization.
■ Dierential Diagnosis
• Iatrogenic uterine artery laceration: There is no good
dierential. Both the images and the clinical course are
diagnostic.
■ Essential Facts
• Acute bleeding is an emergency. Prompt recognition of
clinical ndings and immediate action are critical.
• Ultrasound during the procedure showed an active bleed.
This was temporarily controlled by the insertion of the
drainage catheter.
• Once the drainage catheter was removed and the
compressive eect of the drain was removed, active
bleeding was present.
Pearls and Pitfalls
ü Immediate action and prompt recognition of a potentially
fatal problem are imperative in critical cases.
ü Prompt action is imperative and life-saving.
ü Delays in diagnosis and treatment may result in a fatal
outcome.
Case 13
https://t.me/med1917
A B
25
C
■ Clinical Presentation
An 85-year-old woman underwent endovascular abdominal aneurysm repair. A follow-up CT scan was performed.
D
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https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) A selected axial image of a contrast-enhanced CT angiography scan of the abdomen; arterial phase. The image shows active, central extravasation of
contrast into the aneurysmal sac (arrow). (B) Nonselective digital subtraction angiogram of the abdominal aorta in the lateral view. The image conrms ac-
tive contrast extravasation into the aneurysmal sac directly from the aortic attachment site (arrow). (C) Selected spot lm after coil embolization of the leak.
■ Dierential Diagnosis
• Type I-A endoleak: The ndings on CT scan conrm
contrast extravasation into the aneurysmal sac indicating
a leak. This case shows a type I-A endoleak.
• Type II endoleak: Sometimes, it is dicult to identify the
true source of extravasation on CT and an arteriogram is
used to determine the site.
• Type III endoleak: Unlikely, because the leak in this case is
at the most cephalad segment of the endograft. Type III
endoleaks are usually more caudal.
■ Essential Facts
• Endoleaks are relatively common after endovascular
aneurysm repair. Around 35 to 40% of patients who
undergo an endovascular aneurysm repair will show an
endoleak on follow-up scans.
• Type I and type III endoleaks are direct leaks into the sac,
increase the sac pressure, and are associated with high
risk of rupture.
• Type II endoleaks are treated only if they are
symptomatic or are associated with sac growth.
• Type I endoleaks are treated with stent graft
dilatation; deployment of an aortic cu extension; or,
as shown in this case, coil embolization.
Pearls and Pitfalls
ü Five types of endoleaks:
Type I-A. Aortic attachment site
Type I-B. Iliac attachment site
Type II. Collaterals of the lumbar arteries or inferior
mesenteric artery
Type III. Fracture of graft material or segment
separation
Type IV. Identiable leak without an identiable source.
This leak is identied during the procedure. It is related
to graft porosity and resolves without treatment 24 to
48 hours after the procedure.
Type V. Endotension; growth of the aneurysmal sac
without an identiable leak or source
ü Body imagers need to know the types of leaks because
diagnosis is key to management decisions.
C
Case 14
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A B
■ Clinical Presentation
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An 85-year-old man underwent endovascular repair of an abdominal aortic aneurysm. The patient comes for a follow-up
CT angiography scan and complains of back pain.
■ Further Work-up
C D
RadCases.thieme.com RadCases Interventional Radiology
https://t.me/med1917
28
■
Imaging Findings
A B C
(A) A selected axial image from a CT angiogram post endovascular repair of an abdominal aortic aneurysm. The image shows active extravasation of
contrast into the aneurysmal sac (arrow). The extravasation is peripheral and to the left side of the spine (arrow), indicating the possible source from the
left L4 artery. (B) A selected image from a superselective digital subtraction angiogram (DSA) of the left iliolumbar artery (black arrow). A type II endoleak
is identied (double arrows). (C) A selected image from a superselective DSA of the left L4 lumbar artery into the aneurysmal sac (arrow). Treatment was
conducted from this catheter position.
■ Dierential Diagnosis
• Type II endoleak: This is an example of a type II endoleak
arising from the left iliolumbar artery.
• Type III endoleak: The endoleak is clearly arising from
collaterals. On the CT scan, note the peripheral location
of the endoleak. This is not a type III endoleak.
• Type I endoleak: The endoleak is clearly arising from
collaterals, so this is not an option.
■ Essential Facts
• Endoleaks are common after endovascular repair of an
abdominal aortic aneurysm. Approximately 38 to 40% of
patients who undergo endovascular repair will have an
endoleak.
• CT angiography (CTA) is the imaging method of choice for
noninvasive endoleak evaluation.
• Most endoleaks are type II, related to lumbar or
mesenteric collaterals.
Pearls and Pitfalls
ü Type II endoleaks are the most common type of
endoleaks.
ü CTA is useful for diagnosis. The peripheral location of
the endoleak is very suggestive of the diagnosis. These
endoleaks are sometimes subtle in the arterial phase
and are better seen in delayed phases.
ü Not all type II endoleaks need to be treated. Only those
associated with sac enlargement or symptoms need to
be treated.
ü Type II endoleak treatment requires embolization of the
leak at the sac. Proximal embolization of iliac branches
feeding the leak is not recommended.
ü It is sometimes dicult to determine the type of
endoleak on CTA. Communication with the physicians
following the patient is of great importance.
Case 15
https://t.me/med1917
29
A
■ Clinical Presentation
An 85-year-old man underwent endovascular abdominal aortic aneurysm repair. The patient presents for a follow-up
CT angiogram. He is asymptomatic.
■ Further Work-up
B
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https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) A selected axial image from a contrast-enhanced CT scan of the abdomen. The image shows a large leak (arrow) adjacent to the left iliac limb. The leak
is large and centrally located. (B) A selected image from a digital subtraction angiography aortogram for endoleak evaluation. The arteriogram shows a
large leak at the left edge of the stent graft, indicating a rupture of the graft material in the mid-portion of the stent graft.
■ Dierential Diagnosis
• Type III endoleak: This is a nice example of a type III
endoleak. The CT scan clearly shows a large, centrally
located leak, and the arteriogram conrms extravasation
of contrast in the mid-portion of the stent graft.
• Type II endoleak: The arteriogram shows mild
opacication of the left iliolumbar artery, but this is
related to communication to this artery directly from the
sac. This is not a type II leak.
• Type I endoleak: Arteriogram shows intact aortic and iliac
attachment sites. This is not a type I leak.
■ Essential Facts
• CT angiography (CTA) is the imaging modality of choice
to evaluate endoleaks.
• If the type of endoleak cannot be determined with CTA,
an arteriogram is indicated.
• Endoleaks are common after endovascular abdominal
aortic aneurysm repair. Correct identication of the type
of endoleak, interval sac growth, and correlation with
patient symptoms is critical to decide management.
Pearls and Pitfalls
ü Type III endoleaks are usually large, central, and
associated with sac growth.
ü Look for the source of the leak. Usually, a stent or graft
fracture is identied.
ü Failure to identify a type III endoleak can result in
treatment delay and a grave complication.
Case 16
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A
■ Clinical Presentation
A 65-year-old woman with end-stage renal disease presents for evaluation of an arteriovenous graft.
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