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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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https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) A selected image from a digital subtraction angiography stulogram. The diagnostic catheter has been advanced in a retrograde fashion into the in-
ow artery, and the entire graft is shown. There is a discrete area of extravasation (arrow), indicative of an active bleeding site in the arteriovenous graft.
(B) A stulogram obtained after stent graft placement. The stulogram shows no extravasation, indicating successful leak repair.
■ Dierential Diagnosis
• Active bleeding pseudoaneurysm in an arteriovenous
(AV) graft: The area of extravasation is indicative of a site
of active bleeding. Clinical correlation is in order. This
patient presented with active bleeding to the emergency
department (information not disclosed).
• Graft degeneration: Good option, but in the presence of
active bleeding, this possibility is less likely.
• Normal arteriovenous graft study: If the abnormal area
is missed (which is actually subtle), this could pass as a
normal study; however, clinical correlation is critical in
this case.
■ Essential Facts
• The development of a pseudoaneurysm in an AV graft
is multifactorial; repeated graft puncture with large
needles for dialysis plays an important role.
• The process is usually chronic and develops over a long
period of time.
• These bleeding spots need to be addressed immediately
because they pose a great risk to the patient.
Pearls and Pitfalls
ü AV graft perforations with active bleeding used to
be treated with surgical revision; however, with the
development of stent grafts, these lesions can be treated
with endovascular stent graft placement.
ü Clinical suspicion and quick intervention may be
life-saving in these cases.
ü Graft puncture is possible through stent grafts.
ü If undetected, these lesions may bleed, leading to
patient death by exsanguination.
Case 17
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■ Clinical Presentation
A 65-year-old woman presents with symptomatic arrhythmia.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
The gure shows an abdominal lm obtained in this patient. The lm shows a TrapEase inferior vena cava (IVC) lter placed within the suprarenal IVC.
The lter has a fracture in one of its struts (black arrow). The fractured strut is lodged within the right atrium (white arrow).
■ Dierential Diagnosis
• Fractured inferior vena cava (IVC) lter: Strut migration
to right atrium—symptomatic.
• Intact inferior vena cava lter:Thelmneedstobe
examinedcarefully.Itisclearfromthelmthatthelter
hasafracture.Themigratedstrutneedstobeidentied
either in the lungs or the heart.
■ Essential Facts
• Filterfractureisawell-knowncomplicationofIVClters.
• ThemostcommonindicationforIVClterplacement
isvenousthromboembolismandacontraindicationto
anticoagulation.
• ProphylacticIVClterplacementhasincreasedwiththe
availabilityofretrievablelters.
Pearls and Pitfalls
ü The best imaging method to identify the type of
IVClterisaplainabdominallm.
ü Thebestimagingstudytoidentifylterfracturesisa
plainabdominallm.
ü The TrapEase (Cordis/Cardinal Health, Milpitas, CA)
IVCltercanbeplacedfromeitherafemoralorjugular
approach.
ü TheincidenceoffracturewiththisparticularIVClter
is reported to be 3%.
ü Ifalterfractureisidentiedinaplainabdominallm,
a chest x-ray should be obtained to localize possible
migrated prongs in the heart or pulmonary circulation.
ü ThisIVClterisassociatedwithcavalthrombosis.Upto
25%oftheselterswillshowthrombuswithinthelter.
Case 18
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A
■ Clinical Presentation
A patient presents with an occluded dialysis graft for arteriovenous graft declotting.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
BA
(A) Chest x-ray shows the tip of the stent (outow) segment of a Hemodialysis Reliable Outow (HeRO; Merit Medical, South Jordan, UT) device at the
junction of the left innominate vein and superior vena cava (white arrow). (B) Spot lm obtained after HeRO revision shows the tip of the stent segment
of the HeRO device within the right atrium.
■ Dierential Diagnosis
• Misplaced Hemodialysis Reliable Outow (HeRO)
device: The position of the outow segment of the HeRO
device shown in the lm is located at the junction of the
left innominate vein and superior vena cava. The tip of
the stent segment should be in the right atrium. There
is no dierential diagnosis in this case. The radiologist
reading the lm should be aware of the existence of the
HeRO device and its proper positioning.
■ Essential Facts
• The HeRO device is a hybrid arteriovenous graft system
with a graft segment connected to a stent segment using
a special metal connector.
• The stent segment of the HeRO device is a self-expandable
nitinol stent with a silicone cover.
• The distal stent segment has a radiopaque band that
facilitates its identication.
• This device is used as a “last-ditch” eort in patients with
renal failure who are hemodialysis dependent and who
have central venous outow obstruction.
• The device is indicated for patients who are not
candidates for a native stula or AV graft creation.
Pearls and Pitfalls
ü The tip of the HeRO device should be placed within the
right atrium.
ü Attempting a declot in a misplaced HeRO is a useless
eort because the graft will occlude shortly after
declotting.
ü The indicated management of a misplaced HeRO device
is revision and repositioning by combined surgical and
endovascular revision.
ü A HeRO device in a suboptimal position will not
function properly.
Case 19
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A
■ Clinical Presentation
A 65-year-old woman on hemodialysis presents with arm swelling.
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■
Imaging Findings
A
(A) A selected image of a venous digital subtraction angiogram (DSA). The image shows complete occlusion of the right subclavian vein. There are promi-
nent right neck and upper chest venous collaterals. (B) Venous DSA after right subclavian vein recanalization and stent placement. The right venous system
is now patent. No opacication of collaterals is noted.
■ Dierential Diagnosis
• Right subclavian vein occlusion causing venous
hypertension: The digital subtraction angiography
venogram shows complete occlusion of the right
subclavian vein. The presence of large, well-developed
chest and neck collaterals indicates that this is a chronic
process.
• Acute right subclavian vein thrombosis: This is not a good
option because the subclavian vein is not distended and
no acute thrombus is identied. Large collaterals favor a
chronic process.
• Extrinsic compression: Good possibility; however, there
was no history of enlarged mass in the area, and usually
extrinsic compression shows a smooth, long stenosis, not
an abrupt occlusion.
■ Essential Facts
Pearls and Pitfalls
ü Upper extremity swelling in a patient with a working
arteriovenous dialysis access indicates central venous
obstruction.
ü Endovascular management with guidewire
recanalization and stent placement is a very eective,
minimally invasive therapeutic option.
ü Arm swelling related to venous hypertension in
hemodialysis patients can be disguring and disabling.
ü The possibility of acute thrombosis should be
considered because these patients may need to be
treated dierently.
B
• Central venous occlusion is relatively common in
hemodialysis patients.
• Ipsilateral swelling of the extremity with the access is a
classic presentation.
• Previous central venous catheter insertion for
hemodialysis is one of the leading causes of central
venous occlusion in hemodialysis patients.
• Occlusion is signicantly associated with a history of
previous subclavian catheter insertion.
Case 20
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■ Clinical Presentation
An 85-year-old man underwent percutaneous cholecystostomy tube insertion. This is a follow-up cholecystogram.
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■
Imaging Findings
Spot lm obtained during cholecystogram. The lm shows enlarged gallbladder with irregular walls and a large stone within its lumen. The percutaneous
drain is in good position and no leak is identied. There is immediate opacication of the duodenum (arrow). Note air within the intrahepatic ducts, as well
as a plastic common bile duct stent. There is no contrast opacication of the cystic duct, common bile duct, or intrahepatic ducts.
■ Dierential Diagnosis
• Cholecystoduodenal stula: The images show a direct
communication of the gallbladder with the duodenal
bulb.
• Mirizzi’s syndrome: The classic Mirizzi’s syndrome is
the obstruction of the common bile duct by an enlarged
gallbladder. In type II Mirizzi’s syndrome, there is stula
formation to the common bile duct.
• Bouveret’s syndrome: Duodenal gallstone ileus with a
cholecystoduodenal stula. In this case, there is no stone
in the duodenum.
■ Essential Facts
• Cholecystoduodenal stula is a rare complication of
calculous cholecystitis.
• It is the most common form of bilioenteric stula.
• The true incidence is unknown but it is probably in the
range of 2 to 3%.
• Most common causes include stone disease, peptic ulcer
disease, malignancy, and trauma.
• Patients may present with upper gastrointestinal bleed.
Pearls and Pitfalls
ü Careful, slow injection of contrast under uoroscopic
control is necessary, and spot lms are obtained to
check the contrast distribution. It is important to
demonstrate that cystic duct and common bile duct are
not opacied.
ü Management is surgical.
ü Diagnosis before surgery is essential and should not
be missed. These patients usually undergo open
surgery because these cases are dicult to treat
laparoscopically.
Case 21
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A
■ Clinical Presentation
B
A 42-year-old man with diabetes presents with fever.
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