Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3627_Библиотеки_им_академика_М_И_Перельмана
.pdf
62
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
C D
(A, B) Selected images from a contrast-enhanced CT scan of the abdomen and pelvis. (A) Arterial phase, shows a large retroperitoneal hematoma. There is
active extravasation of contrast (arrow). (B) Delayed image, shows pooling of the extravasated contrast within the retroperitoneum. (C) Selected image of
a digital subtraction angiogram (DSA) of the right iliac artery. The image shows active, massive extravasation of contrast. (D) Selected image from a DSA
immediately after placement of a stent graft. No further extravasation is identied.
■ Dierential Diagnosis
• Iliac artery perforation with active bleeding:
The images on the CT scan are diagnostic. The injury
likely occurred after a high puncture during cardiac
catheterization. The bleeding most probably started after
the patient resumed her anticoagulants.
• Spontaneous bleed: This is an unlikely option as there is
history of a previous cardiac catheterization.
Pearls and Pitfalls
ü Ultrasound guidance is useful to prevent puncture-
related complications.
ü CTA is the imaging modality of choice to evaluate these
cases.
ü If CTA is positive, it should be reported immediately.
ü Immediate angiographic evaluation is essential and may
be therapeutic.
B
ü Accurate stent graft placement may be life-saving.
ü Make sure all images are read properly; missing one of
■ Essential Facts
these cases can be a fatal mistake.
• Vascular access site–related complications are common.
Range is between 1 and 9%.
• Punctures above the inguinal ligament are complicated
with pelvic and retroperitoneal bleeding.
• Punctures below the inguinal ligament distribute into the
thigh compartments.
• Triple-phase CT and CT angiography (CTA) are excellent
diagnostic methods to detect acute internal bleeding.
• Active bleeding detected on a CTA is a medical
emergency; it needs to be assessed immediately.
Case 32
https://t.me/med1917
63
A
■ Clinical Presentation
A 42-year-old man with a history of alcoholism presents with upper gastrointestinal bleeding.
B
64
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A, B) Selected images from a contrast-enhanced CT scan of the abdomen. (A) A delayed axial image showing absence of the splenic vein and large gastric
varices. (B) A coronal reconstruction showing similar ndings. (C) Selected spot lm obtained during a transhepatic variceal embolization. The occlusion
balloon is placed within the left gastric vein. The presence of large gastric varices is conrmed with a balloon-occluded retrograde venogram.
■ Dierential Diagnosis
• Sinistral portal hypertension: Splenic vein occlusion and
isolated gastric varices. Images show large gastric varices
but no esophageal varices.
• Cirrhosis with gastric varices: This is a possibility because
the patient has a history of ethanol abuse. However, most
patients with post-sinusoidal portal hypertension usually
have esophageal varices.
■ Essential Facts
• Isolated gastric varices are not common.
• The presence of gastric varices without esophageal
varices should signal the possibility of splenic vein
occlusion.
• Splenic vein occlusion may be secondary to pancreatitis
or tumors.
• A common clinical presentation of splenic vein occlusion
is bleeding from gastric varices.
Pearls and Pitfalls
ü The presence of gastric varices without esophageal
varices is strongly associated with splenic vein
occlusion.
ü Transcatheter embolization of bleeding gastric varices
is eective.
ü Endovascular approach to gastric varices for
embolization may be antegrade, via the left gastric vein,
or retrograde, via the adrenal vein (balloon-occluded
retrograde transvenous obliteration [BRTO]).
ü Splenic vein recanalization and stent placement is
another endovascular option to solve this problem.
ü A fatal complication of BRTO is a fatal pulmonary
embolism resulting from accidental embolization of the
therapeutic embolic agents to the lungs.
C
Case 33
https://t.me/med1917
65
A
C
■ Clinical Presentation
A 62-year-old man with a history of alcohol abuse presents with grade 3 encephalopathy.
B
66
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A, B) Selected axial images from a contrast-enhanced MRI of the abdomen. The images show a small, irregular liver consistent with a cirrhotic liver. The
spleen is enlarged as well. There is a small amount of ascites. The portal vein is patent. There is a large recanalized paraumbilical vein, which forms a large
shunt into the lower areas of the abdomen. The shunt arises from the left portal vein. (C) A coronal view at the supercial anterior abdominal wall. The
large shunt is clearly demonstrated.
■ Dierential Diagnosis
• Recanalized paraumbilical vein forming a large
portosystemic shunt: The images are diagnostic. The
classic entry point in the left portal vein is nicely
demonstrated.
• Vascular venous malformation: A possibility. However,
with the history of alcohol abuse and other signs of
portal hypertension, this possibility loses strength.
• Arterioportal stula: This is another option; however, this
is usually related to trauma in childhood, and this patient
has no such history. The hepatic or mesenteric arteries
are usually prominent in case of stulas.
■ Essential Facts
• Spontaneous portosystemic shunts form in people who
have cirrhosis with signicant portal hypertension.
• Examples include the following: Esophageal varices drain
into the azygos system; gastrosplenic shunt arises from
the short gastric veins, connecting with the splenic vein,
and then drain into the left renal vein.
• The recanalized paraumbilical vein is another example.
These shunts typically arise from the left portal vein,
have a tortuous course, form the “caput medusa” in the
umbilical region, and usually drain into the left iliac veins.
B
Pearls and Pitfalls
ü Angiographic evaluation and management of these
shunts is possible.
ü Encephalopathy improves after successful embolization
of these shunts.
ü It is important to describe the nding in detail because
it is clinically important.
ü Most clinicians only read the conclusion of the imaging
reports. If these ndings are not described in the
nal comments, the clinician may miss the cause of
encephalopathy.
ü These shunts need to be addressed because if they
bleed, bleeding may have a fatal outcome.
C
Case 34
https://t.me/med1917
67
BA
■ Clinical Presentation
A patient with liver cirrhosis presents with upper gastrointestinal bleeding. Patient had a history of a transjugular intrahepatic
portosystemic shunt procedure 2 years prior to this admission.
68
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A) A spot lm from a selective splenic arteriogram. The angiographic catheter was placed in the mid-splenic artery. The splenic artery is patent and the
spleen parenchyma is opacied. (B) A spot lm in the venous phase of a splenic arteriogram. The image shows a patent splenic vein, patent main portal
vein, and a patent transjugular intrahepatic portosystemic shunt.
■ Dierential Diagnosis
• Patent transjugular intrahepatic portosystemic shunt
(TIPS): There are no gastric or esophageal varices
opacied. The shunt is patent, and there is no reux to
the mesenteric vein.
• There is really no good dierential diagnosis: The TIPS
is patent, no varices are seen, and the splenic artery is
normal.
■ Essential Facts
• If a patient has a TIPS and the patient has an acute
gastrointestinal (GI) bleed, the rst thought is TIPS
failure.
• TIPS created with VIATORR (W. L. Gore & Associates,
Flagsta, AZ) stent grafts have a signicantly improved
patency.
• Patients with cirrhosis may bleed from gastric ulcers or
duodenal ulcers.
• Patients with acute GI bleed and a patent TIPS need a
diagnostic work-up.
Pearls and Pitfalls
ü Doppler ultrasound is the imaging method of choice to
evaluate a TIPS.
ü Clinical correlation is of great importance.
ü Variceal bleeding is unusual if the patient has a patent
and functional TIPS.
ü Other sources of bleeding need to be identied,
including ulcers, tears, or even portal gastropathy.
B
Case 35
https://t.me/med1917
69
BA
■ Clinical Presentation
A 62-year-old man with a history of abdominal trauma presents with melena.
70
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A) A spot lm showing the arterial phase of selective superior mesenteric artery injection. The superior mesenteric artery branches are normal. (B) A spot
lm during the venous phase of the same injection. The superior mesenteric vein branches are patent. There is occlusion of the main trunk of the portal
vein. Small irregular venous collaterals are identied around the hepatic hilum and the stomach.
■ Dierential Diagnosis
• Chronic portal vein thrombosis: The superior mesenteric
arterial branches are patent and normal. The venous
phase shows occlusion of the main trunk of the portal
vein.
• Acute portal vein thrombosis: This is not a good option
because there is no opacication of the main portal vein
or its branches. The main trunk of the portal vein is
usually visible in acute thrombosis.
Pearls and Pitfalls
ü Injection of 30 mg of intra-arterial papaverine
immediately before intra-arterial contrast
injection improves imaging of the mesenteric veins
(pharmacoangiography).
ü Papaverine injection requires technical skill. Iodinated
contrast cannot be injected immediately after
papaverine injection. Papaverine will crystallize and
may cause local acute occlusion. The angiographic
catheter needs to be ushed with 10 to 15 mL of saline
immediately before contrast is injected.
B
■ Essential Facts
• Chronic portal vein thrombosis can be diagnosed by CT,
MRI, or angiography.
• The main advantage of angiography is that it provides a
map for therapy planning.
• Portal vein recanalization and stent placement are
excellent therapeutic options.
• Surgical correction with mesoportal shunt is feasible in
good surgical candidates.
Case 36
https://t.me/med1917
71
A
■ Clinical Presentation
A 75-year-old man with psoriasis under treatment with methotrexate. Transjugular liver biopsy was performed to evaluate
abnormal liver function tests. Presents to the emergency department 8 days after biopsy with sudden, severe abdominal
pain.
B
Соседние файлы в папке Библиотека им академика М.И. Перельмана