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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
(A) A selected axial image of a contrast-enhanced CT scan of the abdomen showing a large, hypodense, irregular area in the right lobe of the liver.
(B) A coronal view showing an extensive, hypodense, irregular area with a small area of contrast extravasation indicating active bleeding (arrow).
■ Dierential Diagnosis
• Delayed bleed after transjugular liver biopsy (TJLB):
The diagnosis was established by the history and CT scan
ndings. The patient was asymptomatic until the 8th day,
when he developed severe, sudden abdominal pain.
• Hematoma: There is a hematoma, but the active bleed is
identied and needs to be treated.
• Pseudoaneurysm of hepatic artery: Good possibility, but
this was actually an active bleed.
■ Essential Facts
• TJLB is a safe procedure.
• The complication rate of this procedure ranges between
1 and 6%.
• Most complications are minor and include abdominal
pain and neck hematoma.
• Major complications occur in , 1% of patients.
• The reported mortality after TJLB is , 0.1%.
Pearls and Pitfalls
ü Three to four liver cores should always be obtained for
grading and staging of liver disease.
ü Use prophylactic antibiotics in patients with a history
of biliary surgery.
ü The most common cause of technical failure is inability
to catheterize a hepatic vein.
ü Liver laceration can occur if needle manipulation is
forceful.
B
Case 37
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73
BA
■ Clinical Presentation
A 63-year-old woman presents with a massive pulmonary embolism that required catheter-directed thrombolysis. These
images were obtained during a follow-up pulmonary arteriogram.
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■
Imaging Findings
A B
(A, B) Selected spot lms obtained during a pulmonary angiogram. (A) The catheter was located in the main pulmonary artery (white arrow). (B) Images
obtained immediately after contrast injection show opacication of the pericardium, and the borders are clearly delineated (black arrows).
■ Dierential Diagnosis
• Iatrogenic pericardial injection of contrast: The contrast
was injected into the pericardium. Most probably, the tip
of the catheter was in close contact with the pulmonary
artery wall, and contrast injection created a high-ow jet
that resulted in subintimal injection of the contrast with
consequent opacication of the pericardium.
• There is no good dierential diagnosis on this case:
Images are diagnostic and there are no other diagnostic
possibilities.
■ Essential Facts
• Pulmonary catheter-directed thrombolysis is indicated
in patients with massive pulmonary embolism who are
symptomatic or hemodynamically decompensated.
• The procedure is reasonably safe, with good technical
and clinical results.
• Most common complications are related to bleeding
secondary to thrombolytic drugs.
• The complication presented in this case is very unusual.
Pearls and Pitfalls
ü A volume of contrast higher than 7 mL/s should not
be power-injected via an end-hole catheter. Vessel
dissection as a result of contrast extravasation can occur.
ü If a volume larger than 7 mL/s needs to be injected to
obtain good diagnostic images, a high-ow catheter
with side holes must be used.
ü Subintimal contrast injection may result in severe
complications. The patient in this case had no
symptoms during or after the injection, and contrast
cleared shortly after injection.
Case 38
https://t.me/med1917
A
75
B
■ Clinical Presentation
A 40-year-old man with history of lung cancer presents with face swelling.
C
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A
(A) Selected axial image of a contrast-enhanced CT scan of the chest showing irregular enlargement of the mediastinal soft tissues and severe compression
of the superior vena cava (SVC). (B) Coronal reconstruction showing the extent of SVC extrinsic compression (arrow). (C) Spot lm of a venogram showing severe SVC stenosis (arrow), conrming CT scan ndings. (D) Spot lm after self-expandable stent placement, which shows resolution of the stenosis.
■ Dierential Diagnosis
• Superior vena cava (SVC) syndrome: There is severe
compression of the mid-segment of the SVC by
enlargement and irregularity of the mediastinal soft
tissues.
• The dierential diagnosis includes recurrent carcinoma,
mediastinal brosis, and radiation-induced injury: This
patient had a history of radiation, and his cancer was in
remission.
■ Essential Facts
• SVC syndrome occurs secondary to stenosis of the SVC.
• SVC stenosis may be related to compression due to
brosis, radiation injury, or recurrent carcinoma.
• Symptoms include swelling, dizziness, headaches, and
dyspnea on supine position.
• Management includes conservative management with
anticoagulation and stent placement.
• Surgical options are limited.
B
Pearls and Pitfalls
ü Stent placement renders excellent results in these
patients.
ü Reconstructing only one side may resolve symptoms
because ow from the contralateral side is possible.
ü Long, self-expandable stents are recommended,
although balloon expandable stents may also be used.
ü Stent migration is the worst complication. A “through-
and-through” access is recommended.
C D
Case 39
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A
■ Clinical Presentation
A patient with a chest port presents. The port cannot be accessed.
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■
Imaging Findings
A
(A) Spot lm obtained immediately after port access attempt. This is a power port and the letters are in the wrong orientation, indicating 180-degree
port ipping, making it impossible to access the port chamber. (B) Spot lm obtained immediately after chest port revision. The letters CT are now clearly
identied and easily readable. Port is now in good position.
■ Dierential Diagnosis
• Flipped chest port: There is no dierential; the diagnosis
is made by looking at the radiopaque marking letters.
The letters are in the wrong orientation. The catheter and
catheter course are in the expected anatomic location.
Pearls and Pitfalls
ü When placing a port, ask the patient if he or she is
active (e.g., golf, swimming, tennis, yoga).
ü If active, suture the port to the fascia with two sutures.
This will prevent port ipping.
B
ü Open port revision is necessary when external
maneuver unipping fails.
■ Essential Facts
• Chest port ipping is an unusual event.
• Flipped ports may be “unipped” with external
maneuvers, but this is usually not eective as ports
usually ip back to the wrong orientation. This maneuver
may be painful to the patient.
• Arm activity is thought to cause port ipping.
• Other factors that may cause port ipping include large
patients and active sports such as tennis, golf, swimming,
and weightlifting.
ü Open revision of a ipped port is stressful to most
patients.
Case 40
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■ Clinical Presentation
79
BA
A 65-year-old man with a history of trauma presents with lower extremity swelling.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Selected axial image from a contrast-enhanced CT scan of the abdomen shows a large lling defect within the lumen of the inferior vena cava (IVC)
consistent with IVC thrombus. (B) Coronal reconstruction of the scan shows an IVC lter (OptEase; Cordis/Cardinal Health, Milpitas, CA) and extensive
thrombus cephalad to the lter cone, within the lter cone, and in the IVC caudal to the lter.
■ Dierential Diagnosis
• Inferior vena cava (IVC) thrombus associated with IVC
lter: The lms show the presence of thrombus within
the IVC, cephalad to the tip of the lter, within the lter,
and below the lter.
• There is really no good dierential diagnosis: This nding
must be identied and immediately reported because
this patient is at high risk for pulmonary embolism.
■ Essential Facts
• IVC lters increase the risk of vena cava thrombosis.
• It is dicult to determine if the lter causes the thrombus
or if the thrombus within the lter was “captured” by the
lter and then propagated.
• Certain lters are associated with higher incidence of IVC
thrombosis.
Pearls and Pitfalls
ü The best imaging method to identify the type of an IVC
lter is an abdominal lm.
ü Identication of the lter is useful when removal is
considered.
ü Dierent lters have dierent optimal removal window
time frames.
ü The OptEase and TrapEase (Cordis/Cardinal Health,
Milpitas, CA) lters have a higher incidence of IVC
thrombosis when compared to other IVC lter designs.
Case 41
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A B
■ Clinical Presentation
81
A 63-year-old man presents to the emergency department with shortness of breath.
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