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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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Case 30 Hepatic Artery Aneurysm
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Figure 30.4
Figure 30.6
Figure 30.5
Figure 30.7
Figure 30.8
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Figure 30.9
Findings
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▶ Reconstruction from an arterial-phase computed tomography (CT) scan (Fig. 30.4) and a single image from
a digital subtraction angiogram (Fig. 30.5) demonstrate a saccular aneurysm (arrow) of the common hepatic
artery at the bifurcation into the proper hepatic and gastroduodenal arteries. Asingle axial image shows this
to be partially thrombosed (Fig. 30.6, arrow).
▶ Figure 30.7 shows a common hepatic angiogram aer embolization of the gastroduodenal artery, which was
done to prevent retrograde ow from the superior mesenteric artery from causing an endoleak (arrow).
▶ Aer placement of a stent-gra extending from the common hepatic artery into the proper hepatic artery
just proximal to the bifurcation into right and le hepatic arteries (Fig. 30.8), there is no further lling of the
aneurysm sac.
▶ One month later, reconstruction from an arterial-phase CT (Fig. 30.9) shows the covered stent in good
position with no lling of the aneurysm sac or the embolized gastroduodenal artery.
Teaching Points
▶ True aneurysms represent saccular or fusiform dilation of a vessel whose wall is intact (i.e., all three layers of
the vessel wall are present in the aneurysm). is is in contradistinction from pseudoaneurysms (which are
much more common) that can be thought of as contained rupture with loss of the integrity of at least one layer
of the vessel wall. Most pseudoaneurysms require treatment, whereas true aneurysms are treated based on size
or interval growth in order to prevent rupture.
▶ e most common visceral artery aneurysms involve the splenic artery.
▶ Hepatic artery aneurysms can be associated with celiac artery stenosis and the presence of a median arcuate
ligament.
▶ Indications for treatment include symptomatic aneurysms (e.g., pain), size >2cm, or rapid growth.
Management
▶ Both pseudoaneurysms and true aneurysms may be treated successfully with stent-gra placement
across the lesion. True aneurysms may be obliterated by lling the aneurysm sac with coils, onyx, or
glue. Pseudoaneurysms, on the other hand, because they are contained ruptures, require occlusion of
the vessel immediately proximal and distal to the injury. An exception is catheter-related femoral artery
pseudoaneurysms, which have been successfully treated with thrombin injection.
▶ e size of visceral stent-gras can be determined by measuring the diameter of the vessel proximal to the
aneurysm where the walls are parallel and oversizing by 10%–20%.
▶ If a stent-gra cannot be placed to treat a hepatic artery aneurysm, embolization of the hepatic artery
proximal and distal to the aneurysm is a reasonable alternative in the setting of a patent portal vein.
▶ Aer placement of a visceral artery stent-gra, consideration of short-term antiplatelet therapy should be
considered.
Further Reading
Jackson, James E. Management of Visceral Aneurysms in Image guided interventions. Mauro, M, Murphy K, omson K,
Venbrux A, Morgan R editors. Philadelphia, PA:Elsevier Saunders, 2013:508–515.
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History
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▶ Renal Cell Carcinoma Status Post Fall
Case 31
Figure 31.1
Figure 31.3
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Figure 31.2
Figure 31.4
Case 31 Embolization of Renal Cell Carcinoma Bone Metastasis
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Figure 31.5
Figure 31.6
Figure 31.7
Findings
▶ Radiograph of the right humerus (Fig. 31.1) shows a displaced fracture of the proximal diaphysis at the site of
a lytic metastasis.
▶ An angiographic catheter has been placed from right radial artery approach into the right subclavian artery.
Note catheter tip (Fig. 31.5, arrow) and catheter course in Figure 31.6.
▶ At the fracture site, a hypervascular so tissue mass is identied (Fig. 31.6). Draining veins are seen coursing
medially from the tumor (arrows).
▶ Aer embolization (Fig. 31.7) the mass is markedly less vascular. e subclavian artery remains widely patent.
Teaching Points
▶ Radial access may be performed safely aer conrmation of a patent palmar arch in the hand using the Allen
test. Radial artery access was chosen in this case to avoid the risk of stroke from catheter manipulation in the
aortic arch across the origins of the carotid arteries.
▶ Preoperative embolization of hypervascular tumors has been shown to reduce intraoperative blood loss and
transfusion requirement. e most common hypervascular bone metastases include renal cell carcinoma, as in
this case, multiple myeloma and thyroid carcinoma.
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▶ It is important to determine whether early visualization of draining veins represents a shunt, because
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embolization in this setting would result in nontarget embolization to the lungs. When in doubt, use of
larger particles or PVA, which tends to clump and result in a slightly more proximal embolization, should
be considered.
Management
▶ Aer preoperative bone embolization, surgery should be performed within 3days to minimize
revascularization of the tumor from collateral vessels.
▶ On occasion, embolization of a spine tumor may be performed in the absence of planned surgery to prevent
neural encroachment.
Further Reading
Owen RJT. Embolization of musculoskeletal bone tumors. Semin Intervent Radiol. 2010; 27(2):111–123.
92
History
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▶ An 85-Year-Old Male with Massive Hemoptysis
Case 32
Figure 32.1
Figure 32.3
Figure 32.2
Figure 32.4
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Case 32 Bronchial Artery Embolization
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Figure 32.5
Figure 32.6
Figure 32.8Figure 32.7
Figure 32.9
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Findings
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▶ Single image from a computed tomography (CT) (Fig. 32.5) shows bronchiectasis and air space disease in the
lingula (arrows).
▶ Bronchial artery angiogram (Figs. 32.6 and 32.7) demonstrates a markedly hypertrophied le bronchial artery.
No active extravasation is seen.
▶ Immediately aer embolization with large particles, there is no longer llling of the bronchial artery branches
(Fig.32.8).
▶ In another patient (Fig. 32.9), an intercostal angiogram demonstrates an accessory anterior spinal artery,
which can also arise from the bronchial artery.
Teaching Points
▶ Bronchial arteries most commonly arise from the descending thoracic aorta between T4 and T8. e most
common conguration is a single right and multiple le arteries, although this is quite variable. Other
potential sites of origin include internal mammary, subclavian, thyrocervical, phrenic, and intercostal arteries.
▶ Common causes of hemoptysis requiring intervention include chronic inammatory conditions such as cystic
brosis, tuberculosis, aspergillosis, bronchiectasis, and, as in this case, malignancy.
▶ e anterior spinal artery may have medullary branches arising from proximal bronchial arteries.
Embolization of the anterior spinal artery can cause permanent paralysis and must be avoided. e
charateristic “hairpin” loop (Fig.32.9) and consistent position over the spine in multiple obliquities are clues
to the presence of a spinal artery branch.
Management
▶ e denition of massive hemoptysis varies, ranging from 200 to 600 cc/day. Treatment is generally indicated
to prevent/minimize the risk of aspiration and asphyxiation.
▶ It is rare to see active extravasation from the bronchial arteries. Most patients with massive hemoptysis
have diuse lung disease and hence diusely abnormal bronchial arteries. For that reason, lateralization of
hemoptysis before embolization using bronchoscopy is very helpful in preprocedure planning.
▶ Although a less common cause of hemoptysis, bleeding from a pulmonary artery source should also be
considered when hemoptysis is not controlled with bronchial artery embolization or a structural abnormality
of the pulmonary artery is detected by CT.
▶ Immediate success rate is approximately 85%; however, recurrent hemoptysis is relatively common due
to recanalization or hypertrophy of collateral vessels or due to progression of the underlying process.
Embolization with particles (rather than coils) is recommended as coil embolizaiton makes subsequent
intervention more complicated.
Further Reading
Bronchial artery embolization. In:Mauro, Murphy, omson, Venbruz, and Zollikofer, eds.:Image-Guided Interventions,
volume 2. Philadelphia, PA:Saunders Elsevier, 2008:931–938.
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Case 33
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History
▶ A54-year-old woman was referred from a pulmonologist aer she presented with progressive shortness of
breath. e patient has an abnormal echocardiographic bubble study and the following ndings. What is the
appropriate management?
Figure 33.1
Figure 33.2
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Case 33 Pulmonary Arteriovenous Malformation
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Figure 33.3
Figure 33.4
Figure 33.5
Findings
▶ Contrast-enhanced computed tomography (CT) angiogram (Fig. 33.4) and three-dimensional reconstruction
(Fig. 33.3) demonstrate three simple pulmonary arteriovenous malformations (arrows) as characterized by
a single feeding artery entering the aneurysmal segment followed by a draining vein. Malformations are
identied in the right middle and lower lobes as well as the le lower lobe.
▶ Figure 33.5 is a digital subtraction angiogram (DSA) with a catheter in the distal right main pulmonary artery.
e pulmonary arteriovenous malformation (PAVM) in the right middle lobe (arrow) is shown. e PAVM
within the right lower lobe does not become evident until aer embolization of the PAVM within the right
middle lobe due to the large shunt from this malformation.
▶ DSA image with a ush catheter in the main pulmonary artery (Fig. 33.6) following successful embolization
of all three PAVMs. An amplatzer vascular occlusion device (hollow arrow) was used in the PAVM within the
right middle lobe in addition to metallic coils due to its size. e remaining PAVMs were embolized utilizing
metallic coils (arrows).
Figure 33.6
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