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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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Teaching Points
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▶ Presenting symptoms may include hypoxia, transient ischemic attacks, stroke, cerebral abscess, and/or
hemoptysis.
▶ If le untreated, Gossage etal. (1998) calculated stroke incidence to be 11.4%, brain abscess 6.8% with total
morbidity, and mortality at 23%.
▶ Traditional teaching suggests that all detected AVMs with feeding arteries larger than 3mm in adults should
be treated; some authors have suggested treatment of any detected PAVMs.
▶ Between 60% and 90% of patients with PAVMs have hereditary hemorrhagic telangiectasia (HHT).
▶ Catheter and wire exchanges should be performed in a saline bath to diminish the risk of paradoxical air
emboli.
Management
▶ Patients with suspected HHT should have family members screened for the disease with genetic testing.
Family members should also be screened with an echocardiographic bubble study.
▶ Between 10% and 20% of patients with HHT will have cerebral vascular malformations, and magnetic
resonance imaging (MRI) should be performed for evaluation. Other manifestations of HHT include visceral
telangectasias such as in the gastrointestinal tract and liver. ese are treated symptomatically and routine
screening is not recommended.
▶ Following embolization of a PAVM in a patient with HHT, follow up with contrast chest CT scans, or to
minimize radiation exposure, echocardiographic bubble study is recommended.
Further Reading
Faughnan ME, Palda VA, Garcia-Tsao G, etal. International guidelines for the diagnosis and management of hereditary
haemorrhagic telangiectasia. J Med Genet. 2011; 48:73–87.
Gossage JR, Kanj G. Pulmonary arteriovenous malformations. Astate of the art review. Am J Respir Crit Care Med. 1998;
158:643–661.
Meek ME, Meek JC, Beheshti MV. Management of pulmonary arteriovenous malformations. Semin Intervent Radiol. 2011;
28:24–31.
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History
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▶ A45-Year-Old Female with Persistent, Disabling Pelvic Fullness
Figure 34.1
Case 34
Figure 34.2
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Case 34 Pelvic Congestion Syndrome
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Figure 34.3
Figure 34.4
Figure 34.5
Findings
▶ Coronal magnetic resonance (MR) images demonstrate an enlarged ovarian vein draining pelvic varices
(Figs. 34.3 and 34.4, hollow arrows).
▶ e le ovarian vein has been catheterized via the le renal vein (Fig. 34.5). Venography conrms the MR
ndings of engorged pelvic veins. Note the more distal veins should be smaller in caliber than the vein into
which they drain.
▶ Aer embolization with sodium tetradecyl sulfate and coils, there is no residual lling of the pelvic
variscosities (Fig. 34.6).
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Figure 34.6
Teaching Points
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▶ Incompetence of valves and retrograde ow in an engorged ovarian vein can manifest as chronic pelvic
pain, which is dened as noncyclic pelvic pain for at least 6months. is constellation is known as “pelvic
congestion syndrome.” Hemodynamically, this is analogous to the male varicocele (see Case 42).
▶ Pelvic congestion syndrome usually presents in premenopausal women as unilateral pelvic pain exacerbated
with standing, liing, and sexual intercourse.
▶ e dierential diagnosis of chronic pelvic pain in women is broad, and it includes endometriosis, broids,
adhesions from pelvic inammatory disease, atypical menstrual pain, urologic disorders, and inammatory
bowel disease. Pelvic inammatory disease should be ruled out prior to consideration of embolization. In
some patients, vulvar varicosities can be seen involving the upper medial thigh.
▶ Noninvasive imaging is oen performed early in the initial workup of pelvic congestion syndrome, and it is
particularly useful in excluding other etiologies. Ovarian vein diameter >5mm with slow ow and/or dilated
pelvic veins suggest the diagnosis, but catheter venography remains the gold standard. Findings at venography
suggestive of the syndrome include ovarian vein reux with incompetent valves and contrast lling vessels
across the midline.
Management
▶ Treatment options include surgical ligation of the ovarian veins, hysterectomy, and transcatheter
embolization.
▶ Venography while the patient is performing a Valsalva maneuver is helpful to conrm the presence of
incompetent valves with reux into pelvic varicosities. Ideally, this would be performed in a semierect
position, but in practice this is dicult to accomplish.
▶ Similar to internal spermatic vein embolization for varicocele, treatment includes embolization of the
oending vein. is can be accomplished with coil embolization, foamed sodium tetradecyl sulfate, n-butyl
cyanoacrylate, or the Amplatzer device.
▶ Embolization should start at the level of the sciatic notch and progress cranial to within a few centimeters
from the insertion of the ovarian vein into the inferior vena cava (right) or renal vein (le).
▶ Bilateral ovarian vein embolization is oen performed. is is in contradistinction to internal spermatic vein
embolization in which embolization is oen only performed on the side of the varicocele.
▶ Signicant improvement in pelvic pain is seen in 70%–80% following embolization, with a recurrence of
symptoms in 5% over time. ere is no evidence of alteration of menstrual cycle or fertility.
▶ In patients with persistent symptoms aer embolization, interrogation and embolization of varices seen
arising from the anterior division of the internal iliac veins may be considered.
Further Reading
Bittles MA, Hoer EK. Gonadal vein embolization:treatment of varicocele and pelvic congestion syndrome. Semin Intervent
Radiol. 2008; 25(3):261–70.
Katz MD, Sugay SB, Walker DK, Palmer SL, Marx MV. Beyond hemostasis:spectrum of gynecologic and obstetric indications
for transcatheter embolization. Radiographics. 2012; 32(6):1713–31. doi:10.1148/rg.326125524.
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History
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▶ A45-Year-Old Female with Acute Right-Sided Flank Pain
Figure 35.1
Case 35
Figure 35.2
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Case 35 Ruptured Renal Angiomyolipoma
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Figure 35.3
Figure 35.4
Figure 35.5
Findings
▶ An exophytic lesion (Fig. 35.3, black arrow) is shown arising from the lower pole of the right kidney with
associated high-density material in the retroperitoneum representing hemorrhage (white arrow).
▶ Coronal computed tomography (CT) image through the same region (Fig. 35.4) exemplies fat density
material within the lesion (white arrow), conrming the diagnosis of a ruptured angiomyolipoma (AML).
▶ Right renal arteriogram (Fig. 35.5) demonstrates lling of the tumor with associated tortuous tumor
vasculature (white solid arrows). Of note, superselective angiogram of one of these segmental renal arteries
(white hollow arrow) reveals that most of the supply of this tumor is from this artery.
▶ Renal arteriogram aer particle embolization of the segmental artery supplying the tumor (white hollow
arrow) with contrast stasis in the stump and no distal ow. Tumor vasculature is no longer seen.
Teaching Points
▶ Renal AML is the most common benign renal neoplasm.
▶ Treatment is reserved for patients with hemorrhage, pain, or for tumors larger than 4cm because they are at
high risk of hemorrhage.
▶ Active contrast extravasation in the setting of acute hemorrhage may not always be identied on angiography,
as the surrounding hematoma may obscure the bleeding.
Figure 35.6
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▶ ere is no consensus as to the embolic material of choice.
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▶ Multiple AMLs may be seen in the setting of tuberous sclerosis.
Management
▶ Follow-up imaging should demonstrate cessation of bleeding with reduction of hematoma.
▶ Aer embolization, follow-up imaging should show the tumor to decrease in size; however, the fatty
component of AMLs are relatively insensitive to embolization, and therefore there is variability in size
reduction.
▶ Lifelong follow-up is suggested in patients with associated tuberous sclerosis complex secondary to high
tumor recurrence rates.
Further Reading
Han YM, Kim JK, Roh BS, etal. Renal angiomyolipoma:selective arterial embolization—eectiveness and changes in
angiomyogenic components in long term follow-up. Radiology. 1997; 204:65–70.
Kothary N, Soulen MC, Clark TW, etal. Renal angiomyolipoma:long-term results aer arterial embolization. J Vasc Interv
Radiol. 2005; 16:45–50.
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History
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▶ A12-Year-Old Girl Kicked by a Horse. What are the Treatment Options?
Figure 36.1
Case 36
Figure 36.2
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Case 36 Liver Trauma
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Figure 36.3
Figure 36.4
Figure 36.5
Figure 36.6
Findings
▶ Two images from a contrast-enhanced computed tomography (CT) (Figs. 36.3 and 36.4) show a liver
parenchyma fracture with a small subcapsular hematoma (arrow, Fig.36.3) and active extravasation of
contrast (arrow, Fig. 36.4).
▶ Hepatic artery angiogram shows active extravasation from a branch of the right hepatic artery (Fig. 36.5,
arrow, aer placement of a single straight coil) corresponding to the nding on CT. Also note relative
hypoperfusion of the liver supplied by this branch of the hepatic artery (star) and the mass eect crowding
branches of the more caudal right hepatic artery.
▶ Aer embolization with additional straight coils (Fig. 36.6), extravasation is no longer seen.
Teaching Points
▶ e liver is the second most commonly injured intraabdominal organ in blunt trauma and penetrating
trauma.
▶ To facilitate communication between radiologists and surgeons and to help guide treatment, grades of liver
injury have been developed. is case represents a grade IV injury.
Grade I—subcapsular hematoma <10% surface area, or capsular tear <1cm of parenchymal depth
Grade II—subcapsular hematoma 10%–50% of surface area, or laceration 1–3cm deep and <10cm long
Grade III—subcapsular hematoma >50% surface area, or laceration >3cm of parenchymal depth
Grade IV—parenchymal disruption 24%–75% of single lobe or 1–3 Couinaud segments in a single lobe
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Grade V—parenchymal disruption >75% of single lobe or >3 Couinaud segments in a single lobe,
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juxtahepatic venous injury (hepatic vein, inferior vena cava)
Grade VI—hepatic avulsion
▶ Because the liver parenchyma derives up to 80% of nutrient blood supply from the portal vein, in the
setting of a patent portal vein, embolization of the entire hepatic artery rarely causes permanent liver
damage.
Management
▶ Hemodynamic, instability and peritonitis aer abdominal trauma are indications for urgent laparotomy. Stable
patients should have a contrast-enhanced CT. Hepatic angiography and embolization should be considered
as a rst-line treatment of (1)patients with transient response to resuscitation, (2)in hemodynamically stable
patients with evidence of active extravasation on CT, and (3)hemodynamically stable patients who rebleed
aer surgical intervention.
▶ Most patients with liver laceration are managed conservatively, with fewer than 1 in 5 requiring surgical
intervention.
Further Reading
e American Association for the Surgery of Trauma Injury Scoring Scale. http://www.aast.org/library/traumatools/
injuryscoringscales.aspx. Accessed November 10, 2013.
Malhotra AK, Fabian TC, Croce MA, etal. Blunt hepatic injury:a paradigm shi from operative to nonoperative management
in the 1990s. Ann Surg. 2000; 231:804.
Ong CC, Toh L, Lo RH, etal. Primary hepatic artery embolization in pediatric blunt hepatic trauma. J Pediatr Surg. 2012;
47(12):2316–2320.
Stassen N, Bhullar I, etal. Nonoperative management of blunt hepatic injury:An Eastern Association for the Surgery of
Trauma practice management guideline. J Trauma Acute Care Surg. 2012; 73:S288.
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