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_3645_Библиотеки_им_академика_М_И_Перельмана
.pdf
Findings
https://t.me/med1917
▶ Preembolization digital subtraction selective splenic arteriogram shows an enlarged spleen with normal
vascularity (Fig. 43.3). e splenic artery divides into superior (black arrows) and inferior (hollow arrows)
terminal branches near splenic hilum.
▶ Digital subtraction splenic arteriogram obtained aer embolization of approximately 70% of spleen (Fig. 43.4)
shows embolization coils in the inferior splenic artery branches (arrows). Lack of parenchymal blush (stars) is
now seen in inferior portion of the spleen.
▶ Tc99m sulfur colloid nuclear scan before (Fig. 43.5) and aer (Fig. 43.6) partial splenic embolization shows
lack of parenchymal uptake in the lower aspect of the spleen (stars) due to partial splenic infarction.
▶ Platelet count trend before and aer embolization showing improvement in the platelet count aer partial
splenic artery embolization (Fig.43.7), allowing laparoscopic cholecystectomy to be performed with a
lower risk of bleeding. ere is oen a rebound elevation of platelet count that peaks at 2–4 weeks following
embolization.
Teaching Points
▶ Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired nonmalignant stem cell disorder, that occurs
mainly in young adults and is characterized by intravascular hemolysis, hemoglobinuria cytopenias, and
despite thrombocytopenia there is an an increased risk of life-threatening thrombotic events.
▶ rombocytopenia was thought to be secondary to hypersplenism. Partial splenic artery embolization was
performed to optimize the platelet count prior to elective surgery.
▶ Prior to coil placement, embolization was performed with particles for terminal vessel blockade. Embolization
of the more proximal splenic arteries with coils alone would not cause infarction of splenic tissue due to the
presence of collateral vessels, principally via the short gastric and capsular arteries.
▶ Partial splenic embolization reduces sequestration and destruction of the blood elements, while maintaining
the opsonization function of the spleen.
Management
▶ Embolization of 50%–70% of splenic volume is performed, preferably of the lower pole both to minimize
diaphragmatic irritation resulting in pain and associated sympathetic pleural eusion/atelectasis and to allow
for easier drainage of abscess should one develop.
▶ Complication of splenic embolization includes abscess formation, splenic rupture, necrosis of the gastric
wall, renal insuciency, acute pancreatitis, splenic vein thrombosis, postembolization pain, sepsis, and
pneumonia.
▶ Postembolization abdominal pain is usually well controlled by medication. Continuous epidural analgesia has
been also used.
▶ e local eect of arterial embolization on the spleen can be assessed by nuclear medicine studies
(Technetium-99 sulfur colloid scan), computed tomography (CT), ultrasound, or magnetic resonance imaging
(MRI); however, clinical success is judged by improvement in platelet count.
Further Reading
Krishnan SK, Hill A, Hillmen P, etal. Improving cytopenia with splenic artery embolization in a patient with paroxysmal
nocturnal hemoglobinuria on eculizumab. Int J Hematol. 2013; 98(6):716–8. doi:10.1007/s12185-013-1454-1.
Mado DC, Denys A, Wallace MJ, etal. Splenic arterial interventions:anatomy, indications, technical considerations, and
potential complications. Radiographics. 2005; 25:S191–S211.
Rotoli B, Luzzatto L. Paroxysmal nocturnal hemoglobinuria. Baillieres Clin Haematol. 1989; 2:113–138.
128
Case 44
https://t.me/med1917
History
▶ Aer embolization of the gastroduodenal artery for active extravasation (not shown), an angiogram is done.
What happened and what are the treatment options?
Figure 44.1
Figure 44.3
Figure 44.2
129
Case 44 Retrieval of Nontarget Coil
https://t.me/med1917
Figure 44.4
Figure 44.5
Figure 44.6
Findings
▶ Hepatic angiogram and aer coil embolization of a gastroduodenal artery, pseudoaneurysm (not shown)
demonstrates a coil that has migrated into the right hepatic artery (Fig. 44.4, arrow). Based on the position of
the catheter and the right hepatic artery, the expected course of the gastroduodenal artery (now packed with
coils) is shown by the arrowheads.
▶ Unsubtracted digital angiogram with the catheter in the common hepatic artery (Fig.44.5) shows early takeo
of the le hepatic artery proximal to the gastroduodenal artery (hollow arrow). Note again the malpositioned
coil in the course of the right hepatic artery (arrow).
▶ e migrated coil was snared (not shown) and removed, aer which there is restoration of antegrade
ow in the right hepatic artery (arrow, Fig. 44.6). Distal to the nest of coils, the gastroduodenal artery
is reconstitued (hollow arrow) by the inferior pancreaticoduodenal arteries arising from the superior
mesenteric artery.
130
Teaching Points
https://t.me/med1917
▶ Coil migration can occur when the diameter of the coil is either too small or too large to form in the target
vessel, or if the coil is too long. Arule of thumb is to choose a coil that is 10% larger than the diameter of the
target vessel.
▶ In situations where coil migration can have potentially catastrophic consequences, use of detachable coils
should be considered. For example, when occluding the feeding artery of a pulmonary arteriovenous
malformation, if a coil were to pass through the malformation, it would pass into the le heart via the
pulmonary vein and cause paradoxical embolism such as a cerebrovascular event.
Management
▶ Coils come in a variety of diameters, lengths, and shapes, both with and without dacron brils. It is
important to remember that the coils themselves do not occlude the vessel, but the slow ow they create
and the brils promote thrombosis, which can take a few minutes to occur. Tincture of time rather
than placing coils one aer another ultimately saves time, reduces cost, and minimizes the risk of coil
migration.
▶ When not contraindicated, anticoagulation should be considered at the time a coil is placed in a nontarget
vessel to prevent non-target vessel occlusion while retrieval is attempted.
▶ Devices used for retrieval include snares (multiloop snares are particularly useful for intravascular retrieval)
and alligator forceps.
▶ In this case, if the coil had not been successfully retrieved, inadvertant embolization of the right hepatic artery
in the setting of a patent portal vein is unlikely to have been clinically signicant.
Further Reading
Egglin TK, Dickey KW, Rosenblatt M, etal. Retrieval of intravascular foreign bodies:experience in 32 cases. Am J Roentgenol.
1995; 164(5):1259–1264.
131
History
https://t.me/med1917
▶ A70-Year-Old Female with Pelvic Mass Presents with Anuria and Increasing Creatinine
Case 45
Figure 45.1
Figure 45.2
132
Case 45 Hydronephrosis from Obstructing Mass Failing
https://t.me/med1917
Ureteral Stent
Figure 45.3
Figure 45.5
Figure 45.4
Figure 45.6
Figure 45.7
133
Findings
https://t.me/med1917
▶ Coronal computed tomography (CT) scan (Fig. 45.3) demonstrates marked hydronephrosis of the right
kidney (arrows) with obstructing pelvic mass. Ureteral stents were placed cystocopically; however, creatinine
remained elevated with persistent hydronephrosis (white arrow) on follow-up ultrasound (Fig. 45.4). Note the
ureteral stent on ultrasound (open arrow).
▶ Anephrostomy tube was placed (Fig. 45.5, black arrow) and the proximal portion of the ureteral stent is seen
(white arrow).
▶ Figure 45.6 demonstrates intraprocedural snare retrieval of the cystoscopically placed ureteral stent (black
arrow). Asnare is looped around the proximal pigtail of the ureteral stent (white arrow).
▶ Figure 45.7 demonstrates a nephroureterostomy tube in place (open arrow) with pigtails formed in the renal
pelvis and bladder.
Teaching Points
▶ In patients with normal bladders who require urinary drainage, cystoscopic ureteral stent placement should be
attempted rst for patient comfort and safety.
▶ In the event of sepsis or failed ureteral stent placement, nephrostomy or nephroureterostomy catheters can be
placed. Nephroureterostomy catheters are preferred in most situations because they can be capped to allow for
internal drainage and the length of catheter minimizes the risk of inadvertent dislodgement.
▶ In certain situations, however, nephrostomy is favored over nephroureterostomy. ese include (1)urinary
diversion to prevent urine from entering the bladder (e.g., in the presence of a vesicovaginal stula), (2)to
relieve debilitating bladder spasm associated with nephroureterostomy or stent, and (3)bladder hemorrhage
that is exacerbated by the presence of a catheter.
▶ Ureteral stents can be removed cystoscopically or through the nephrostomy tract. In this case, the advantage
to the latter is twofold:(1)access across the obstruction is maintained, facilitating nephroureterostomy
catheter placement; and (2)it is done by a single operator in a single procedure.
▶ Ureteral stents should not be placed in patients who are unable to void spontaneously or who are
incontinent.
▶ Ureteral stents should also not be placed in patients who have neo-bladders or conduits because the mucus
secreted by the bowel quickly occludes the distal holes in the catheter.
Management
▶ Nephrostomy, nephroureterostomy, and ureteral tubes/stents should be exchanged every 3–6months to
prevent occlusion.
▶ e use of prophylactic antibiotics for routine exchange is controversial.
Further Reading
Dyer RB, Regan JD, Kavanagh PV, etal. Percutaneous nephrostomy with extensions of the technique:step by step.
Radiographics. 2002; 22:503–525.
134
History
https://t.me/med1917
▶ Cervical Cancer. Pulsatile Blood Seen during Retrograde Exchange of Indwelling Ureteral Stent
Case 46
Figure 46.1
Figure 46.2
135
Case 46 Ureteral-Right Iliac Artery Fistula
https://t.me/med1917
Figure 46.3
Figure 46.5
Figure 46.4
Figure 46.6
Figure 46.7
136
Findings
https://t.me/med1917
▶ Retrograde injection of contrast into the right ureter at the time of stent exchange demonstrates lling of
branches of the right iliac artery (Fig. 46.3, arrow).
▶ Aballoon has been placed over a wire and inated (Fig. 46.4, arrow) to tamponade and prevent further
extravasation aer the stent was removed.
▶ Digital subtraction angiography of the right iliac artery shows a lling defect (Fig. 46.5, arrow) consistent with
clot at the bifurcation into the internal and external iliac arteries. ough largely subtracted, the course of the
balloon in the ureter can be seen crossing the artery at exactly this level (hollow arrows).
▶ Aer thrombectomy and coil embolization of the internal iliac artery (Fig. 46.6, arrow) to prevent retrograde
endoleak, right iliac angiogram shows extravasation into the ureter (hollow arrows).
▶ Acovered stent was placed (Fig. 46.7) extending from the common iliac to the external iliac artery, spanning
the stula; there is no further extravasation seen.
Teaching Points
▶ Uretero-arterial stulae are most commonly seen in patients who have undergone either abdominal/pelvic
surgery or radiation therapy and have chronic ureteral stents.
▶ e common iliac artery bifurcation is the most common site of stula formation because it is where the
ureter crosses immediately anterior to the artery.
▶ Uretero-arterial stulae are notoriously dicult to diagnose and should be suspected in patients at high risk
who have persistent hematuria and no other identiable source.
Management
▶ Morbidity related to uretero-arterial stula is high; once identied, it should be treated urgently with either
placement of a stent gra across the stula, as in this case, or open surgical repair.
▶ Surgical repair is oen dicult because most patients have adhesions from having undergone previous
surgery and/or radiation. Surgical repair, either uretero-ureterostomy or nephrectomy, is usually reserved for
failure or recurrence aer endovascular treatment.
▶ Prophylactic antibiotics should be considered because of the communication between potentially colonized
urine and the bloodstream.
Further Reading
Tselikas L, Pellerin O, Di Primio M, etal. Uretero-iliac stula:modern treatment via the endovascular route. Diagn Interv
Imaging. 2013; 94(3):311–318.
137
Соседние файлы в папке Библиотека им академика М.И. Перельмана