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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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History
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▶ Hematemeis. What is the Procedure Being Performed?
Case 64
Figure 64.1
Figure 64.3
Figure 64.2
Figure 64.4
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Case 64 Balloon-Occluded Retrograde Transvenous
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Obliteration of Gastric Varices
Figure 64.5
Figure 64.7
Figure 64.6
Figure 64.8
Figure 64.9
Figure 64.10
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Figure 64.11
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Findings
▶ A coronal reformat (Fig. 64.5) from a contrast-enhanced computed tomography (CT) demostrates a large
gastrorenal shunt (arrow) arising from the le renal vein (star). An axial image from the same CT (Fig. 64.6)
shows submucosal gastric varices (arrow) covered by a thin layer of gastric mucosa (hollow arrow).
▶ e gastrorenal shunt (GRS) has been catheterized from a femoral vein approach (Fig. 64.7). Contrast
injection with a balloon inated lls the gastric varices (arrow). Asystemic vein (phrenic) is seen medial to
the shunt (hollow arrow).
▶ Aer coil embolization of the systemic vein (arrow), the catheter has been advanced distally within the shunt (Fig.
64.8). Contrast injection shows reux into short gastric veins (arrowheads) and the splenic vein (hollow arrow). Note
that contrast is injected through the endhole of the catheter, and a more proximal balloon is inated to prevent reux.
▶ With the balloon of the catheter inated, a sclerosant has been injected to ll the volume of the GRS and
varices (Fig. 64.9).
▶ One month aer balloon-occluded retrograde transvenous obliteration (BRTO), contrast-enhanced CT
(Figs. 64.10 and 64.11) shows retention of lipiodol in the embolized gastric varices (arrows). ere is no
residual enhancement of the GRS or varices.
Teaching Points
▶ Indications for BRTO are bleeding or high-risk gastric varices and hepatic encephalopathy secondary to
shunt volume. Unlike TIPS, BRTO can be performed in the setting of decompensated liver function and
encephalopathy, and it may even improve encephalopathy by increasing hepatopedal ow in the portal vein.
▶ In some cases, BRTO can be performed in conjunction with TIPS or balloon-occluded antegrade transvenous
obliteration (BATO) to relieve sequela of portal hypertension.
▶ e sclerosant is typically a mixture of 1 part ethiodol, 2 parts3% sotradechol, and 3 parts air agitated through
a three-way syringe into a liquid foam. e average injectate is approximately 30–50 cc.
Management
▶ e balloon of the catheter is le inated for a 4- to 24-hour dwell time of the sclerosant to obliterate the shunt
and varices.
▶ Portal vein thrombosis is a relative contraindication to BRTO because it can cause increased venous pressure
in the mesenteric veins. Other potential complications include liver failure and gastric ulcers.
▶ Follow-up imaging with either CT, magnetic resonance, or endoscopic ultrasound is important to evaluate for
residual varices that may require additional therapy.
Further Reading
Saad, WEA, Al-Osaimi AMS, Caldwell SH. Pre and post balloon occluded retrograde transvenous obliteration clinical evaluation,
management and imaging:indications, management protocols and follow up. Tech Vasc Interv Radiol. 2012; 15(3):165–202.
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Case 65
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History
▶ A45-Year-Old Female with Uncontrolled Hypertension
A right adrenal nodule is identied on computed tomography (CT) imaging with Houndseld value of–7. What
is being shown here?
Figure 65.1
Figure 65.3
Figure 65.2
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Case 65 Adrenal Vein Sampling
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Figure 65.4
Figure 65.5
Figure 65.6
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Table65.1
RATIO
SERUM Aldosterone 105.8 ng/dL 4.2
Cortisol 24.9µg/dL
RIGHT Aldosterone 15,180 ng/dL 52.1
Cortisol 291.5µg/dL
LEFT Aldosterone 363 ng/dL 2.1
Cortisol 175.45µg/dL
Findings
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▶ e right adrenal vein has been catheterized and a small amount of contrast has been injected by hand
(Fig.65.4). e adrenal gland can be recognized angiographically as a gland-like structure, which is usually
triangular in appearance (triangle).
▶ Figure 65.5 demonstrates the catheter in the le adrenal vein (hollow arrow). Reux of contrast is noted in
the le inferior phrenic vein inow (black arrow). is is a common nding with the le adrenal vein and le
inferior phrenic vein draining into a common trunk prior to joining the le renal vein.
▶ Figure 65.6 show the le adrenal gland (hollow arrow).
▶ Table 65.1 shows levels of aldosterone and cortisol in the serum, right and le adrenal veins. Elevated
cortisol levels in the adrenal vein samples help to conrm that the samples are from the adrenal glands. An
aldosterone to cortisol ratio in the adrenal vein that is higher than that of serum suggests unilateral hormone
production from the right adrenal adenoma.
Teaching Points
▶ Adrenal vein sampling is performed to determine whether autonomous hormone production is unilateral or
bilateral, thereby directing therapy.
■ Most commonly performed for primary aldosteronism
■ Less commonly performed to isolate biochemically proven pheochromocytoma not visible on imaging.
▶ While there are some exceptions, the drainage of the central adrenal veins is fairly constant. e right central
adrenal vein typically drains into the midposterior wall of the inferior vena cava, while the le central adrenal
vein usually joins the inferior phrenic before entering the le renal vein.
▶ Preprocedure computed tomography (CT) scan can be helpful in identifying the adrenal vein, expected
location of the adrenal gland, and characterization of mass lesions. It should be noted that adenomas detected
on CT may not necessarily be associated with the patient’s clinical symptoms.
▶ Comparison of the adrenal vein blood samples and peripheral blood is performed. Acortisol level at least 2–3
times that of peripheral blood conrms accurate adrenal vein sampling.
■ Adrenals producing aldosterone will show an aldosterone-cortisol ratio higher than that of the peripheral
blood sample.
■ Normal glands will result in a ratio that is equal to or less than peripheral blood.
■ In cases of unilateral adenoma, the contralateral normal adrenal gland may show suppressed aldosterone
secretion.
Management
▶ Postprocedure management includes bed rest for femoral venipuncture.
▶ In cases with persistent pain aer a procedure with escalating analgesic requirements, consider intraadrenal
hemorrhage as a cause.
Further Reading
Daunt N. Adrenal vein sampling:how to make it quick, easy, and successful. Radiographics 2005; 25:S143–S158.
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Case 66
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History
▶ A45-Year-Old Male with Biopsy-Proven Small Cell Carcinoma in the Right Chest Presents with Acute
Shortness of Breath and Facial Swelling
Figure 66.1
Figure 66.2
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Case 66 Superior Vena Cava Syndrome
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Figure 66.3
Figure 66.4
Figure 66.5
Findings
▶ Alarge mass is seen in the right upper lobe (Fig. 66.3) extending into the hilum (white arrow). Of note, the
superior vena cava (SVC) is not identied and contrast is seen lling a dilated azygous venous system (white
hollow arrow).
▶ Coronal images through the chest (Fig. 66.4) demonstrate the right upper lobe mass with complete occlusion
of the SVC just distal to the conuence of the right internal jugular and subclavian veins (white hollow arrow)
to the level of the mid atrium (black hollow arrow).
▶ Venogram performed from the right internal jugular vein (Fig. 66.5) demonstrates SVC occlusion (black
hollow arrow) with lling of the azygous and accessory hemiazygous systems (white arrows).
▶ Placement of an SVC stent (Fig. 66.6, black arrow) demonstrates rapid transit of contrast into the right atrium
(white arrow). Note that the azygous and hemiazygous systems no longer ll.
Figure 66.6
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Teaching Points
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▶ Symptoms of SVC syndrome include dyspnea, facial and/or upper-extremity swelling, cough, stridor, chest
pain, or cyanosis.
▶ e most common cause of SVC syndrome is malignancy, with lung cancer being the most common.
▶ Benign causes of SVC syndrome include catheter-related stenosis and granulomatous mediastinitis and
radiation therapy.
▶ Primary patency is 70%–80% in 6months, with secondary patency ~95% at 6months.
Management
▶ First-line therapy for acute malignant SVC syndrome is stenting with concomitant radiation and/or
chemotherapy. Benign disease may be treated with balloon venoplasty and/or stent placement.
▶ Venous thrombolysis, either mechanical or chemical, may need to be performed prior to stenting if acute
thrombus is present.
▶ Most patients experience complete resolution of symptoms within 1–3days aer stenting.
▶ Use of postprocedure anticoagulation/antiplatelet is controversial.
▶ Complications include stent migration and cardiac tamponade due to rupture of the SVC into the
pericardium.
Further Reading
Ganeshan A, Hon LQ, Warakaulle DR, etal. Superior vena caval stenting for SVC obstruction:current status. Eur J Radiol.
2009;71:343–349.
Warren P, Burke C. Endovascular management of chronic upper extremity deep vein thrombosis and superior vena cava
syndrome. Semin Intervent Radiol. 2011; 28:32–38.
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History
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▶ A17-Year-Old Wrestler with Pain and Swelling of the Right Arm
Figure 67.1
Case 67
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