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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 67 Paget Schroetter
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Figure 67.2
Figure 67.3
Figure 67.4
Findings
▶ Venogram demonstrates occlusion of right axillary vein (arrow, Fig. 67.2) with multiple engorged collateral
veins.
▶ Aer subclavian vein thrombolysis, balloon venoplasty (arrow, Fig. 67.3) was performed, resulting in minimal
recanalization of the subclavian vein with decrease in retrograde lling of collateral veins (Fig. 67.4). Note the
waist in the balloon at the thoracic outlet (Fig.67.4, arrow).
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Teaching Points
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▶ Subclavian vein eort thrombosis, or Paget Schroetter syndrome, results from compression of the subclavian
vein in the thoracic outlet, which is comprised of the anterior scalene muscle, clavicle, and rst rib. It may also
occur in the setting of compression from a cervical rib or secondary to marked hypertrophy of the anterior
scalene muscles.
▶ Symptoms include pain, swelling, and numbness of the aected arm; eort thrombosis most commonly
occurs in young men who perform repetitive arm abduction, such as weight liers or painters.
▶ e brachial plexus, subclavian vein, and artery all pass through the thoracic outlet. e majority of symptoms
result from pressure on the brachial plexus, followed by the subclavian vein and artery, respectively.
Management
▶ Although contrast venography is the gold standard for diagnosis, Doppler ultrasound or magnetic resonance
venography with provocative maneuvers should be obtained rst to conrm the diagnosis.
▶ rombolysis is usually the rst treatment modality to recannalize the occluded vein. is is typically
followed by early surgical decompression of the thoracic outlet by resection of the cervical or rst rib and
anterior scale muscle. In some cases, a trial of anticoagulation prior to surgery may be considered with
surgical intervention reserved for recurrence of symptoms.
▶ Catheter-directed thrombolysis should only be performed aer a careful history to exclude any
contraindications to thrombolytic agents. In this case, aer the acute clot was traversed with a multi-sidehole
catheter, alteplase was infused at a rate of 1 mg/h. Alternatively or in conjunction, mechanical thrombectomy
may be considered.
▶ Stent placement should be considered only for patients who cannot tolerate surgery or who have recurrent
thrombosis or stenosis aer surgical decompression.
Further Reading
ompson RW. Comprehensive management of subclavian vein eort thrombosis. Semin Intervent Radiol. 2012;
29(1):44–51.
199
Case 68
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History
▶ A2-Month-Old Female with Right Neck Swelling. What Are the Treatment Options for the Lesion Shown?
Figure 68.1
Figure 68.2
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Case 68 Sclerosis of Lymphatic Malformation
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Figure 68.3
Figure 68.5
Figure 68.4
Figure 68.6
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Findings
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▶ Ultrasound of the right neck demonstrates multilocular thin-walled macrocysts (Fig. 68.3). No ow was seen
within the cysts (not shown).
▶ T2-weighted saggital magnetic resonance image (MRI) (Fig. 68.4) shows high signal intensity consistent with
uid-lled cysts. Note macrolobulations within the lesion similar to those seen on ultrasound.
▶ A catheter was placed directly into the malformation using ultrasound guidance (not shown). Coronal
computed tomography (CT) reconstruction shows the catheter within the lesion (Fig. 68.5).
▶ Follow-up ultrasound 8 weeks aer sclerosis (Fig. 68.6) demonstrates signicant reduction in the size of the
lymphatic malformation with near-normal cosmesis.
Teaching Points
▶ e International Society of the Study of Vascular Anomalies Classication System separates vascular
proliferative neoplasms from vascular malformations based on the presence or absence of endothelial
proliferation.
▶ Vascular malformations are further divided into high-ow and slow-ow types. Lymphatic malformations are
classied as slow-ow vascular malformations.
▶ Lymphatic malformations represent 5% of benign tumors in infancy and childhood. ey occur when
embryonic lymphatics fail to join central channels or secondary to congenital obstruction of lymphatic
drainage.
▶ Lymphatic malformations of the neck (previously referred to as “cystic hygromas”) are associated with Turner
syndrome; trisomies 13, 18, 21, 22; Noonan syndrome; and exposure to teratogens.
Treatment
▶ Primary modalities used to imaging vascular malformations include ultrasound and MRI because of the lack
of ionizing radiation and ability to characterize blood ow and extent of lesions.
▶ Microcystic malformations are more resistant to chemical sclerosis than macrocystic lesions and may require
thermal ablation or surgical resection.
▶ Sclerosants used for lymphatic malformations include ethanol, doxycycline, and bleomycin. Doxycycline
can be used eectively because it can be given in large volumes. OK-432 (Pacibinal), a combination of a
low-virulence strain of Streptococcus pyogenes and benzylpenecillin, has been used with success in Japan and
Europe but is not FDA approved in the United States.
▶ In this case, a pigtail catheter was placed and the lymphatic malformation treated for 3 successive days.
Further Reading
Gilony D, Schwartz M, Shpitzer T, etal. Treatment of lymphatic malformations:a more conservative approach. J Pediatr Surg.
2012; 47(10):1837–1842.
Lowe LH, Marchant TC, Rivard DC, etal. Vascular malformations:classication
and terminology the radiologist needs to know. Semin Roentgenol. 2012; 47(2):106–117.
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History
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▶ Le Lower-Extremity Varicose Veins and Swelling
Figure 69.1 Figure 69.2
Case 69
Figure 69.3
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Case 69 May Thurner Syndrome
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Figure 69.4
Figure 69.5
Figure 69.6
Findings
▶ Coronal magnetic resonance image (MRI) (Fig. 69.4) demonstrates compression and narrowing of the le
common iliac vein at the conuence with the right. e area of narrowing conforms to the shape of the
overlying right iliac artery (arrows).
▶ Narrowing of the le common iliac vein is conrmed at venography (arrow, Fig. 69.5). Collateral lumbar and
hemiazygous veins are seen (arrow, Fig. 69.6). No deep venous thrombosis was seen (not shown).
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Teaching Points
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▶ May urner syndrome, or iliac vein compression syndrome, results from compression of the le common
iliac vein between the right common iliac artery and spine at the level of the sacral promontory.
▶ May urner accounts for <4% of lower-extremity deep venous thrombosis. It is most common in young
to middle-age females and should be considered in the setting of chronic unilateral le leg swelling or
varicosities.
▶ Patients usually present with acute-onset le leg swelling and pain.
▶ e combination of mechanical compression and pulsatile vibrations from the right common iliac artery
causes chronic microtrauma, leading to endothelial injury.
Treatment
▶ Treatment is dependent on symptomatology. Conservative treatment includes use of compression stockings
and elevation of the leg when possible.
▶ In the presence of deep venous thrombosis, endovascular pharmacological and/or mechanical thrombolysis
with venous stent placement can be considered. Early thrombolysis is critical in preventing postthrombotic
syndrome, which can include pain, paresthesias, swelling, varicose veins, skin discoloration, and ulcer.
▶ When stent placement is indicated, self-expanding stents are used because, unlike balloon expandable stents,
they are not subject to the deformity due to extrinsic compression.
▶ Following stent placement, anticoagulation and compression stockings are recommended to prevent
recurrence.
Further Reading
Butros SR, Liu R, Oliveira GR, etal. Venous compression syndromes:clinical features, imaging ndings and management. Br J
Radiol. 2013; 86(1030):20130284.
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Case 70
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History
▶ A45-Year-Old Female Status Post Recent Resection of Craniopharyngioma with Postoperative Pulmonary
Embolism, Referred for Inferior Vena Cava Filter Placement
Figures70.1 and 70.2 are of two dierent patients. What is the dierence?
Figure 70.1
Figure 70.2
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Case 70 Inferior Vena Cava Filter Placement
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Figure 70.1
Figure 70.2
Figure 70.3
Findings
▶ Figure 70.1 depicts an inferior venacavagram performed with the catheter tip within the le common iliac
vein. Carbon dioxide gas is used as the contrast agent because the patient has an anaphylactic reaction to
iodinated contrast.
▶ Figure 70.2 demonstrates a typical inferior venocavagram performed with iodinated contrast.
Figure 70.4
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