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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 78 Traumatic Pseudoaneurysm of the Carotid Artery
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Carotid stenting with coil embolization of the pseudoaneurysm sac was performed.
Figure 78.5
Figure 78.7
Figure 78.6
Figure 78.8
Figure 78.9
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Figure 78.10
Findings
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▶ Axial contrast CT demonstrates air and so tissue swelling from the bullet entry (white arrow, Fig. 78.5).
ere is asymmetric so tissue swelling of the le parapharyngeal space (black arrow, Fig. 78.5) with
irregularity of the distal le internal carotid artery, better appreciated in reconstructed views (white arrow,
Fig. 78.6).
▶ Frontal and lateral arteriograms (Figs. 78.7 and 78.8) of the le internal carotid artery show irregularity of the
distal le internal carotid artery with contrast extravasation into a pseudoaneurysm sac.
▶ Astent was placed across the area of injury (white arrow). Initial postdeployment images show leak of contrast
out the stent interstices into the pseudoaneurysm sac. Repeat angiogram aer a short delayed shows this leak
to persist (black arrow, Fig.78.9).
▶ Secondary to the persistent leak, coil embolization of the sac was performed through the stent interstices
(black arrow, Fig. 78.10) with good angiographic result.
Teaching Points
▶ Pseudoaneurysms are typically saccular outpouchings that do not involve all three layers of the arterial wall
(as opposed to true aneurysms).
▶ CT angiogram can underestimate the injury. Angiography should be performed if there is a high index of
suspicion of vascular injury.
▶ Repair can be performed with endovascular techniques versus open repair. Open repair includes clipping,
resection with primary end-to-end anastomosis or gra, exclusion and bypass, or carotid ligation.
▶ Interventional techniques to treat traumatic vessel injury or pseudoaneurysm include embolization of the
vessel distal and proximal to the site of injury and covered stent placement. Covered stent placement, when
feasible, is preferred because it preserves vessel patency.
▶ More typically, common carotid artery stents are placed for the treatment of carotid artery stenosis. In
symptomatic patients (transient ischemic attack, amaurosis fugax, or other cerebrovascular event) the
threshold for stent placement in angiographic stenoses is greater than 50%, whereas in asymptomatic patients
it is greater than 70%.
Management
▶ Endovascular management was utilized here secondary to a dicult neck dissection and high carotid injury.
▶ Endovascular options include exclusion with a stent gra or stenting with coil embolization of the sac through
the interstices, performed here.
▶ Stent size should be 10%–20% larger than the diameter of the vessel proximal to the injured (or in the case of
atherosclerotic disease, stenotic) site.
▶ Anticoagulation following stent placement is important to prevent stent occlusion. In the setting of trauma,
as in this case, it may need to be delayed. Anticoagulation following arterial stent placement typically includes
antiplatelet agents such as aspirin and clopidogrel.
Further Reading
Brott TG, Hobson RW, Howard G etal. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med.
2010; 313:11–23.
Garg K, Rockman CB, Lee V, etal. Presentation and management of carotid artery aneurysms and pseudoaneurysms. J Vasc
Surg. 2012; 55(6):1618–1622.
239
History
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▶ A50-Year-Old Female in High-Speed Motor Vehicle Collision
Case 79
Figure 79.1
Figure 79.3
Figure 79.2
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Case 79 Acute Traumatic Aortic Injury
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Figure 79.4
Figure 79.6
Figure 79.5
Figure 79.7
Figure 79.8
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Findings
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▶ Chest radiograph (Fig. 79.4) demonstrates a widened mediastinum (black arrow) and shi of the trachea to
the right (white arrow). Depression of the le main bronchus may also be seen in the setting of traumatic
aortic injury (not well depicted here).
▶ Axial and sagittal postcontrast images (Figs. 79.5 and 79.6) demonstrate disruption of the descending thoracic
aorta just distal to the origin of the subclavian artery with associated contained pseudoaneurysm (white
arrow).
▶ Figure 79.7 demonstrates the aortic injury on le anterior oblique aortic angiogram (white arrow) prior to
successful endovascular repair (Fig. 79.8).
Teaching Points
▶ Most (75%–80%) aortic injuries are associated with high-speed motor vehicle collisions.
▶ Immediate mortality is 80%–90%, with 60%–80% of those who reach the hospital surviving a denitive repair.
▶ Traumatic aortic injury occurs following acute deceleration at locations where the aortic is relatively
immobile. ese include the aortic root, at the diaphragmatic hiatus, and most commonly at the aortic
isthmus (as was seen in this case), where the aorta is tethered by the ligamentum arteriosum.
Management
▶ Acute traumatic aortic injury is a surgical emergency. Most patients undergo open surgical repair with aortic
cross-clamping and cardiopulmonary bypass.
▶ Select cases, such as the one shown, can be treated with endovascular techniques depending on the degree
and location of the injury as delineated on a contrast-enhanced computed tomography (CT) and immediate
availability of appropriate size stent gras.
Further Reading
Steenburg SD, Ravenel JG, Ikonomidis JS, etal. Acute traumatic aortic injury:imaging evaluation and management. Radiology.
2008; 248:748–762.
242
Case 80
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History
▶ A50-Year-Old Male with Persistent Hypertension Despite Being Treated with ree Antihypertensive
Medications
Figure 80.1
Figure 80.3
Figure 80.2
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Case 80 Renal Artery Stenosis
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Figure 80.4
Figure 80.5
Figure 80.6
Findings
▶ Nonselective aortogram demonstrates a high-grade stenosis involving the right renal ostium (Fig. 80.4,
arrow).
▶ Figure 80.5 shows deployment of a balloon expandable stent (arrow) across the ostial stenosis. Use of balloon
expandable stents oers more precise deployment.
▶ Figure 80.6 shows a technically successful deployment of the stent (arrow). Blood pressure normalization
occurred later that evening.
Teaching Points
▶ Renal artery stenosis (RAS) is a relatively common disease with a mortality rate of approximately 16%.
▶ While many patients are asymptomatic, this diagnosis should be considered in patients presenting with
uncontrollable or abrupt onset of hypertension, hypertension with asymmetric renal length, and less
commonly, ash pulmonary edema. If onset of hypertension occurs in a young person (<30years of age),
bromuscular dysplasia should be considered.
▶ RAS results in activation with release of renin from renal juxtaglomerular cells. Renin catalyzes the breakdown
of angiotensinogen to angiotensin I.Angiotensin Iis transformed by angiotensin-converting enzyme into
angiotensin II; and angiotensin II, a potent vasoconstrictor, promotes the release of aldosterone from the
adrenal cortex.
244
▶ RAS is suggested to cause two types of hypertension:
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■ Unilateral RAS with a normally perfused and normally functioning contralateral kidney; hypertension
is referred to as “renin dependent” and is characterized by increased peripheral resistance. Renin and
angiotensin levels are elevated, but volume expansion is limited by natriuresis of the contralateral normally
functioning kidney.
■ Bilateral RAS or unilateral RAS with absent or dysfunctional contralateral kidney; intravascular volume
increases and renin secretion decreases. Without the natriuretic eect of a normally perfused contralateral
kidney, hypertension is maintained by volume expansion.
▶ Primary stenting is generally reserved for ostial lesions.
Management
▶ Use of renal artery angioplasty/stenting for treatment of hypertension is highly controversial, secondary to
reports of no clinical benet despite technical success. is may be secondary to poor patient selection and
overtreatment. us, strict adherence to guidelines is suggested. Guidelines for renal artery revascularization
suggest that a hemodynamically signicant RAS is dened as the presence of ≥50% to 70% diameter stenosis
by visual estimation on angiography, a systolic pressure gradient ≥20mmHg, or a mean gradient ≥ 10mmHg
measured with a ≤ 5 French catheter or a pressure guidewire.
▶ Blood pressure normalization can be quick and profound occurring within hours to days aer the procedure.
Close monitoring and titration of blood pressure medications is important.
Further Reading
Hirsch AT, Haskal ZJ, Hertzer NR, etal. Practice guidelines for the management of patients with peripheral arterial disease
(lower extremity, renal, mesenteric and abdominal aortic). Circulation. 2006; 113:e463–e654.
245
History
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▶ Right Groin Swelling and Pain 2 Weeks aer Cardiac Catheterization
Figure 81.1 Figure 81.2
Case 81
Figure 81.3
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Figure 81.4
Case 81 Femoral Artery Pseudoaneurysm
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Figure 81.5
Figure 81.6
Figure 81.7
Findings
▶ Ultrasound of the groin demonstrates a right femoral artery pseudoaneurysm with a class “yin-yang”
appearance of to-fro ow within (Fig. 81.5) and a narrow neck (Fig. 81.6) between the pseudoaneurysm and
common femoral artery (arrow).
▶ A 22-gauge needle was advanced into the pseudoaneurysm (Fig. 81.7, arrow) under ultrasound guidance away
from the neck.
▶ Aer injection of 1000 units of thrombin injection (Fig. 81.8) the pseudoaneurysm has completely
thrombosed with no residual ow seen in the pseudoaneurysm sac.
Teaching Points
▶ Aer catheterization of the common femoral artery, the risk of pseudoaneurysm is approximately 2%.
▶ Risk factors include arterial puncture above the inguinal ligament or below the femoral head, use of
anticoagulation, large sheaths, and female sex. Femoral access should be performed at the level of the femoral
head because the hard bone acts as a back stop for manual compression of the artery.
▶ Swelling, pain, or a bruit at the site of an arterial puncture should raise the possibility of pseudoaneurysm. e
diagnosis is made by ultrasound, which can demonstrate both anatomy and ow characteristics.
Figure 81.8
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