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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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Management
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▶ Small, asymotomatic pseudoaneurysms (<2cm) may be managed conservatively with follow-up ultrasound in
2–4 weeks to conrm resolution.
▶ Treatment options include percutaneous thrombin injection, ultrasound-guided compression, and surgical
repair.
▶ Ultrasound-guided compression involves compression with the ultrasound probe using enough pressure to
collapse the pseudoaneurysm but to allow ow in the parent femoral artery. Aer 20 minutes, the pressure is
released and ow within the lesion is reassessed. is may be repeated several times, but it is dicult for both
the operator and patient to tolerate.
▶ rombin injection, when technically feasible, is performed by injection of small volumes (usually <1 cc) of
1,000 IU/mL topical thrombin as far from the neck as possible under constant ultrasound guidance. Care
should be taken to avoid overinjection, which can result in thrombosis of the parent vessel.
Further Reading
Tisi PV, Callam MJ. Treatment for femoral pseudoaneurysms. Cochrane Database Syst Rev. 2013; 11:CD004981.
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History
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▶ A78-Year-Old Female with History of Atrial Fibrillation and Acute Abdominal Pain
Figure 82.1
Case 82
Figure 82.2
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Case 82 Acute Superior Mesenteric Artery Embolism
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Figure 82.3
Figure 82.4
Figure 82.5
Findings
▶ Figure 82.3 demonstrates thickening of small-bowel loops in the mid-abdomen (white arrow). is nding is
nonspecic but suggestive of an inammatory or ischemic process.
▶ Figure 82.4 depicts a superior mesenteric angiogram with a lling defect (white arrows) in an intestinal
branch of the superior mesenteric artery (SMA) supplying distal jejunal branches.
▶ Figure 82.5 is a sagittal computed tomography (CT) scan reconstructed from the scan from Figure 82.3. In
retrospect, this lling defect may have been identied (white arrow); however, the phase of contrast injection
and calcium makes the diagnosis dicult.
▶ Follow-up CT angiogram 6months aer emergent open thrombectomy and vein patch demonstrating a
patent jejunal branch (Fig.82.6, white arrow).
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Figure 82.6
Teaching Points
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▶ SMA embolism is the most common cause of acute mesenteric ischemia. Sudden obstruction of the celiac or
inferior mesenteric artery is a rare cause of acute symptoms.
▶ Arteriography can be performed if ndings on noninvasive imaging are equivocal, if nonocclusive ischemia is
suspected, or if endovascular therapy is planned.
▶ Acute SMA embolism is best treated with surgical embolectomy with or without patch angioplasty or bypass
graing. is allows for evaluation of bowel viability and resection of infarcted bowel, if needed. In select cases
without evidence of threatened bowel, thrombolysis may be considered.
▶ Vasodilator infusion (Papaverine) may be considered as a preoperative therapy in cases of nonocclusive
embolism.
▶ Emboli typically lodge at branch points within the vessel and cause abrupt cuto with a meniscus or tram-
track appearance of contrast around the clot.
Management
▶ e most common source of acute mesenteric embolism is cardiac. In this case, le atrial thrombus due to
atrial brillation was the culprit.
▶ Workup for cause of any embolic disease requires an evaluation for the source. In the case of visceral emboli,
the workup should include an echocardiogram and possibly a CT angiogram of the aorta to exclude aneurysm
as a source.
Further Reading
Ryer EJ, Kalra M, Oderich GS, etal. Revascularization for acute mesenteric ischemia. Jour Vas Surg. 2012; 55:1682–1689.
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History
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▶ A35-Year-Old Female Presenting with Menorrhagia
Figure 83.1
Case 83
Figure 83.2
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Case 83 Uterine Fibroid Embolization
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Figure 83.3 Figure 83.4
Figure 83.5
Findings
▶ Figure 83.3 demonstrates an enlarged uterus with multiple broids, some of which demonstrate internal cystic
changes.
▶ Magnetic resonance angiogram (MRA) demonstrating enlarged uterine arteries (Fig. 83.4, open white arrows)
and enlarged ovarian arteries (solid white arrows) supplying the hypervascular broids. Because of this
nding, the patient was counseled that initial embolization may be suboptimal secondary to collateral supply
from the ovarian vessels.
▶ Intraprocedural angiogram (Fig. 83.5) demonstrates enlarged uterine arteries (black arrows). Both right and
le uterine arteries were selectively catheterized and embolized with spherical particles.
▶ Figure 83.6 is a companion image from a dierent patient demonstrating a submucosal broid with large
intracavitary component (white arrows). Findings like this on a preprocedural magnetic resonance image
(MRI) should prompt discussion of risk of postembolization infection and passage of necrotic tissue.
Figure 83.6
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Teaching Points
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▶ MR evaluation should be used to evaluate patients for candidacy and for follow-up aer uterine broid
embolization (UFE). Attention should be paid to the following:
■ Intracavitary broids are likely to be expelled in weeks to months aer a UFE, which may require
antibiotics, analgesia, or assisted expulsion by a gynecologist.
■ Pedunculated subserosal broids are considered a relative contraindication for embolization secondary
to risk of detachment. Recent literature seems to suggest its safety; however, most practitioners are still
cautious.
■ Cervical broids may be resistant to UFE secondary to rich collateral blood supply.
▶ Contraindications to UFE include current uterine or adnexal infection, pregnancy, and suspected gynecologic
malignancy.
▶ While controversial, UFE should not be considered rst-line treatment for women with infertility secondary
to broids or who desire to become pregnant, with studies suggesting myomectomy oering better outcomes.
Management
▶ Pain management plays an important role in the postprocedure setting with most patients receiving
intravenous narcotics via a patient-controlled analgesia pump overnight.
▶ Most patients are discharged home the following day with oral analgesics, with pain expected to continue for
about 1 week.
▶ Postembolization syndrome is expected 3–5days aer the procedure, comprised of low-grade fevers,
generalized fatigue, and loss of appetite.
Further Reading
Bulman JC, Ascher SM, Spies JB. Current concepts in uterine broid embolization. Radiographics 2012; 32:1735–1750.
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History
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▶ A30-Year-Old Male Runner with New-Onset Bilateral Calf Claudication
Figure 84.1
Case 84
Figure 84.2
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Case 84 Popliteal Entrapment
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Figure 84.3
Figure 84.4
Findings
▶ Lower extremity arteriogram (Fig. 84.3) in neutral position of the ankle demonstrates normal ow and runo
of the bilateral popliteal arteries to the anterior tibial artery and tibioperoneal trunk.
▶ In plantar exion (arrows, Fig. 84.4) there is abrupt occlusion of the le popliteal artery and signicantly
decreased runo to the right calf.
Teaching Points
▶ Popliteal artery entrapment syndrome presents with calf claudication exacerbated with exercise. On physical
examination distal pulses that decrease with plantar exion should raise the possibility of entrapment.
▶ Anatomic popliteal entrapment is characterized by deviation and compression of the artery by the medial
head of the gastrocnemius that can result in adventitial thickening, brosis, aneurysm formation, thrombosis,
and distal embolization (“blue toe syndrome”).
▶ Popliteal entrapment is bilateral in 20%–60% of cases and is most common in young and middle-aged
patients.
▶ In functional popliteal entrapment, there is a normal anatomic relationship of the popliteal artery as it exits
the popliteal fossa and passes between the medial and lateral heads of the gastrocnemius muscle and posterior
to the popliteus muscle. In this situation, it is hypertrophy of the normally positioned calf muscles that results
in compression of the artery during exercise.
Treatment
▶ With entrapment, the popliteal artery may appear normal in neutral position. Compression with plantar
exion clinches the diagnosis.
▶ Surgical release of the muscle or tendon is necessary for anatomic entrapment. ere is no role for angioplasty
or stent.
▶ rombolysis can be performed prior to surgery in patients who present with occlusion or emboli.
Further Reading
Wright LB, Matchett WJ, Cruz CP, etal. Popliteal artery disease:diagnosis and treatment. Radiographics 2004; 24(2):467–479.
Acknowledgments
Images courtesy of Jim Caridi, MD, University of Florida, Gainesville, FL.
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History
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▶ Colon Cancer with Limited Liver Metastases Preoperative Right Trisegmentectomy
Figure 85.1
Case 85
Figure 85.2
Figure 85.3
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