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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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▶ Neuroendocrine Liver Metastases. What is the Finding on the CT conrmed on the Angiogram?
Figure 89.1
Case 89
Figure 89.2
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Case 89 Variant Hepatic Arterial
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Figure 89.3
Figure 89.5
Figure 89.4
Figure 89.6
Figure 89.7 Figure 89.8
Findings
▶ Contrast enhanced axial CT image (Fig.89.1) shows a vessel arising from a the superior mesenteric artery
(SMA) and coursing between the portal vein and inferior vena cava. Catheter angiography conrms the rst
branch of SMA is a replaced right hepatic artery (Fig. 89.3).
▶ Celiac angiogram in a dierent patient (Fig. 89.4) with the same anatomy demonstrates the le hepatic artery
(arrow) and no artery to the right hemiliver (star) arising from the common hepatic artery.
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▶ In a dierent patient, celiac angiogram shows a vessel arising from the le gastric artery (Fig. 89.6, arrow)
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supplying the le hemiliver.
▶ e corresponding CT (Fig. 89.7) shows the replaced le hepatic artery arising from the le gastric artery
(arrow).
▶ Figure 89.8 is a reconstruction from a CT angiogram demonstrating an uncommon variant, a double hepatic
artery, in which the right and le hepatic arteries arise separately from the proximal celiac artery. In this case
the gastroduodenal artery (star) is a branch of the le hepatic artery (arrow).
Teaching Points
▶ Replaced or accessory hepatic vessels are common, seen in approximately 40% of patients.
▶ e most common hepatic artery variant is an accessory le hepatic artery, followed by a replaced right
hepatic artery (approximately 10% each). e term “accessory” refers to the situation in which only a part of
the blood supply to a hemiliver is derived from the aberrant vessel.
▶ Recognition of variant anatomy is important for both surgeons contemplating liver and pancreatic surgery and
interventional radiologists treating liver tumors or hemorrhage.
▶ On CT the dierential diagnosis of so tissue in the portocaval space includes a replaced right hepatic artery,
papillary process of the caudate lobe, and enlarged lymph node(s).
Management
▶ Assessment of hepatic artery anatomy on preprocedure or preoperative imaging is an important part of the
workup of patients undergoing hepatobiliary or pancreatic intervention in order to avoid either incomplete
treatment when performing embolization or unanticipated intraoperative hemorrhage.
Further Reading
Covey Am, Brody LA, Maluccio MA, etal. Variant hepatic arterial anatomy revisited:digital subtraction angiography
performed in 600 patients. Radiology 2002; 224:542–547.
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History
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▶ A15-Year-Old Female with Progressive Right Lower-Extremity Pain
Figure 90.1
Case 90
Figure 90.2
Figure 90.3
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Case 90 Venous Malformation Sclerosis
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Figure 90.4
Figure 90.5
Figure 90.6
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Figure 90.7
Findings
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▶ Figure 90.4 demonstrates a T2 hyperintense venous malformation anterior to the right distal femur (white
arrow) associated with a single feeding artery from the distal popliteal artery.
▶ Figures90.5 shows the corresponding ultrasound demonstrating the feeding artery (white arrow) and
associated malformation (black arrow).
▶ Figure 90.6 shows percutaneous access to the feeding artery.
▶ Figure 90.7 shows direct puncture of the nidus (white arrow) with associated draining vein (black arrow).
Teaching Points
▶ Vascular malformations are congenital lesions characterized by an inborn defect in various stages of
embryogenesis involving one or a combination of arteries, veins, capillaries, or lymphatics.
▶ Vascular malformations are categorized into lymphatic malformations, low-ow venous malformations, or
high-ow arteriovenous malformations (see Case 68).
Management
▶ Treatments are directed toward the malformation itself, not the arterial supply:
■ First-line treatment of lymphatic or low-ow venous malformations includes direct puncture of the
malformation and sclerosant injection.
■ First-line treatment of a high-ow arteriovenous malformation involves percutaneous transarterial
embolization.
■ Sclerosants include ethanol, polidocanol, 3% sodium tetradecol sulfate (STS), and bleomycin, all with
varying ecacy and complication proles.
▶ Tourniquet use proximal to the treatment site should be considered to limit reux on sclerosant into the
normal venous system. Atourniquet was used during injection of the malformation shown in Figure90.7 to
increase dwell time of the sclerosant and to limit escape of sclerosant into the draining vein.
▶ Patients should be counseled on the likely need for multiple sessions of sclerosant injection spanned over
weeks to months for complete treatment.
Further Reading
El-Merhi F, Garg D, Cura M, etal. Peripheral vascular tumors and vascular malformations:imaging (magnectic resonance
imaging and conventional angiography), pathologic correlation and treatment options. Int J Cardiovasc Imaging. 2013;
29:379–393.
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History
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▶ A70-Year-Old Male with “Drop Attacks”
Figure 91.1
Case 91
Figure 91.2
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Case 91 Subclavian Steal
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Figure 91.3
Figure 91.4
Findings
▶ Coronal (Fig. 91.3) and axial (Fig. 91.4) computed tomography (CT) following le upper-extremity contrast
injection images show dense calcication of the origin of the le subclavian artery.
▶ No contrast is seen opacifying the origin of the subclavian artery; distal to the calcic occlusion there is
reconstitution by retrograde ow in the le vertebral artery (hollow arrow).
Teaching Points
▶ “Subclavian steal” occurs when there is occlusion of a subclavian artery proximal to the origin of the
vertebral artery. “Steal” results when retrograde ow in the ipsilateral vertebral artery provides the ow to the
subclavian artery, resulting in decreased perfusion of the posterior cerebral circulation and syncope when the
aected arm is exercised.
▶ Patients can also present with headaches, nausea, vertigo, ataxia, arm pain, paresthesias, and weakness.
Vigorous exercise and a sudden sharp turning of the head in the direction of the aected side can also evoke
symptoms.
▶ Contrast magnetic resonance (MR), computed tomography (CT), or Doppler ultrasound can be useful in
making the diagnosis, but of the three, only Doppler ultrasound is truly dynamic and can measure dierential
ow during the cardiac cycle.
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▶ Severity is classied by ow in the vertebral artery:
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■ Grade 1 (presubclavian steal)—reduced antegrade vertebral ow
■ Grade 2 (intermittent/partial/latent)—retrograde ow in systole and antegrade ow in diastole
■ Grade 3 (permanent/advanced)—permanent retrograde vertebral ow
▶ Subclavian steal is most commonly due to atherosclerosis but can also be seen in patients with dissecting
aneurysm, medium-vessel vasculitis (e.g., Takayasu arteritis), and radiation brosis.
▶ Signs on physical examination include weak or absent pulse or dierential systolic pressure compared to the
contralateral arm. In patients with le internal mammary coronary artery bypass gras, symptoms can include
cardiac ischemia.
Treatment
▶ Medical therapy is recommended for all patients with atherosclerotic disease, focusing on reducing the risk of
atherosclerosis, including treating hypertension, hyperlipidemia, diabetes mellitus, and smoking cessation.
▶ Surgery and endovascular stent placement are indicated when symptoms of syncope, or coronary ischemia in
the presence of a le internal mammary coronary artery bypass gra is present.
Further Reading
Burihan E, Soma F, Iared W. Angioplasty versus stenting for subclavian artery stenosis. Cochrane Database Syst Rev. 2011;
(10):CD008461.
Ernemann U, Bender B, Melms A, etal. Current concepts of the interventional treatment of proximal supraaortic vessel
stenosis. Vas a. 2012; 41(5):313–318.
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History
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▶ A9-Year-Old Girl with Facial Swelling. What Are the Treatment Options?
Case 92
Figure 92.1
Figure 92.2
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