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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 92 Arteriovenous Malformation
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Figure 92.3
Figure 92.4
Findings
▶ MIP magnetic resonance image (MRI) (Fig. 92.3) shows an arteriovenous malformation (AVM) in the
mandible with markedly enlarged branches of the internal maxillary artery (narrow arrow) and overlapped
lingual and submental arteries (block arrow) with drainage into the jugular veins (arrowheads).
▶ Lateral view of a digital subtraction angiogram of the external carotid artery (Fig. 92.4) demonstrates the
vascular nidus (star). Again noted are enlarged mandibular (small arrow), submental, and sublingual (arrow)
feeding arteries.
▶ Acombination of Onyx and coils was used to embolize the nidus and feeding vessels. Postembolization
angiogram shows a decrease in the size of the nidus (star, Fig. 92.5).
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Figure 92.5
Teaching Points
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▶ AVMs consist of multiple dysplastic arteries that shunt directly into arterialized veins, creating a vascular
nidus without a normal intervening capillary network.
▶ High-ow AVMs usually present in childhood. Periods of rapid growth are typically seen with growth spurts,
puberty, and pregnancy.
▶ Syndromes associated with AVMs include hereditary hemorrhagic telengectasia and Parkes-Weber syndrome,
which usually involves a lower extremity.
▶ e clinical staging system of AVMs based on the Schobinger Scale is as follows:
Stage I(Quiescence):cutaneous blush, skin warmth, arteriovenous shunt on Doppler ultrasound
Stage II (Expansion):darkening blush, lesion shows pulsation, thrill, and bruit
Stage III (Destruction):arterialsteal, distal ischemia, pain, dystrophic skin changes, ulceration, necrosis,
so tissue/bony changes
Stage IV (Decompensation):high-output cardiac failure
Treatment
▶ Most AVMs are inoperable or require extensive resection, which can be severely disguring.
▶ Destruction of the nidus is imperative to treating these dicult lesions. Simply embolizing the feeding arteries
leads to recruitment of collateral vessels, which are typically a more circuitious route to accessing the nidus in
the future.
▶ Percutaneous embolization can be used as primary treatment or as an adjunct to surgery. Complete
eradication of the nidus can be extremely dicult, and repeat treatments are oen necessary. Any one or a
combination of ethanol, particles, tissue adhesives, nonadhesive liquid embolic agents (Onyx), and coils have
been used.
▶ Particles should be avoided because they do not destroy the nidus and can pass into the venous outow,
resulting in paradoxical emboli.
▶ In this case, the patient underwent three embolizations of feeding vessels prior to surgery. e rst two
were with Onyx to decrease the size of the AVM. Final embolization was performed with coils to decrease
intraoperative bleeding.
Acknowledgments
Images courtesy of Deborah Rabinowitz, MD, Alfred I.Dupont Children’s Hospital, Wilmington, DE.
Further Reading
Cahill AM, Nijs EL. Pediatric vascular malformations:pathophysiology, diagnosis, and the role of interventional radiology.
Cardiovasc Intervent Radiol. 2011; 34(4):691–704.
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History
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▶ Abdominal Pain and Fever
Figure 93.1
Case 93
Figure 93.2
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Figure 93.3
Case 93 Ruptured Appendix
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Figure 93.4 Figure 93.5
Figure 93.6
Findings
▶ Figure 93.4:ere is a complex uid collection in the right lower quadrant with an enhancing rim (star).
Athickened appendix is identied immediately anterior to the collection (arrows).
▶ Anterior to the iliacus and posterior to the right colon, a 21-gauge needle has been advanced into the
collection using computed tomography (CT) guidance (Fig. 93.5).
▶ A drainage catheter was placed into the collection (Fig. 93.6), and 25 cc of foul-smelling pus was aspirated.
Aer placement of the catheter, there is minimal residual collection.
Teaching Points
▶ Perforated appendicitis may be drainage percutaneously prior to semielective appendectomy.
▶ Using CT guidance, drainage of the collection was performed even with a very narrow window of access.
Other routes to collections deep in the pelvis include transgluteal, transpiriformis, transgluteal and
approaches.
Management
▶ Antibiotics should be given within 1 hour of drainage of an abdominal abscess to minimize the risk of sepsis.
▶ Historically, drainage catheters were le in place until interval appendectomy was performed, but
contemporary data suggest that in select cases conservative (nonoperative) management has fewer
complications and similar reoperation rate to interval appendectomy.
Further Reading
Simillis C, Symeonides P, Shorthouse AJ, etal. A meta-analysis comparing conservative treatment versus acute appendectomy
for complicated appendicitis (abscess or phlegmon). Surgery 2010; 147(6):818–829.
281
History
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▶ A50-Year-Old Female with Fevers and Leukocytosis 6 Days aer Right Hemicolectomy
Figure 94.1
Case 94
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Case 94 Transgluteal Pelvic Abscess Drainage
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Figure 94.2
Figure 94.4
Figure 94.3
Figure 94.5
Findings
▶ An enhancing collection (black arrow) is seen the pelvis posterior to the urinary bladder (white arrow,
Fig. 94.2) ere is no safe route for transabdominal drainage, but the collection is amenable to transgluteal
drainage.
▶ An access needle (Fig. 94.3, white arrow) is being advanced into the collection, taking care to be as close to the
sacrum as possible. In this case, access below the piriformis and at the level of the sacrospinous ligament was
used.
▶ Figure 94.4 shows the access wire within the collection prior to drain placement.
▶ Interval follow-up computed tomography (CT) (Fig. 94.5) shows near-complete resolution of the collection
(white arrow).
Teaching Points
▶ Major neurovascular structures are located above the sacrospinous ligament, which marks the inferior border
of the greater sciatic foramen.
▶ An approach inferior to the piriformis muscle is preferred to avoid risk of injury to the sacral plexus or gluteal
vasculature.
▶ If entry to the collection is obscured by air in the distal sigmoid, consider placing a rectal tube to decompress.
▶ If an obvious route to the collection is not identied, consider techniques such as angling the CT gantry or
hydrodissection.
▶ Pain radiating down the patient’s leg during the procedure suggests that the needle is close to the sciatic nerve
or a sacral nerve branch. e trajectory of the needle should be revised.
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Management
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▶ As with most abscess drains, catheter outputs are monitored daily and 10 cc forward ushes are performed
2–3 times daily, taking care to ush both the catheter entering the cavity and the tubing to the drainage bag.
▶ Removal of drain is considered once there is resolution of clinical and laboratory signs of infection.
▶ If there is persistent increased output in the drain, an enteric stula should be suspected.
Further Reading
Harisinghani MG, Gervais DA, Hahn PF, etal. CT-guided transgluteal drainage of deep pelvic abscesses:indication, technique,
procedure-related complications, and clinical outcome. Radiographics. 2002; 22:1353–1367.
284
Case 95
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History
▶ An 87-Year-Old Diabetic Male with Bladder Cancer, Fever, and Pelvic Pain. Where is the Abscess and What is
the Most Appropriate Approach for Aspiration?
Figure 95.1
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Case 95 Transrectal Aspiration of Prostatic Abscess
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Figure 95.2 Figure 95.3
Figure 95.4
Figure 95.5
Findings
▶ Axial computed tomography (CT) (Fig. 95.2) shows a 3.2cm rim enhancing collection within the inferior
aspect of the prostate (arrows) gland just anterior to the rectum (star).
▶ Transrectal ultrasound (Fig. 95.3) demonstrates a nonloculated collection within the prostate corresponding
to the nding on CT.
▶ Using transrectal ultrasound for guidance, a 20-gauge needle (Fig. 95.4, arrow) was advanced into the abscess
under direct sonographic visualization.
▶ Aer 12 cc purulent uid was aspirated, there is near complete resolution of the abscess cavity (Fig. 95.5,
arrows).
Teaching Points
▶ Transrectal drainage is a reasonable treatment option in patients with deep pelvic or prostate abscesses not
otherwise amenable to percutaneous (transgluteal/transperineal) drainage.
▶ Endocavitary drainage (transrectal, transvaginal) is surprisingly well tolerated by patients, and in some cases
even for percutaneously accessible collections may be favorable to percutaneous drainage for this reason. is
is especially the case in pediatric patients.
▶ Prostatic abscesses are usually seen in patients who have diabetes or other cause for immunosuppression who
become inoculated from a urinary tract infection, indwelling urinary drainage catheter, or biopsy.
▶ Historically, prostatic abscesses were most commonly related to Neisseria gonorrhea. Current oending
organisms are those related to urinary tract, including Escherichia coli and other gram-negative bacilli.
Management
▶ For periuretheral abscesses, transureteral prostate resection is an alternative treatment option.
▶ In some cases, a drain may be le in place for a short dwell time to maximize drainage.
286
Further Reading
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Arrabal-Polo MA, Jimenez-Pacheco A, Arrabal-Martin M. Percutaneous drainage of prostatic abscess:case report and
literature review. Urol Int. 2012; 88(1):118–120.
Sudako GS, Lundeen SJ, Otterson MF. Transrectal and transvaginal sonographic intervention of infected pelvic uid
collections:a complete approach. Ultrasound Q. 2005; 21(3):175–185.
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