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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3751_Библиотеки_им_академика_М_И_Перельмана

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FIGURE3.6 Digitalsubtractionangiography(DSA)andComputedtomographicangiography(CTA)with
NASCETmeasurements.A,NASCETmeasurementsonCTAminimalluminaldiameter(blackline)comparedwith
thestraightportionoftheinternalcarotidarterybeyondanypoststenoticdilatation(whiteline).B,Withheavy
calcification(blackarrow),absolutemeasurementinmmmaybepreferable.CandD,Thispatienthadsymptoms
referabletoreducedcerebralperfusion.Pre-andpoststentcervicalimagesdemonstrateresidualstenosisdueto
theheavycalcificplaque.EandF,CerebralDSApre-andpoststentshowremarkableimprovementonperfusionon
therightandhissymptomsimproved.
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FIGURE3.7 Fibromusculardysplasia(FMD)andspontaneousdissection.A,AxialsourcecontrastMRA
demonstratedheterogeneoussignal(arrow)surroundingtheinternalcarotidartery(ICA)lumen.B,Noncontrast
TOFMRAshowsirregularityoftheICAlumen.C,ThecontrastMIP(maximumintensityprojection)MRAimage
betterdepictsthedegreeofnarrowingandbetterdepictsthefeaturesofFMD.D,TOFMIPnoncontrastMRAshows
minimalluminalirregularityoftheICAs,left>right.E,ThisisbetterseenonthecontrastMRAMIPimage(arrows).
F,ThebestandmostreliableistheaxialT1fatsaturationimageshowingintramuralhemorrhageinthesettingof
bilateralICAdissections.
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FIGURE3.8 Traumaticdissection,pseudo-occlusion,pseudoaneurysm.AandB,SagittalandaxialCTA
demonstrateaninternalcarotidarterydissectioninthisadolescenthitintheneckwithalacrosseball.Notethe
luminaldeformityontheaxialview(arrow).C,DiffusionweightedMRIshowsmultiplefociofrestricteddiffusion
consistentwithdistalembolizationandstroke.DandE,Longitudinalandtransverseultrasoundimagesofthe
commoncarotidarteryshowmarkedwallthickeningandluminalcompromiseinthispatientwhowasinamotor
vehiclecollisionandhadaseatbeltmarkonherneck.FandG,DSAdemonstratesraggedappearanceand
narrowingofthecommoncarotidartery.Thiswassuccessfullytreatedwithcoveredstents.HandI,This95-year-
oldpatientpresentedwithanexpandingneckmass,andUSwithcolorDopplerdemonstratesacarotid
pseudoaneurysm(PSA).JandK,DSAshowsthePSAandtheappearancefollowingcoveredstentplacement.
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FIGURE3.9 Carotidblowout(CBO).AandB,This50-year-oldwomanwithrecurrenttonsillarcancerpresented
withmassiveoralbleeding,andCTAshowsanirregularprojectionfromthecarotiddirectlyadjacenttothepharynx
(arrows),whichwasconfirmedbyDSA.C-F,Theinitialplanwastosacrificethecarotid,butaballoonocclusion
tolerancetest(whitearrowinPanelD)showsreducedcerebralperfusionontheleft(blackarrows)andcovered
stents(arrowinpanelF)wereplacedwithpreservationofthecerebralflow.
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FIGURE3.10 Filterembolicprotectiondevice(EPD).A,DUSdemonstratesinternalcarotidarterystenosiswith
increasedvelocities.B,DSAconfirmsstenosisandfavorableanatomyfordistalprotection.C,TheEPDis
deployed.DandE,ThestentisadvancedanddeployedwiththeEPDinplace.F,FinalDSApoststentdeployment.
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FIGURE3.11 Filterembolicprotectiondevice(EPD)withfillingandembolizationpostremoval.A-C,Archand
LCCADSAdemonstrateatightinternalcarotidarterystenosiswithnearocclusionoftheECAinapatientwith
tonsillarcarcinomapostradiationandsurgery.DandE,TransfemoralCASwithdistalprotectionwasuneventful
untilthepoststentDSAshowednoflowbeyondthestent(F).Theconcernisthatthefilterwasfilledwithdebris.The
exportcatheterwasutilizedtoclearthebasketandtheflowwasimproved.H,IWhentheEPDwasremoved,it
containeddebris.H,I.Unfortunately,thecarotidlookedimproved,buttherewasdistalembolizationofdebristothe
brain.J,DespiteintracranialTPA,thepatienthadalargelefthemisphericstroke.
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FIGURE3.12 Proximalembolicprotectiondevice(EPD)-Mo.Ma(Medtronic).A,Carotidstenosisinvolvesthebulb,
andboththeinternalandexternalcarotidoriginsandthekinkintheinternalcarotidabovethestenosiswouldpose
challengestoplacementofadistalprotectiondevice.B,Theballoonisplacedintheexternalcarotidarteryandthe
stentandangioplastyballoonsareplacedunderflowreversal.C,FinalstentplacementDSAwithballoondeflated.
CasecourtesyofDr.CarlosMena.
FIGURE3.13 TranscarotidCarotidArteryRevascularization(TCAR).A,UnsubtractedDSAdemonstrates
internalcarotidstenosisandthevascularaccessroutejustabovetheclavicleontheleft.BandC,SubtractedDSA
imagesbeforeandaftersuccessfulstentplacement.
Table3.1
AorticArchClassification
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TypeI Greatvesselsarisingfromthetopofthearch TypeII Greatvesselsarisingbetweentheparallelplanesdelineatedbytheouterandinnercurvesofthearch TypeIII Greatvesselsarisingcaudaltotheinnersurfaceofthearchoroftheascendingaorta
Table3.2
StepsforPercutaneousTransfemoralCarotidAngioplastyandStentingUsingDistalEmbolicProtectionDevice
Vascularaccessviafemoralartery Placementof6F80-90cmsheathintothecommoncarotidarteryusingdiagnosticcathetercoaxiallyversusexchange Targetlesionangioplastyusingmonorailsystem(5mmballoon) Followingremovaloftheballoon,thestentisadvancedintoidealpositionusingroadmapandbonylandmarks Poststentdeployment,thelesionispostdilated Thefilterdeviceisretrievedusingaretrievalcatheter Poststentdeployment,thelesionispostdilatedatthediscretionoftheoperator Postproceduralangiogramshouldincludeboththeneckandthecerebralvasculature Vascularclosureusingmanualpressurewithorwithoutmechanicalclosuredevice
Table3.3
StepsforPercutaneousTransfemoralCarotidAngioplastyandStentingUsingMo.Ma(Medtronic)Device
Vascularaccessviafemoralartery Placementof6F80-90cmsheathintothecommoncarotidarteryusingdiagnosticcathetercoaxiallyversusexchange ForproximalEPDuse:Thedistalballoonisplaceintotheexternalcarotidarteryandthemoreproximalballoonisplacedintothecommon carotidartery Theballoonsareinflatedandthelesioniscrossedwiththewiretobeusedasamonorail Targetlesionangioplastyusingmonorailsystem(5mmballoon) Followingremovaloftheangioplastyballoon,thestentisadvancedintoidealpositionusingroadmapandbonylandmarks Poststentdeployment,thelesionispostdilated Theballoonsaredeflated:externalcarotidfirstfollowedbythecommoncarotidballoon Postproceduralangiogramshouldincludeboththeneckandthecerebralvasculature Vascularclosureusingmanualpressurewithorwithoutmechanicalclosuredevice
Table3.4
StepsforTranscarotidCarotidArteryRevascularizationforCarotidAngioplastyandStenting
Vascularaccessviacarotidarterycutdownjustabovetheclavicle Placementof6Fshortsheathintothecommoncarotidartery Establishmentoffemoralveinaccessforconduitforcerebralprotection Targetlesionangioplastyusingmonorailsystem(5mmballoon) Followingremovaloftheangioplastyballoon,thestentisadvancedintoidealpositionusingroadmapandbonylandmarks Poststentdeployment,thelesionispostdilated Antegradeflowisreestablished Postproceduralangiogramshouldincludeboththeneckandthecerebralvasculature Vascularclosure
References
1.GrantEG,BensonCB,MonetaGL,etal.Carotidarterystenosis:grayscaleandDopplerultrasounddiagnosis–SocietyofRadiologistsin
Ultrasoundconsensusconference.UltrasoundQ.2003;19(4):190-198.
2.WintermarkM,AroraS,TongE,etal.Carotidplaquecomputedtomographyimaginginstrokeandnonstrokepatients.AnnNeurol.
2008;64(2):149-157.
3.SilvennoinenHM,IkonenS,SoinneL,RailoM,ValanneL.CTangiographicanalysisofcarotidarterystenosis:comparisonofmanual
assessment,semiautomaticvesselanalysis,anddigitalsubtractionangiography.AJNRAmJNeuroradiol.2007;28(1):97-103.
4.MenonBK,d’EsterreCD,QaziEM,etal.MultiphaseCTangiography:anewtoolfortheimagingtriageofpatientswithacuteischemic
stroke.Radiology.2015;275(2):510-520.
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