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224 C. W. Bakal and J. Cynamon
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A–C
FIGURE 20-23. (A). Acute occlusion due to in situ thrombo-
sis of the right popliteal artery. (B). After an overnight transcatheter intrathrombic thrombolytic infusion, a tight underlying critical stenosis is identified. (C). This was dilated with a
5 mm balloon.
taneous or surgical technique is necessary to preser ve
41
long-term patency (Fig. 20-23).
Until recently, urokinase was the agent of choice for catheter-directed thrombolysis in the extremities; however, withdrawal of this
agent from the market in late 1998 and early 1999 saw
increased use of tissue plasminogen activators in the periphery (Activase rt-PA, and retavase, r-PA).
Absolute contraindications to thrombolysis include recent gastrointestinal bleeding, recent neurosurgery or intracranial trauma, active bleeding diathesis, or recent
transient ischemia attack or stroke. Relative contraindications include recent history of major nonvascular surgery
or trauma, uncontrolled hypertension, and intracranial
tumor.
Results of thrombolysis
Randomized trials comparing catheter-directed thrombolysis and surgical revascularization have been published and included hundreds of patients. These trials are
not directly comparable because of differences in inclusion and exclusion criteria as well as in endpoints. There
appears to be no significant difference in limb salvage at
6 to 12 months, reported at 81 to 89%. Patients having
catheter-directed thrombolysis as initial therapy, however,
appear to have decreased mortality (6.5 to 16%) compared with patients undergoing surgical revascularization
(8.5 to 42%). Many interpret these findings to suggest
that catheter-directed therapy may be safer for high-risk
patients, with lysis appearing beneficial to the myocardium as well as the periphery. Furthermore, lysis appears
to reduce the magnitude of the surgical procedure
needed to restore perfusion. These trials used both tPA
and urokinase.
42–44
It is important to remember that the
ultimate result of thrombolysis is highly dependent on
treating the underlying lesion. Treatment of a diffusely
diseased native vessel or bypass graft is unlikely to yield a
durable result. Catheter-directed lysis is best when the
duration of ischemia is 14 days or less.
If there is an embolic complication during lysis, the
catheter can be advanced into the clot and lysis can be
continued or a percutaneous aspiration can be performed using nontapered, large-diameter catheters attached to a 50-mL suction syringe. Thrombectomy devices
such as the AngioJet by Possis Medical Inc. (Minneapolis,
MN) can be used to augment thrombolysis and decrease
infusion time.
45
A variety of percutaneous mechanical
thrombectomy devices have been used in Europe.
Miscellaneous conditions with vascular
narrowing
Giant cell arteritis generally affects the upper extremities,
but it occasionally can affect the femoral artery segments
and is typically a disease of the medium-sized arteries.
Takayasu’s disease is of gradual onset and rarely affects
the lower extremities; however, Takayasu’s disease can
involve the midabdominal aorta and renal arteries. Renal
artery involvement is seen in about 35% of patients; the
celiomesenteric arteries also can be involved. These patients can present with claudication (upper and lower
extremity), renovascular hypertension, and abdominal
angina (Fig. 20-24). Abdominal aortic coarctation (“midaortic” syndrome) can occur without the typical aortic
arch lesions of Takayasu’s disease and generally is seen in
younger patients; there is controversy over whether midaortic syndrome is a subtype of Takayasu’s disease or
Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities
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A–C
FIGURE 20-24 A 43-year-old woman with Takayasu’s disease who presented with arm claudication. (A). There is a smooth,
nonatherosclerotic aortic arch. There is occulusion of the innominate artery (
subclavian artery (
retrograde filling of the vertebral artery. (C). Abdominal aortogram demonstrates very minimal atheroscleroses of the infrarenal
aorta and mild left renal artery stenosis (
arrows
). (B). The late-phase film demonstrates reconstitution of the right subclavian artery (
arrow
).
arrowhead
) and marked disease of the left
arrow
225
) via
whether it is a distinct entity. Neurofibromatosis also must
be considered in the differential diagnoses of renal or
abdominal aortic narrowing.
Buerger’s disease
Buerger’s disease (thromboangiitis obliterans) is found
46
in male smokers aged 25 to 45 years.
It is a rare vasculitis
and characteriscally presents with focal gangrene or ischemic ulcers. Angiographically, there are abrupt occlusions and stenoses of the tibial arteries with small corkscrew collaterals. There may be thrombotic occlusion;
there is proximal sparing. Buerger’s disease also can affect the upper extremities and can present as an acute
ischemia.
Ergot disease
Ingestion of ergot compounds, typically for headache,
may cause arterial spasm that can progress to thrombosis
if untreated. The lesions are usually smooth, asymmetric,
and atypical for atherosclerosis (Fig. 20-25). Withdrawal
of the offending drug will clear the symptoms.
47
Aneurysm disease
An aneurysm is a focal dilation of an artery greater than
1.5 times normal caliber. When diffuse, it is termed arte-
riomegaly. Aneurysm disease traditionally was considered
a manifestation of atherosclerosis, but recent evidence
suggests it to be a heritable autoimmune process resulting in inflammation and degradation of the medica and
adventitia of the wall vessel.
48–51
Aneurysmal disease is
also thought to be a deficiency in collagen elastase; there
is an association between aortic aneurysm disease and
pulmonary emphysema.
Abdominal aortic aneurysm
The aorta is the most common site of aneurysm formation; 90 to 95% of abdominal aortic aneurysms (AAAs)
are infrarenal. AAA disease predominates strongly in
A
FIGURE 20-25. Ergotism. A 40-year-old woman presented with painful lower extremities and decreased pedal pulses. She had
a history of café ergot ingestion for headaches. (A,B). Smooth stenoses in asymmetric, atypical locations. There is occlusion of
the right popliteal artery. After withdrawal of her headache medication, the pedal pulses reappeared, and symptoms resolved.
B
226 C. W. Bakal and J. Cynamon
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men. Iliac aneurysms usually occur as an extension of
AAAs or are associated with femoral and popliteal aneurysms. Iliac aneurysms generally do not occur as isolated
findings.
Abdominal aortic aneurysms are associated with complications that can be catastrophic if left untreated. The
most feared complication of an AAA is rupture. The risk
of rupture increases with aneurysm size. Generally, elective repair is recommended for AAAs greater than 5 cm
in diameter. AAAs also can thrombose or embolize
thrombus peripherally. Inflammatory aneurysms have an
added component of perianeurysmal fibrosis that can
entrap or obstruct ureters; inflammation is best depicted
by computed tomography (CT). The surgical procedure
for AAA depends on the extent of the disease.
Aorto–aorto grafts (tube grafts) are placed when there is
a good cuff above the aortic bifurcation; if there is no cuff
and the aneurysm extends down to the bifurcation or
into the common iliac arteries, an aortobiiliac bypass
usually is performed.
Imaging of abdominal aortic aneurysms has undergone change over the past few years. Previously, most
patients with AAAs underwent aortography. Now most
uncomplicated aneurysms are imaged by CT, with aortography reserved for problem cases. These problem
cases may include aneurysms in which there is less than
1.5 cm infrarenal neck or in which the aneurysm extends
to the suprarenal aorta. Patients with suspected stenosis
of the renal, mesenteric, or celiac arteries also may undergo aortography. Angiography is indicated if there is
associated iliac stenosis because the usual aorto–aorto or
aortoiliac bypass graft may need to be modified to an
aorto–bifemoral bypass graft. The aortogram also may
depict the status of the inferior mesenteric artery and the
presence or absence of large lumbar arteries, which can
cause problems with bleeding at surgery. Other problems
encountered during surgery include unsuspected retroaortic or circumaortic renal veins, and these must be
searched for on preoperative CT. Endovascular grafting
for AAA is currently under active investigation, with two
devices recently approved for market use: These devices
typically need mapping angiography prior to placement.
These patients are followed by interval CT after placement. Angiography is usually necessary to plan treatment
for postimplant complications such as endoleaks, which
can be seen in up to 22% of patients (Fig. 20-26).
Aortography performed for abdominal aortic aneurysms must include biplane views with a pigtail above the
celiac artery. The lateral view is essential to demonstrate
the presence or absence of an infrarenal neck because
the aorta usually buckles forward at this level, underestimating the neck length on the frontal projection. The
celiac axis and proximal aorta are demonstrated best on
the lateral view. Pelvic arteriography is performed to
demonstrate the distal extent of the AAA. In patients who
have lower-extremity pulse decrements or a history of
claudication or critical ischemia, associated runoff studies are obtained. The slow flow within an aneurysm may
mandate decreasing the injection rate and lengthening
the film series timing. Unstable patients with suspected
rupture should not undergo CT or angiography but
should be brought directly to surgery. Angiograms will
not show a leak and may delay getting the patient to the
operating room. In stable patients with suspected rupture, an emergency CT should be obtained to confirm
the leak and demonstrate anatomy prior to repair.
Angiographic findings in AAA include a focal widening
of the aortic lumen greater than 3 cm; this is typically
fusiform but may be saccular. This focal widening occasionally may be absent because contrast may progress
A,B
FIGURE 20-26. An tube endovascular graft has been placed for
treatment of an abdominal aortic aneurysm. (A). Opaque markers which line the graft material (
heads show the distal anchoring stent. (B). A distal endoleak
caused by retraction of the distal stent (
Due to the difficulty in anchoring a stent-graft in the distal aorta,
most physicians are placing bifurcated stent-grafts even when
the distal aorta may be normal.
straight arrows
arrow
) is demonstrated.
). The arrow-
A, B
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Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities 227
FIGURE 20-27. (A). Lateral aortogram of abdominal aor-
tic aneurysm. This demonstrates large, soft tissue mass;
mild forward angulation of the neck; and draping of the
superior mesenteric artery over the aneurysm mass (
row
). (B). AP aortogram shows paradoxical smoothness
of the aorta due to laminated thrombus and absence of
arrow
lumbar arteries (
occluded, with marginal artery collaterals from the superior mesenteric artery (
). The inferior mesenteric artery is
curved arrow
).
ar-
down a nondilated luminal channel surrounded by
thrombus. (The distance between the contrast column
and intimal calcium will be increased.) A “bald” aorta
with absent lumbar arteries, inferior mesenteric artery
occlusion, slow flow, and draping of the superior mesenteric artery over the aneurysm are all angiographic findings associated with the presence of AAA (Fig. 20-27).
Paradoxic smoothness of the lumen as a result of laminated thrombus also may be present.
If the aneurysm is unusually shaped (e.g., saccular) or
in an unusual location, a mycotic aneur ysm should be
considered. Salmonella species and Staphylococcus aureus
are usually responsible for mycotic aneurysms. Mycotic
aneurysms also include syphilitic aneurysms; these are
rare but are more frequently suprarenal and may be
multiple.
Lower-extremity aneurysms
Aneurysms in the lower extremities may be multiple.
Extremity aneurysms are usually due to atherosclerosis.
Lower-extremity aneurysms are associated with aortic,
common iliac, and internal iliac artery aneurysm; thus,
aortography and pelvic arteriography also should be
obtained.
Common femoral artery aneurysms are defined as having a diameter larger than 150% of the external iliac
artery diameter. There is a high incidence of bilaterality
and an association with popliteal aneurysms. These aneurysms can rupture, occlude, or embolize. The differential
diagnosis must include pseudoaneurysm. Common
femoral artery pseudoaneurysms usually have a neck and
usually are related to previous catheterizations; these may
be treated by ultrasound compression if of recent origin
and small.
52
Popliteal aneurysms are focal dilatation of the popliteal artery, with a diameter greater than 150% the di-
ameter of the distal superficial femoral artery. The popliteal artery is most frequently the lower-extremity site for
the development of an aneurysm. Popliteal aneurysms
typically occur above the knee joint, starting just distal to
Hunter’s canal (Fig. 20-28). More than 50% of popliteal
aneurysms are bilateral, and bilaterality is associated with
the presence of aortic, iliac, and femoral aneurysms.
Only 25% of popliteal aneurysms are solitary; thus, it is
essential to invoke a search for other sites when a popliteal aneurysm is seen.
AAAs occur in one third of patients with popliteal
aneurysms. Abdominal ultrasound should be obtained.
FIGURE 20-28. Right lower-extremity ischemia as the result
of a thrombosed popliteal artery aneurysm. A patent left popliteal aneurysm is noted; the left leg was asymptomatic.
228 C. W. Bakal and J. Cynamon
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There is a high association of popliteal aneurysms with
diffuse pelvic and lower extremity arteriomegaly. In cases
of popliteal artery thrombosis or in other cases where
popliteal aneurysms are suspected, the arteriographer
should search for calcium or mass effect as evidenced by
draping of collaterals. Ultrasound is essential if a suspect
popliteal aneurysm cannot be seen on angiography.
Complications of popliteal aneurysms include thrombotic occlusion and distal embolization. There is a high
incidence of limb loss (33 to 50%) if a popliteal aneurysm
is missed. Rupture is rare, occurring in fewer than 4% of
cases. These patients present with limb ischemia from
embolization or thrombosis, but rarely they present with
deep venous thrombosis from aneurysmal compression
of the popliteal vein. Popliteal aneurysms are treated by
excluding them from the circulation by a surgical bypass.
Catheter-directed thrombolysis may be used to restore
distal popliteal and trifurcation runoff after acute thrombotic or thromboembolic occlusion to improve the results of bypass.
Other vascular abnormalities in the popliteal
fossa
Cystic adventitial disease of the popliteal artery is a rare
cause of popliteal occlusion or stenosis, typically occurring in young men. Cysts develop in the media and adventitia and compress the lumen. Calf pain is the usual presenting symptom. On angiography, there may be
segmental popliteal artery stenosis or occlusion with nor-
mal caliber proximally and distally. Ultrasound can be
used to make a definitive diagnosis. The popliteal artery
maintains a normal course.
Popliteal entrapment syndrome is another rare cause
of peripheral ischemia and is due to an aberrant attachment of the gastrocnemius or popliteus muscle. Usually,
medial deviation of the popliteal artery occurs, although
the artery may have a normal course or lateral deviation,
depending on the type of entrapment. Aneurysm formation and thrombosis may develop. Narrowing is elicited
by forced plantar flexion (Fig. 20-29).
■ Extremity Trauma
Emergency angiography is indicated for enlarging hematoma, pulse deficit, or neurologic abnormality. Angiography is also usually obtained if there is knee dislocation or
if the patient has suffered a shotgun wound, even if there
are no immediate symptoms. Proximity injury without
physical findings has a low angiographic yield (1 to 5%),
and most now agree that emergency angiography is not
needed.
53
With trauma, the angiogram may show
pseudoaneurysm or extravasation, with or without arteriovenous fistula occlusion; dissection; intimal flap; mural
hematoma; or distal embolization. Whereas street or vehicular incidents are prominent causes of arterial
trauma, iatrogenic trauma from needle punctures or
catheterization is another increasingly important etiology
(Figs. 20-30 through 20-33). Arterial standing waves (Fig.
A,B
FIGURE 20-29. Popliteal entrapment. A 46-year-old woman presented with subacute disabling right lower-extremity claudication
and an absence of the right popliteal pulse. (A). The right lower extremity arteriogram demonstrates occlusion of the popliteal
artery at the patella. The presentation and level of occlusion are atypical for atherosclerotic disease. (B). Arteriogram of the left
lower extremity in the same patient demonstrates slight medial deviation of the popliteal artery in the popliteal fossa. This
extremity was asymptomatic. (C). Active plantar flexion during arteriography of the left lower extremity demonstrated increased
angulation of the vessel and lumen narrowing. (D). Further plantar flexion lead to occlusion.
C,D
Atherosclerotic Disease of the Aorta, Pelvis, and Lower Extremities
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A,B C,D
FIGURE 20-30. A 17-year-old patient with expanding hematoma in the left thigh after a knife wound. (A). Anteroposterior
arteriogram demonstrates a small collection of contrast overlying the superficial femoral artery. (B). Oblique view better
arrow
demonstrates a small pseudoaneurysm (
associated arteriovenous fistula, with prominent early venous drainage (
to enter the pseudoaneurysm and its branch feeder. (D). Coils (
its solitary feeder. The hematoma resolved over several days.
) from a muscular perforating branch of the superficial femoral artery. There is an
arrow
curved arrow
) have been placed to embolize the pseudoaneurysm and
). (C). A catheter guidewire system is used
229
FIGURE 20-31. Pseudoaneurysm (
femoral deep femoral artery junction with arteriovenous fistula
(
vein, curved arrow
precluded treatment by a covered stent or coils; it was repaired
surgically.
arrow
) of the left common
) after cardiac catheterization. The position
FIGURE 20-32. Iatrogenic retrograde dissection. Magnetic
resonance angiogram of a patient who previously underwent
attempted cardiac catheterization from the left femoral approach. An intimal flap is seen in the left iliac artery (
arrow
), and a false lumen is also seen (
decreased signal intensity relative to the true lumen.
curved arrow
straight
), with
230 C. W. Bakal and J. Cynamon
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FIGURE 20-33. Translumbar aortogram of a 70-year-old man
with an ongoing history of chronic intravenous drug abuse. He
presented with acute profound lower-extremity ischemia and
pulsatile masses in both groins. The arrowhead demonstrates
a pseudoaneurysm of the left common femoral artery, which
resulted from a direct needle injury and was responsible for
distal embolization to the trifucation vessels (not shown), the
cause of his acute ischemia. Note also the absence of the left
deep femoral artery, due to needle related trauma. The right
common femoral artery also had a smaller pseudoaneurysm,
which is not seen well in this single view.
FIGURE 20-34. Arterial standing waves.
20-34), which are seen in compliant vessels in young
patients, or early atheromatous lesions can be sources of
confusion. Thus, some angiographers prefer to perform
bilateral angiograms for extremity trauma so that the
uninvolved leg can serve as a comparison.
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https://t.me/med1917
T. P. MurphyVenousThromboembolic Disease and Vena Cava Filters
https://t.me/med1917
Venous Thromboembolic Disease and
21
■■■
Vena Cava Filters
TIMOTHY P. MURPHY
■ Epidemiology
Lower-extremity deep-vein thrombosis (DVT) is a common condition that is seen in 34% of unselected medical
patients and in 60% of unselected surgical patients by
1
autopsy series.
tremity DVT, 35% to 51% have evidence of pulmonary
embolism (PE) by ventilation perfusion scan, indicating
that these two disease processes should be thought of as
a continuum of the same process rather than as two
separate conditions.
leading cause of death in this country
most common disease of the cardiovascular system, after
myocardial infarction and stroke.
The incidence of PE in the United States has been
estimated to be as high as 750,000 to 900,000 cases per
year, with a mortality of 120,000 to 150,000 cases annu-
7,8
Untreated, proximal DVT or PE has a 30.5 to 50%
ally.
chance of developing into recurrent PE, with a mortality
rate of 18 to 26%.
arise from the iliofemoral veins,
other 5 to 15% arising from thrombi in the vena cava,
ovarian veins, right atrium, or upper extremities.
Asymptomatic thrombus formation in the veins of the
calf, particularly the soleal sinuses, is probably a normal
process that occurs throughout life in all persons. It is
only when thrombus is not lysed by the body but rather
propagates to a large central vein that a pathological
condition exists. The propensity for progression to this
pathological state has been observed for several groups
of hospitalized patients, including those with recent surgery or trauma, heart disease, neoplastic disease, and
systemic diseases.
Of the patients presenting with lower-ex-
2–4
PE has been stated to be the third
9–11
Of pulmonary emboli, 85 to 95%
6
Ultrasound examinations of the lower
5
and is the third
6
12,13
with most of the
12,14,15
extremities often demonstrate asymptomatic DVT in
many of these patients. For example, routine ultrasound
examination of the lower-extremity veins in 542 asymptomatic intensive care unit (ICU) patients demonstrated
previously unsuspected DVT in 11.4% of patients.
suspected proximal DVT has been reported in 13 to 16%
of patients presenting with acute hip fracture in two series using ultrasound;
has been reported as even higher (32%) in one series
using ascending venography.
postoperative DVT in 50 patients who underwent abdominal aortic aneurysm repair was reported as 18%,
although involvement was limited to the calf veins in
78% of these patients.
tients, the diagnosis of PE is not made before the patient
21
dies.
■ Diagnosis of DVT
Before the arrival of real-time ultrasound, the standard
method of documenting lower-extremity DVT was contrast venography (Fig. 21-1). Contrast venography possesses several disadvantages relative to ultrasound that
have led to replacement of venography by ultrasound as
the initial imaging method for diagnosing this disease.
First, contrast venography cannot be performed at the
bedside. Patients must be transported to the radiology
department to be evaluated by this technique and additionally must be able to tolerate the changes in position
required for optimal performance of this examination.
Also, contrast introduced into the lower-extremity veins
has been associated with an increased incidence of
postvenography thrombophlebitis. This condition is sus-
17,18
the incidence of proximal DVT
19
Recently, the incidence of
20
Unfortunately, in 70% of pa-
16
Un-
233
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