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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3886_Библиотеки_им_академика_М_И_Перельмана
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80
RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Selected axial image from a computed tomographic (CT) scan of the chest demonstrates a round mass with spicules
in the right lower lobe. This is highly suggestive of a metastatic lesion or primary lung carcinoma. (B) Selected axial image
from a CT scan obtained during radio-frequency ablation (RFA) of the mass. The radio-frequency needle is seen within the
mass. A discrete area of ground glass appearance surrounding the tumor is most probably related to mild hemorrhage or
heat eff ect during the procedure.
■
Diff erential Diagnosis
• Metastatic lesion to the lung : Treatment is with lung RFA.
The history is important here. The fact that the patient has
history of colon cancer makes metastatic disease the fi rst
possibility.
• Primary lung carcinoma: This would be a very good option
if patient did not have a history of previous cancer.
• Granuloma: No calcifi cations are seen, so granuloma is not
a good option.
• Pulmonary arteriovenous (a-v) malformation: The CT does
not show a feeding vessel and a draining vein, which are
necessary elements to make a diagnosis of pulmonary a-v
malformation.
■
Essential Facts
• RFA of lung tumors was fi rst described in 2000, and its use
has rapidly increased.
• RFA is minimally invasive and provides maximal preserva-
tion of normal parenchyma.
• Most procedures are performed with the patient under
conscious sedation; some require general anesthesia.
• Lesions that can be treated with this method range be-
tween 1.5 and 5.2 cm in diameter.
• Pneumothorax is the most frequent complication. It occurs
in ~40% of patients, with 10 to 15% requiring intervention.
• The mortality rate associated with this procedure is 0 to
5.6%.
• Most centers use contrast-enhanced CT or positron emis-
sion tomography for imaging follow-up after ablation.
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81
Case 41
BA
C
D
■
Clinical Presentation
This is a 55-year-old patient with left back pain.
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82
RadCases Interventional Radiology
■
Imaging Findings
ABC
(A) Image obtained during ultrasound-guided percutaneous nephrostomy (PCN) tube placement. A posterior calyx of the
lower pole of the kidney has been selected for access. The needle used for access is clearly demonstrated entering the calyx
( arrow ). (B) Spot fi lm obtained during PCN tube placement. The needle was placed into a posterior calyx of the lower pole of
the kidney under sonographic guidance. A small amount of diluted contrast has been injected through the access needle to
opacify the collecting system. A wire has been advanced into the collecting system and is seen to be within the renal pelvis
( arrow ). (C) Spot fi lm obtained after nephro-ureteral stent placement. The access to the collecting system seen in previous
images has been used to advance a pigtail catheter into the urinary bladder.
■
Diff erential Diagnosis
• Hydronephrosis requiring PCN tube placement
• There is no diff erential diagnosis for this case. The impor-
tance is to identify hydronephrosis and establish the need
for percutaneous drainage.
■
Essential Facts
• The most common indication for PCN tube placement is
urinary obstruction. Other indications include pyonephro-
sis, urinary fi stulas, access for percutaneous nephrolithot-
omy, and hemorrhagic cystitis.
• The technique described here is the single-puncture tech-
nique. The patient is placed in the prone position. Ultra-
sound guidance is used for needle placement. The access of
choice is a posterior calyx of the lower pole of the kidney.
Once adequate needle position is confi rmed within the
collecting system, a small amount of diluted contrast is
injected to opacify the collecting system. The procedure
is now conducted under fl uoroscopic guidance. A wire
is advanced into the collecting system. Tract dilation is
then performed with sequentially larger dilators. Next, a
drainage catheter is advanced into the renal pelvis or uri-
nary bladder to provide drainage of the collecting system.
✔ Pearls & ✘ Pitfalls
✔
Avoid traversal of the pleural space (if possible avoid an
intercostal approach), and avoid puncture of adjacent or-
gans such as the liver, spleen, and colon. Be careful with
the renal vascular structures.
✔ All patients undergoing PCN tube placement should
receive a dose of prophylactic intravenous antibiotics 1
hour before the procedure.
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83
Case 42
■
Clinical Presentation
The patient is an 80-year-old man with a liver mass and rapid deterioration of his liver function test values.
Further Work-up
A
B
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84
RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Selected axial image from a three-phase computed tomographic (CT) scan of the abdomen in
the arterial phase demonstrating excellent enhancement of the abdominal aorta. The left portal
vein is clearly depicted, and the density within the lumen of the left portal vein is very similar to
that of the aorta. Note that the density within the inferior vena cava is still inferior to that of the left
portal vein. (B) Selected image from a selective injection of the common hepatic artery showing
opacifi cation of the left hepatic artery and a large communication with the left portal vein ( arrow ).
Other branches seen include the right hepatic artery, gastroduodenal artery, and pancreaticoduo-
denal branches fi lling branches of the superior mesenteric artery in a retrograde fashion.
■
Diff erential Diagnosis
• Arterioportal fi stula: There is really no good diff erential
diagnosis here. The communication between the hepatic
artery and portal vein is clearly demonstrated.
■
Essential Facts
• Approximately 20 to 30% of arterioportal fi stulas are con-
genital or idiopathic.
• Most of the acquired lesions are related to tumor shunting,
penetrating or blunt trauma, or a previous intervention
such as a percutaneous biopsy, radio-frequency ablation,
or biliary drainage.
• The fi stulas may be large enough to cause severe portal
hypertension, bleeding esophageal varices, and ascites.
• Arterioportal fi stulas are diffi cult to treat. In the past,
surgical correction was the treatment of choice; however,
endovascular correction has recently gained popularity.
In some cases, more than one embolization session is
necessary to completely treat the lesion.
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85
Case 43
A
B
■
Clinical Presentation
The patient is a 32-year-old man with abdominal pain.
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86
RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Image from a selective digital subtraction arteriogram (DSA) of the celiac trunk. The hepatic artery is patent.
A large fusiform aneurysm of the common hepatic artery is demonstrated ( long white arrow ), as well as multiple
small fusiform aneurysms within the right hepatic artery ( short white arrow ). The splenic artery is partially oc-
cluded by multiple metallic coils ( double black arrows ). No active bleeding is demonstrated. (B) Image from a
selective DSA of the superior mesenteric artery (SMA). Multiple fusiform aneurysms are identifi ed within the
branches of the SMA ( black arrows ). There is no evidence of active bleeding.
■
Diff erential Diagnosis
• Ehlers–Danlos syndrome (EDS) type 4 with multiple fusi-
form aneurysms in the visceral arteries
• Polyarteritis nodosa: This disease process must be included
in the diff erential. The clinical history is important.
• Neurofi bromatosis: This disease process must be included
in the diff erential. The clinical history is important.
• Fibromuscular dysplasia: This disease process must be in-
cluded in the diff erential. The clinical history is important.
■
Essential Facts
• Vascular EDS is a rare autosomal-dominant disorder that re-
sults from a mutation of the gene encoding type 3 collagen.
• Complications are rare in childhood and appear later in
life; up to 25% of cases develop before the age of 20, and
✔ Pearls & ✘ Pitfalls
✔
The keys to diagnosis include family history, clinical ap-
pearance, and age of the patient at presentation.
80% before the age of 40. The aff ected vessels are usually
medium-sized arteries.
• The most common cause of death is arterial rupture.
Arterial dissections are also seen in these patients.
• There is no optimal therapy for this condition. EDS type 4
usually results in premature death before age 50.
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87
Case 44
A
B
■
Clinical Presentation
The patient is a 50-year-old woman with no previous medical history.
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88
RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Selected enhanced T1-weighted axial image of the right knee demonstrating a rim of high sig-
nal intensity surrounding the wall of the popliteal artery ( white arrow ). The popliteal vein is spared.
(B) Selected enhanced T1-weighted axial image of the right knee at a lower level demonstrating
large, irregularly shaped cysts surrounding the popliteal artery and compressing its lumen ( white
arrow ). The popliteal vein remains free of involvement.
■
Diff erential Diagnosis
• Cystic adventitial disease of the popliteal artery : The
fi ndings are characteristic.
• Popliteal entrapment: No signs of entrapment are demon-
strated in this fi lm.
• Popliteal aneurysm: No evidence of popliteal aneurysm is
identifi ed in the images.
■
Essential Facts
• Cystic adventitial disease is characterized by cystic degen-
eration of a peripheral artery.
• It was originally described as a lesion in the iliac artery;
however, the popliteal artery is probably the most com-
mon site.
• This entity typically aff ects young to middle-aged patients
with no evidence of atherosclerosis.
• Aff ected patients typically present with the sudden onset
of calf claudication and leg pain.
• The cysts are fi lled with a thick mucinous gel containing
varying combinations of mucoproteins, mucopolysaccha-
rides, hyaluronic acid, and hydroxyproline.
• Treatment options include aspiration of the cyst (not rec-
ommended because of the high incidence of recurrence)
and stenting of the popliteal artery (has been attempted
but is usually associated with clinical failure).
• The best therapeutic option is surgical excision of the
cyst with or without venous patching.
✔ Pearls & ✘ Pitfalls
✔
The magnetic resonance imaging appearance of cystic ad-
ventitial disease is quite characteristic, showing multiple
arterial intramural cystlike masses.
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89
Case 45
B
A
■
Clinical Presentation
The patient is a 55-year-old woman with severe abdominal pain and fever.
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