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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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90
RadCases Interventional Radiology
■
Imaging Findings
ABC
(A) Selected axial image from a contrast-enhanced computed tomo-
graphic (CT) scan of the abdomen at the level of the gallbladder show-
ing thickening of the gallbladder wall ( black arrow ) and air within the
gallbladder lumen ( white arrow ). (B) Spot fi lm obtained during percu-
taneous cholecystostomy showing the puncture needle directed to the
air-fi lled gallbladder ( arrow ). (C) Spot fi lm obtained immediately after
cholecystostomy tube placement showing the pigtail catheter within
the gallbladder lumen. There is no extravasation of contrast.
■
Diff erential Diagnosis
• Emphysematous cholecystitis (pneumocholecystitis): The
presence of air and stranding peripheral to the gallbladder
are very suggestive. There is no history of previous biliary
surgery to suggest abscess.
• Abscess in the gallbladder fossa: In the absence of a clinical
history, this diagnosis is diffi cult to support.
■
Essential Facts
• Acute emphysematous cholecystitis is a rare entity.
• The condition is caused by gas-forming bacteria. It is more
common in patients with diabetes.
• Clostridium welchii and Escherichia coli have been the most
commonly isolated bacteria.
• The condition has an ischemic component but does not
appear to be related to gallstones.
• The mortality rate is 15 to 20%, owing to the increased
incidence of gangrene and perforation of the gallbladder
wall in these patients.
• Percutaneous cholecystostomy tube placement is a non-
invasive therapeutic alternative in the management of
these acutely sick patients.
✔ Pearls & ✘ Pitfalls
✔
The technical success rate for percutaneous cholecystos-
tomy tube placement is close to 100% with the combined
use of sonographic and fl uoroscopic guidance.
✔ Preferably, the tract should have a transhepatic course to
reduce the risk for biliary peritonitis.
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91
Case 46
A B
C
■
Clinical Presentation
The patient is a 40-year-old woman with shortness of breath and epistaxis.
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92
RadCases Interventional Radiology
■
Imaging Findings
ABC
(A–C) Selected axial images from a contrast-enhanced computed tomographic (CT) scan of the chest demonstrating a tubular structure in the right
lower lobe that enhances with the administration of contrast. There is clear demonstration of a draining vein that can be traced back to the left atrium
( arrow, C ).
■
Diff erential Diagnosis
• Simple pulmonary arteriovenous (a-v) malformation :
The diagnosis is established by the presence of a feeding
artery or draining vein (Fig. C).
• Primary lung carcinoma: This is a good possibility if only
one slice is shown and has to be part of the diff erential.
• Granuloma: No calcifi cations are seen; this is not a good
option, but you could include it in the diff erential.
■
Essential Facts
• Pulmonary a-v malformations are abnormal vessels
connecting the pulmonary arterial circulation with the
pulmonary venous circulation.
• Eighty-fi ve percent are simple (single feeding artery/single
draining vein).
✔ Pearls & ✘ Pitfalls
✔
The preferred management is transcatheter emboliza-
tion of the malformation with coils, occluding devices, or
detachable balloons.
✔ Do not use Gelfoam or particles for embolization as these
will enter the peripheral circulation.
✔ If left untreated, patients are at risk for the development
of neurologic problems such as stroke, transient ischemic
attacks, and brain abscesses.
• Most of these lesions are congenital; 60 to 90% of patients
with a pulmonary a-v malformation have hereditary
hemorrhagic telangiectasia (HHT).
• In patients with HHT, the prevalence of pulmonary a-v
malformation is 15 to 35%.
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93
Case 47
■
Clinical Presentation
The patient is a 38-year-old woman with severe abdominal pain and hematuria.
A B
C
D
F
E
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94
RadCases Interventional Radiology
■
Imaging Findings
ABC
DE
(A–C) Selected axial images from a non–contrast-enhanced com-
puted tomographic (CT) scan of the abdomen demonstrating a
large perinephric hematoma. Note the diff erent densities seen
within the large hematoma, which are suggestive of recent or
even active bleeding. (D) Selected digital subtraction image
obtained during a selective injection of the right renal artery.
The arteriogram demonstrates active extravasation at the lower
pole of the kidney ( arrow ). (E) Selected digital subtraction im-
age obtained after superselective embolization of the segmental
branch to the lower pole of the right kidney. The extravasation is
no longer demonstrated.
■
Diff erential Diagnosis
• Iatrogenic injury to a renal artery after percutaneous
biopsy : The clinical history is of great importance in a case
like this. The patient was 38 years old and had just under-
gone a kidney biopsy.
• Spontaneous perirenal hematoma: This is unusual but may
be seen in patients on anticoagulant therapy.
• Renal tumor: Not a good option in this case given the his-
tory and fi ndings.
■
Essential Facts
• Severe back pain and tachycardia are strong clinical indica-
tors of a complication after percutaneous biopsy. The clini-
cian should not delay further imaging evaluation in these
patients.
• Non–contrast-enhanced CT is probably the most reliable
imaging method to identify a complication after percuta-
neous biopsy.
✔ Pearls & ✘ Pitfalls
✔
Arteriogram should not be delayed if there is a strong
clinical suspicion of active bleeding.
✔ Superselective transcatheter embolization with coils or
microcoils is the treatment of choice in a case of active
bleeding.
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95
Case 48
■
Clinical Presentation
The patient is a 65-year-old man with end-stage renal disease.
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96
RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Digital subtraction arteriogram (DSA) obtained with a catheter placed within the left brachial artery. The injection
demonstrates a patent radial artery and ulnar artery and a complete palmar arch. A small triangular irregularity seen
in the distal radial artery corresponds to the stump of a side-to-end arteriovenous (a-v) fi stula between the distal radial
artery and the cephalic vein ( arrow ). The a-v fi stula is occluded. (B) DSA obtained after the a-v fi stula had been declot-
ted. Note that the a-v anastomosis is now widely patent ( arrow ). There is no fl ow into the distal radial artery, and all the
fl ow is via the outfl ow vein. The fi stula is now patent.
■
Diff erential Diagnosis
• Occluded arteriovenous fi stula : The history is important.
Previous surgery is the clue to the diagnosis.
• Small aneurysm of the radial artery: This is a possibility,
but the history indicates the diagnosis.
■
Essential Facts
• Native a-v fi stulas are the vascular access of choice for he-
modialysis because their durability and patency rates are
better than those of dialysis access grafts.
• Native a-v fi stulas require a maturation period of ~6 weeks.
• Declotting an a-v fi stula is more complex than declotting
an a-v graft.
✔ Pearls & ✘ Pitfalls
✔
The expected technical success rate for declotting an a-v
fi stula ranges between 75 and 87%.
✔ The clinical success rate is ~80%.
✔ The use of thrombolytic drugs is usually necessary to
open native a-v fi stulas. The primary patency rates after
declotting are somewhat low, in the range of 40% at 6
months and 20% at 12 months.
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97
Case 49
■
Clinical Presentation
The patient is a 73-year-old woman with jaundice.
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98
RadCases Interventional Radiology
■
Imaging Findings
Spot fi lm from a percutaneous cholangiogram.
The biliary system shows multiple stenotic areas
within the intrahepatic and extrahepatic ducts
( arrows ) alternating with areas of irregular dilata-
tion of the ducts. These fi ndings are suggestive
of areas of infl ammation causing severe stenosis
within the entire biliary system.
■
Diff erential Diagnosis
• Primary sclerosing cholangitis (PSC) : This is high on your
list. In the absence of a biopsy, it is your fi rst possibility.
• Cholangiocarcinoma: PSC is associated with cholangiocar-
cinoma. There may be a tumor component here. It must be
included in the diff erential.
• Cystic disease of the biliary system: No cysts are seen. This
should be included in the diff erential, but it is not your
best option.
■
Essential Facts
• PSC is a chronic cholestatic liver disease characterized by
infl ammation and fi brosis of the bile ducts. It is associated
with a high risk for cholangiocarcinoma.
• Most patients present with abnormal liver function test
values.
✔ Pearls & ✘ Pitfalls
✔
The diagnosis is based on imaging: endoscopic chol-
angiography, magnetic resonance cholangiography, or
percutaneous cholangiography.
✔ Histologically, the characteristic fi nding is periductal
fi brosis with an “onion skin” pattern resulting in ducto-
penia.
✔ PSC is a disease of unknown etiology. The best treatment
option is a liver transplant.
• Other symptoms include abdominal pain, jaundice, and
pruritus.
• Cholangiocarcinoma is seen in 3% of these patients.
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99
Case 50
■
Clinical Presentation
The patient is a 64-year-old man with upper gastrointestinal bleeding.
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