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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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100
RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Selected image from a selective injection of the celiac trunk. A large, rounded area of extravasation of
contrast arises from an anterior branch of the left hepatic artery ( white arrow ). The main branches of the
celiac trunk are patent: the splenic artery ( double black arrows ) and left gastric artery ( short black arrow ).
The hepatic artery anastomosis is patent ( broken arrow ). (B) Selected image from an arteriogram after coil
embolization. The pseudoaneurysm is no longer identifi ed.
■
Diff erential Diagnosis
• Hepatic artery pseudoaneurysm: The history is important
in this case. Iatrogenic trauma, such as from a previous bi-
opsy or drainage procedure, is important. You should also
consider the possibility of previous trauma.
• Saccular aneurysm of the hepatic artery: This is rare in the
absence of a systemic vascular disease, such as Ehlers–
Danlos syndrome type 4.
• Arterioportal fi stula: No opacifi cation of the portal vein is
demonstrated.
■
Essential Facts
• Pseudoaneurysms of the hepati c artery are uncommon
lesions that are usually related to penetrating injury to the
liver (stab wounds, biopsies, percutaneous cholangiog-
raphy, and placement of biliary drainage catheters). The
clinical presentation may include massive hemobilia.
✔ Pearls & ✘ Pitfalls
✔
Endoscopic evaluation and management of patients who
have a liver transplant with a bilioenteric anastomosis
and the creation of a Roux-en-Y limb is limited because
of the technical diffi culty encountered in manipulating
the endoscopy tube to the biliary anastomosis through
the Roux-en-Y limb. These patients are better managed
with endovascular or percutaneous techniques.
• Therapeutic options include superselective embolization
or, if feasible, stent-graft placement.
• A few case reports describe successful management of
these lesions with direct injection of thrombin (under
computed tomographic or ultrasound guidance).
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101
Case 51
A B
C
■
Clinical Presentation
A 16-year-old patient presents with chronic abdominal pain and weight loss of 20 lbs.
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102
RadCases Interventional Radiology
■
Essential Facts
A CB
(A) A three-dimensional volume-rendered computed tomograph-
ic angiogram (CTA) obtained during exhalation accentuates par-
tial extrinsic compression ( arrow ) of the superior aspect of the
celiac artery. Annotated is the left gastric artery ( arrowhead ). (B)
Sagittal reformatted image obtained during exhalation again
shows the extrinsic compression ( arrow ) of the superior aspect of
the celiac artery. (C) Sagittal reformatted image obtained during
inhalation shows resolution of the extrinsic compression ( arrow ) .
■
Diff erential Diagnosis
• Median arcuate ligament syndrome (MALS) : Likely, given
isolated celiac involvement in a young patient with marked
weight loss and postprandial pain.
• Accelerated atherosclerosis: Less likely due to underlying
condition such as hyperlipidemia, given the appearance of
the stenosis.
■
Essential Facts
• MALS is compression of the celiac artery by the median ar-
cuate ligament of the diaphragm, most common in young
women (median age 35 years). The clinical presentation is
chronic intermittent nausea and diarrhea, signifi cant weight
loss (> 20 lb), and mild-to-severe abdominal pain, particu-
larly during exercise and eating. An epigastric bruit may be
detected during exhalation.
• Physical examination and imaging studies are performed
in the stressed (exhalation) and unstressed (inhalation)
conditions.
• Conventional CTA or magnetic resonance angiography typ-
ically shows compression of the cranial aspect of the celiac
trunk, often slightly distal to the origin. A “J” confi guration
of the celiac artery may result.
• Untreated, MALS can cause fi xed stenosis, aneurysm, or
complete occlusion of the celiac artery with enlargement
of the pancreaticoduodenal collateral pathways to supply
the celiac distribution. Aneurysms of the pancreaticoduo-
denal arteries, which carry a high risk for rupture, may
result.
• Other causes of mesenteric ischemia include atheroscle-
rosis, fi bromuscular dysplasia, mediastinal fi brosis, and
desmoplastic neoplasms, such as carcinoid.
✔ Pearls & ✘ Pitfalls
✔
With strict selection of patients, 67% describe symptom
relief after surgical release of the median arcuate liga-
ment.
✔ Fixed celiac stenosis (persisting after surgical decompres-
sion) may be treatable by angioplasty and stent place-
ment or by surgical revascularization.
✔ Pancreaticoduodenal aneurysms should be treated with
coil embolization because of a high risk for rupture.
✘ Compression occurs in 5 to 20% of asymptomatic indi-
viduals, so clinical correlation is vital.
✘ Failure to screen patients rigorously (atypical pattern of
pain, absence of bruit, weight loss < 20 lb) can lead to the
overdiagnosis of MALS, contributing to a lowered success
rate for surgical decompression.
■
Other Imaging Findings
• Doppler sonography is a useful screening tool, as is a fol-
low-up imaging test after treatment.
• Multidetector CT and CTA are good fi rst-line tests to
exclude infl ammatory and neoplastic causes of mesenteric
ischemia and to demonstrate the cause, extent, and com-
plications of arterial obstruction.
• Conventional angiography is the best test for detecting the
complication of distal mesenteric thromboembolism, and
many surgeons still prefer this modality for planning treat-
ment. Angiography demonstrates fi xed versus transient ste-
nosis, aneurysm, and the collateral circulation. As this case
illustrates, CTA should be performed initially in the stressed
condition, after which delayed, unstressed images can reveal
resolution of the extrinsic compression.
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103
Case 52
A B
C
■
Clinical Presentation
A 78-year-old woman with a history of postprandial pain presents with intense abdominal pain.
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104
RadCases Interventional Radiology
■
Imaging Findings
ABC
(A) Radiograph shows dilated loops of bowel and possible pneumatosis ( arrows ). (B) Contrast-enhanced computed tomog-
raphy (CT) shows pneumatosis ( arrowhead ) and aortic calcifi cations ( arrow ). (C) Inferior mesenteric artery (IMA: arrow )
angiogram shows superior mesenteric artery (SMA: large arrowhead ) stenosis and reconstitution via the marginal artery
from the IMA; the celiac artery is presumed stenotic because its branches are reconstituted via pancreaticoduodenal arter-
ies supplied by the SMA (proper hepatic artery: small arrowhead ) .
■
Diff erential Diagnosis
• Mesenteric ischemia (MI) with superior mesenteric
artery and celiac artery obstruction : The only diagnosis
for all the imaging fi ndings and the clinical presentation;
the radiographic fi ndings are nonspecifi c (bowel obstruc-
tion, infection, infl ammation, ischemia, and ileus).
■
Essential Facts
• MI can have a variety of causes, including atherosclerosis,
thrombosis, retroperitoneal fi brosis, median arcuate liga-
ment syndrome, fi bromuscular dysplasia, and Takayasu’s
arteritis.
• MI is typically symptomatic if the obstruction involves at
least two primary mesenteric arteries.
• Mesenteric angiography in acute cases may show abrupt
cutoff and thrombus and, in chronic cases, supply to ob-
structed arteries by collaterals from unobstructed arteries .
• Celiac artery obstruction: collateral supply to celiac
branches from the SMA via the pancreaticoduodenal
arcade or arc of Buehler.
• SMA obstruction: collateral supply to the SMA branches
from the celiac artery via the pancreaticoduodenal
arcade or arc of Buehler; collateral supply from the IMA
via the marginal artery or arc of Riolan.
• IMA obstruction: collateral supply to the IMA branches
from the SMA via the left colic and marginal arteries or
arc of Riolan; collateral supply from the internal iliac
artery via retrograde fl ow in the superior rectal artery.
■
Other Imaging Findings
• Contrast-enhanced CT with CT angiography is usually the
fi rst step in the diagnosis of MI to establish a treatment
plan. Look for bowel dilatation, bowel wall thickening,
pneumatosis, arterial stenosis/thrombosis/occlusion, and
enlarged collateral arteries.
✔ Pearls & ✘ Pitfalls
✔
Most patients with peritoneal signs and pneumatosis
undergo emergent laparotomy. This patient underwent
preliminary arteriography to plan the surgical resection,
given the extent of atherosclerotic disease.
✔ Mesenteric artery stenting may be used for chronic fi xed
obstruction associated with atherosclerosis.
✔ Balloon-expandable stents are placed because the lesions
are usually ostial (like renal stenosis).
✘ Mesenteric artery thrombolysis has been described
for acute thromboembolism, but surgery replaces this
treatment in most cases because of the rapid (< 12 hour)
progression to ischemic bowel.
✘ Revascularization of nonviable bowel is contraindicated.
Cases involving pneumatosis and portal venous gas typi-
cally require surgical resection combined with aortomes-
enteric bypass.
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105
Case 53
■
Clinical Presentation
A 60-year-old woman presents with buttock claudication. Pulses in the common femoral artery are not palpable.
A
B
C
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106
RadCases Interventional Radiology
■
Imaging Findings
ABC
(A) Aortogram from the brachial approach shows complete aortic occlusion below the superior mesenteric artery (SMA). The SMA supplies
the middle colic artery ( large arrowhead ), marginal artery ( small arrow ), ascending branch of the left colic artery ( large arrow ), and superior
rectal artery ( small arrowhead ). (B) Delayed view: the ascending branch of the left colic artery supplies the inferior mesenteric artery (IMA:
arrowhead ) and then the superior rectal artery ( arrow ). (C) Further delayed view: branches of the internal iliac artery (pudendal, obturator)
reconstitute the internal iliac ( arrow ), external iliac ( arrowhead ), and common femoral arteries to supply the legs.
■
Diff erential Diagnosis
• Leriche syndrome (LS): Only consideration for distal aortic
occlusion, buttock claudication, and lost femoral pulses,
with the additional symptom of impotence in men.
■
Essential Facts
• The cause is severe atherosclerotic disease of the distal
aorta and common iliac arteries (type 1 peripheral arterial
disease accounts for 5–10% of all cases), rarely aff ecting the
visceral and renal arteries.
• This distribution of disease is common in young (40–50
years old) female smokers with a reduced aortic caliber—
“small aorta syndrome.”
• Involvement of the IMA and SMA may lead to chronic or
acute mesenteric ischemia.
• Collateral arterial pathways
• Anterior: internal thoracic to superior epigastric to infe-
rior epigastric to external iliac
• Middle: superior to inferior mesenteric, superior to
middle hemorrhoidal, internal to external iliac
• Posterior: subcostal and lumbar to deep circumfl ex iliac
to external iliac
• Endovascular treatment
• Thrombolysis: acute worsening of symptoms suggests acute
thrombosis superimposed on chronic atherosclerosis, and
a trial of a catheter-directed recombinant tissue–type plas-
minogen activator (rt-PA) infusion may be indicated.
• Stent placement: bilateral common femoral punctures
and bilateral aortofemoral stents.
• Risks include rupture, distal embolization, and compli-
cations at the puncture site.
• Surgical treatment
• Bypass is the most durable treatment—aorto-bifemoral,
thoraco-bifemoral, or axillo-bifemoral, depending on
the location and extent of the lesion.
• Rates of operative morbidity (18%) and mortality (5%)
are high.
• Impotence commonly persists because of underlying
disease and interruption of the autonomic plexus.
■
Other Imaging Findings
• Multidetector computed tomographic angiography and
magnetic resonance angiography provide suffi cient infor-
mation to plan treatment in most cases.
• Conventional angiography typically requires a brachial
artery approach (as in this case). Occasionally, bilateral
femoral artery punctures and angiograms are necessary for
complete evaluation of the lower extremities.
✔ Pearls & ✘ Pitfalls
✔
LS comprises buttock claudication, lost femoral pulses
(all patients), and impotence (in men) in the setting of
distal aortic occlusion.
✔ Severe atherosclerosis of the distal aorta and common
iliac arteries tends to aff ect female patients and smokers.
Treatment is endovascular or surgical.
✔ Memorize the associated collateral arterial pathways—
anterior, middle, and posterior.
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107
Case 54
■
Clinical Presentation
A 66-year-old woman who has diabetes presents with a painful, nonhealing ulcer of the right foot.
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108
RadCases Interventional Radiology
■
Imaging Findings
ABC
(A) Lower extremity angiogram shows occlusion of the anterior tibial artery and reconstitution by collaterals
( large arrow ). The posterior tibial artery is occluded, and a short segment of the peroneal artery ( small arrow ) is
supplied by collaterals and a diseased tibioperoneal trunk ( arrowhead ). (B) Catheter access across the occlusion
in the anterior tibial artery is verifi ed by injection of contrast. (C) SilverHawk (ev3, Plymouth, MN) atherectomy
of the anterior tibial artery results in re-establishment of patency ( arrow ). On more delayed images, the tibiope-
roneal trunk is patent, supplied predominantly by collaterals.
■
Diff erential Diagnosis
• Anterior tibial artery occlusion treated with SilverHawk
directional atherectomy: Balloon angioplasty is subopti-
mal for occlusions because of poor patency rates and the
risk for distal embolization. Therefore, atherectomy and
stent placement are both viable options in this case.
■
Essential Facts
• To salvage a limb in cases of nonhealing ulcers or surgical
sites, infrapopliteal arterial disease may be treated endo-
vascularly.
• To achieve long-term patency in cases of claudication, in-
frapopliteal surgical bypass (also called distal bypass ) may
be a better option for appropriate candidates.
• For limb salvage, the goal is obtaining patency for the du-
ration of the healing process. Excellent long-term patency
of infrapopliteal lesions is typically not possible after
endovascular revascularization.
• Infrapopliteal occlusions may be treated with stent place-
ment or atherectomy. Subintimal recanalization with stent
placement is another option for occlusions. Angioplasty
with small (low-profi le) balloons may be used to treat
stenoses.
• Irrespective of technique, results are best when a straight-
line fl ow to the foot is achieved.
■
Other Imaging Findings
• Computed tomography angiography (CTA) has largely re-
placed diagnostic angiography of the lower extremities for
the evaluation of peripheral artery disease to plan revascu-
larization.
• Magnetic resonance angiography (MRA) is an alternative to
CTA in patients with an allergy to iodinated contrast, and
in many institutions, MRA is a fi rst-line imaging test.
✔ Pearls & ✘ Pitfalls
✔
Heparin is mandatory for these procedures, and intra-
arterial nitroglycerin is used for peri-procedural vaso-
spasm.
✔ Antiplatelet therapy (clopidogrel and/or aspirin) is typi-
cally used long term after endovascular revascularization.
✔ An antegrade ipsilateral common femoral artery punc-
ture provides mechanical advantage for distal arterial
lesions.
✔ A 6-month cumulative patency rate of 94% has been
achieved.
✘ Complications include bleeding and pseudoaneurysm at
the puncture or treatment site.
✘ Distal embolization is more common with occlusions and
can sometimes be treated with aspiration thrombectomy.
Thrombolysis may be less successful because of the cho-
lesterol content of emboli.
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109
Case 55
■
Clinical Presentation
A 47-year-old man who has head and neck cancer previously treated with radiation to the neck presents to the emergency
department with bleeding into the mouth.
Further Work-up
B C
A
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