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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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140
RadCases Interventional Radiology
■
Imaging Findings
ABCD E
(A) Three-dimensional volume-rendered computed tomographic angio-
gram (CTA) shows saccular aneurysms of the hepatic ( large arrow ) and
left gastric ( small arrows ) arteries. (B) Contrast-enhanced CT scan shows
a thrombosed component of the hepatic artery aneurysm ( arrows ). (C) Se-
lected superior mesenteric artery angiogram shows diff use beading and fo-
cal segments of dilatation ( arrows ). (D) Selected hepatic angiogram shows
beading of the common hepatic artery ( arrow ) and aneurysm of the proper
hepatic artery ( arrowhead ). (E) Selected celiac angiogram shows successful
coil embolization of the left gastric and hepatic aneurysms.
■
Diff erential Diagnosis
• Segmental arterial mediolysis (SAM) : Indicated by pre-
dominantly celiac branch involvement.
• Fibromuscular dysplasia: Suggested by beading of the supe-
rior mesenteric artery.
• Mycotic pseudoaneurysms: Typically sacular.
• Vasculitis: Such as giant cell or Takayasu’s arteritis may
present with aneurysms.
■
Essential Facts
• SAM is a rare disorder that usually aff ects the elderly and
is fatal in > 50% of patients in the acute phase.
• Locations: SAM most commonly involves the celiac arterial
distribution; less commonly aff ected are the superior and
inferior mesenteric arteries and the renal arteries.
• Symptoms include the following: abdominal pain from dis-
section or thrombosis with bowel ischemia; hypotension,
distension, or anemia from gastrointestinal or peritoneal
hemorrhage secondary to aneurysm rupture.
• The acute phase is characterized by the deposition of fi brin
and collagen in the media without an infl ammatory infi ltrate.
• The late phase is characterized by reparative remodeling of
the vessel wall.
• Treatment options include the following: coil emboliza-
tion of aneurysms to prevent rupture; surgical bypass or
thrombectomy (depending on the cause of occlusion).
■
Other Imaging Findings
• Acute phase angiography (CTA, magnetic resonance
angiography, or conventional) shows segments of arterial
dilatation, narrowing, and beading. Occlusion may result
from thrombosis, dissection, or stricture. Aneurysms may
rupture or erode adjacent structures, such as bile ducts,
bowel, and peritoneum.
• Late phase angiography (delayed 6 months) shows resolu-
tion of beading and dilatation, often leaving a smooth
arterial wall.
✔ Pearls & ✘ Pitfalls
✔
Unlike FMD, SAM shows a predilection for the celiac
distribution, has a high rate of mortality from aneurys-
mal rupture and bowel ischemia, undergoes spontaneous
repair and remodeling, and is typically not treated with
angioplasty.
✔ Unlike vasculitis, SAM is not associated with infl amma-
tory infi ltration and does not respond to steroids and
immunosuppressants.
✔ Unlike mycotic aneurysms, the aneurysms of SAM are not
typically associated with arterial branch points.
✘ Complications of coil embolization include arterial dis-
section, rupture, and thrombosis resulting from nontar-
get embolization or clot propagation.
✘ Saccular aneurysms are usually amenable to emboliza-
tion, but fusiform aneurysms may require ligation and
bypass. Stent-grafts may play an increasing role.
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141
Case 71
A
B
■
Clinical Presentation
A 49-year-old woman with a history of metastatic breast cancer presents with facial swelling and shortness of breath.
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142
RadCases Interventional Radiology
■
Imaging Findings
ABC
(A) A contrast-enhanced computed tomographic (CT) scan shows soft-tissue masses ( arrows ) compressing the superior vena
cava (SVC: arrowhead ). (B) Venogram shows stenosis of the right brachiocephalic vein and SVC ( arrows ). (C) Venogram after
stent placement shows resolution of the stenosis.
■
Diff erential Diagnosis
• Malignant superior vena cava syndrome : The most likely
diagnosis, indicated by the clinical history and the masses
compressing the SVC.
• Mediastinal fi brosis: May cause masslike soft-tissue infi ltra-
tion of the mediastinum and SVC narrowing due to fi brosis.
■
Essential Facts
• SVC syndrome consists of symptoms caused by the
obstruction of central veins: swelling of the face, arm,
and neck; shortness of breath; chest pain; and headache.
Causes may be benign or malignant.
• Malignant causes include lung carcinoma (most common),
metastasis, lymphoma, and mesothelioma.
• Benign causes include fi brosis or thrombosis from a central
venous catheter or shunt (most common), fi brosis from
radiation therapy or chest surgery, benign tumors (e.g.,
thymoma), sarcoidosis, aortic aneurysms, and infections
(e.g., tuberculosis).
• Endovascular stent placement palliates the symptoms if the
stent remains patent either for the remainder of the patient’s
life or until adequate venous collateralization has developed.
• Surgical treatment such as central venous bypass has been
largely replaced by stent placement for both benign and
malignant SVC syndrome.
■
Other Imaging Findings
• Duplex scanning serves as a noninvasive, fi rst-line test and
is typically used for patients with suspected benign SVC
syndrome caused by acute thrombosis.
• Contrast-enhanced CT detects the cause of SVC syndrome
in most cases and helps plan endovascular treatment.
• Venography is noninvasive when contrast is injected into
an arm intravenously. Stent placement may require femo-
ral, jugular, and/or upper extremity venous access.
✔ Pearls & ✘ Pitfalls
✔
Symptoms usually resolve with revascularization of the
SVC and at least one brachiocephalic vein.
✔ In malignant SVC obstruction, the goal of stent place-
ment is for the stent to remain patent for the rest of the
patient’s life and thereby improve quality of life.
✔ In benign SVC obstruction, the goal of stent placement is
for the stent to remain patent long enough for adequate
alternative venous collateral pathways to form. Stent
placement is often reserved for chronic occlusions, elastic
stenoses, or early-recurring stenoses following angio-
plasty.
✔ Primary patency rates at 12 months after stent place-
ment for SVC syndrome range from 25 to 69%.
✘ Complications of stent placement include compression,
distortion, fracture, and misplacement or migration of
the stent. Stents are most vulnerable to re-occlusion or
fracture at the thoracic outlet.
✘ For patients on dialysis, stents across the infl ow of patent
central veins that may serve as future options for dialysis
access should be avoided if possible. For example, stents
across the jugular or subclavian vein infl ow compromise
catheter and shunt options.
✘ Stent migration to the right atrium is rare but can cause
death by cardiac tamponade. Most recommend self-
expanding over balloon-expandable stents to minimize
this risk.
✘ Premature venous re-occlusion may occur following cen-
tral venous stent placement as a consequence of throm-
bosis, intimal hyperplasia, fi brosis, and ingrowth/extrin-
sic compression by tumor. The risk for acute thrombosis
is reduced by anticoagulation after complicated cases.
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143
Case 72
A B
C
■
Clinical Presentation
A 79-year-old man who has pancreatic cancer presents with right upper quadrant pain 2 days after stent placement for malig-
nant biliary obstruction.
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144
RadCases Interventional Radiology
■
Imaging Findings
ABC
(A) Coronal contrast-enhanced computed tomographic (CT) scan shows metallic and plastic biliary stents in place ( arrow ). (B) Thickening
( arrow ) and rupture of the gallbladder wall, resulting in a communicating hepatic abscess ( arrowhead ). The absence of gallstones indicates
acalculous cholecystitis (AC). (C) Axial contrast-enhanced CT scan shows sloughing of the gallbladder epithelium ( arrows ), indicating gan-
grenous cholecystitis.
■
Diff erential Diagnosis
• Acalculous cholecystitis (AC): Most likely, indicated by the
history of stenting across the cystic duct and new right
upper quadrant pain. A history of fever and leukocytosis
would be helpful.
• Calculous cholecystitis: May occasionally be indistinguish-
able from AC on CT since some stones are not calcifi ed.
• Neoplasm: Should be considered for gallbladder wall thick-
ening and obstruction in conjunction with a hepatic lesion.
Earlier CT scans would be helpful to establish the timing of
onset of the imaging fi ndings.
■
Essential Facts
• AC is infl ammation of the gallbladder without the presence
of gallstones. AC is associated with a high risk for mortality
if untreated.
• Predisposing conditions include the following: diabetes,
malignancy, burn injury, recent surgery or trauma, cardiac
disease, positive pressure ventilation, and total parenteral
nutrition.
• Symptoms are leukocytosis and fever of unknown origin,
with or without right upper quadrant tenderness.
• Percutaneous cholecystostomy has become a fi rst-line
treatment for AC because it is fast and minimally invasive
in a population with a high surgical risk.
• Surgical cholecystectomy is the defi nitive treatment for
calculous cholecystitis, but severe concomitant illness
often precludes surgery for patients with AC.
• Endoscopic placement of a nasobiliary drain is an alterna-
tive for suboptimal surgical or radiologic candidates (e.g.,
sick patients with a coagulopathy). Nasobiliary drains
are less comfortable during the often-lengthy treatment
period.
■
Other Imaging Findings
• Ultrasonography and contrast-enhanced CT of patients
with cholecystitis may show wall thickness > 3 mm, fl uid
around the gallbladder, and intraluminal sludge. Gallstones
are absent.
• CT commonly makes the diagnosis because patients in
an intensive care unit are being evaluated for nonspecifi c
signs of infection.
• Gangrenous cholecystitis is characterized by sloughing of
membranes, intramural or intraluminal gas, an irregular or
absent gallbladder wall, and abscess.
✔ Pearls & ✘ Pitfalls
✔
For AC, gallbladder drainage with antibiotic coverage can
bridge the gap to surgery or serve as the defi nitive treat-
ment (most cases).
✔ Drain management: Drain removal can be considered
4 weeks after placement to allow time for the tract to
mature and to prevent the peritoneal leakage of bile.
Contrast can be injected through a sidearm sheath over a
guide wire before tube removal to verify patency of the
cystic duct, the absence of stones, and the presence of a
mature tract. Patients should be asymptomatic.
✔ For calculous cholecystitis, cholecystostomy serves to de-
compress the gallbladder in patients too sick for surgery.
More elective cholecystectomy can be planned after the
resolution of fever and leukocytosis.
✘ Complications of cholecystostomy include peritonitis
from leaked gallbladder contents, bleeding, bacteremia,
tube kinking, and nontarget drainage (minor, < 14%;
major, < 2%).
✘ AC is often delayed or missed because it typically occurs
in seriously ill, often intubated patients.
✘ Delay or absence of treatment is associated with rapid
progression to necrosis and rupture.
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145
Case 73
A B
C
■
Clinical Presentation
A 39-year-old woman presents with a long history of leg swelling.
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146
RadCases Interventional Radiology
■
Imaging Findings
ABC
(A) Computed tomographic angiogram (CTA) shows early opacifi cation of the femoral vein ( arrow ) and tufts of
disorganized vessels ( arrowheads ). (B) Arteriogram shows early opacifi cation of the femoral vein ( arrow ) via tufts
of vessels ( arrowheads ). (C) Further delay shows abnormal, enlarged, unnamed veins ( arrowheads ) in the thigh
draining into the femoral and iliac veins.
■
Diff erential Diagnosis
• Peripheral arteriovenous (a-v) malformation : Indi cated
by multiple, enlarged arteries and early draining veins
separated by a nidus of hypervascularity.
■
Essential Facts
• Congenital peripheral vascular malformations are divided
into two main categories—hemangiomas and a-v
malformations.
• Hemangiomas are benign endothelial tumors with two
stages—proliferative (2 weeks–18 months) and involution-
ary (2–6 years). Indications for treatment are uncommon
and include platelet sequestration (as in Kasabach–Merritt
syndrome) and cardiac failure.
• At birth, a-v malformations are often not apparent, and
they grow with the patient without involution. Growth
may be exacerbated by pregnancy, puberty, or trauma.
Indications for treatment include complicating factors such
as pain, bleeding, ulceration, shunt-related cardiac failure,
and gross deformity (e.g., discrepancy of limb length, as in
Parkes–Weber syndrome).
• Low-fl ow a-v malformations respond well to conservative
management (compression stockings) or percutaneous
treatment. High-fl ow a-v malformations are diffi cult to
treat and require a multidisciplinary approach.
• Elimination of the nidus by direct puncture or selected
catheterization is the only potential cure for complicated
a-v malformations. Possible sclerotic agents include abso-
lute ethanol, cyanoacrylate, and polydocanol.
• Embolization with coils and/or particles is often used as an
adjunctive treatment.
• Surgical ligation of the feeding arteries for high-fl ow a-v
malformations is usually ineff ective because of rich col-
lateral recruitment. Surgical resection may be attempted
for cases refractory to sclerotherapy and embolization.
■
Other Imaging Findings
• Ultrasound screens for the presence and size of a vascular
lesion and measures the fl ow rate.
• Magnetic resonance imaging and magnetic resonance
angiography determine the extent of a vascular lesion and
its relationship to adjacent structures. Hemangiomas show
peripheral-to-central enhancement. Dynamic gradient
pulse sequences evaluate the lesion type: high-fl ow a-v
malformations show a signal void and low-fl ow a-v mal-
formations are high-signal on T2-weighted images.
• CT with CTA can demonstrate bone and tissue involve-
ment, calcifi cations, a-v malformation size, and thrombus.
• Conventional angiography and direct puncture are per-
formed with the intent to treat.
✔ Pearls & ✘ Pitfalls
✔
The treatment of a-v malformations starts with direct
puncture of the nidus under imaging guidance and con-
trast opacifi cation to demonstrate the rate and direction
of fl ow, size, and venous drainage.
✔ For high-fl ow a-v malformations with a large draining
vein, sclerotherapy and embolization are more safely
performed with concurrent venous occlusion by balloon
catheter, application of a tourniquet, or coil embolization.
✘ Complications of sclerotherapy and embolization include
tissue necrosis, nontarget embolization (with ischemia),
infection, bleeding, and postembolization syndrome
(nausea, pain, fever, leukocytosis).
✘ High-fl ow a-v malformations commonly recur, and re-
peat sclerotherapy and embolization are often necessary.
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147
Case 74
A B
C
D
■
Clinical Presentation
The patient is a 39-year-old man.
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148
RadCases Interventional Radiology
■
Imaging Findings
ABC D
(A) Frontal chest radiograph shows curvilinear structure ( arrow ) in the right
lower lung fi eld, parallel to the right side of the heart, associated with tent-
ing of the right hemidiaphragm. There is dextroposition of the heart. (B)
Infused computed tomographic (CT) scan shows a curvilinear structure
extending from the pulmonary vein to the posterior pleura ( arrow ). (C,D)
Infused CT scan shows a structure crossing the diaphragm posteriorly,
coursing behind the diaphragm medially, and draining into the renal vein
( arrows ).
■
Diff erential Diagnosis
• Scimitar syndrome : The only diagnosis here, indicated by
the linear opacity connecting the pulmonary vein to the
renal vein, and the cardiac dextroposition suggesting right
pulmonary hypoplasia.
■
Essential Facts
• Scimitar syndrome, or pulmonary venolobar syndrome
(PVLS), is a rare congenital syndrome that is more com-
mon in girls.
• It consists of partial anomalous pulmonary venous return
below the diaphragm, hypoplasia or aplasia of one or more
lobes of the right lung, and an absent or small associated
pulmonary artery with primarily systemic arterial supply
to the lung.
• Presentation in the fi rst year of life is typically with pul-
monary hypertension and right-sided congestive heart
failure. The prognosis is poor despite surgical correction.
• Presentation in adulthood is usually asymptomatic (inci-
dental fi nding), although symptomatic patients have been
reported with a history of shortness of breath on exertion
and a heart murmur.
• Associations include tetralogy of Fallot, truncus arteriosus,
and atrial septal defect (ASD). Other associations include
dextroposition of the heart, anomalies of the ribs or verte-
brae including hemivertebrae and scoliosis, and hypoplasia
or aplasia of an associated lobe and pulmonary artery.
• Treatment ranges from surgical shunting of the venous
drainage to the left atrium to pneumonectomy. In adults,
treatment is indicated only for symptomatic patients and
those with large right-to-left shunts.
■
Other Imaging Findings
• Radiography shows a tenting of the right hemidiaphragm
and a vertical, curvilinear opacity within the right lung,
adjacent to the border of the heart. Thickness depends on
the size and patency of the anomalous vein.
• Magnetic resonance imaging or CT shows a linear struc-
ture extending from a right pulmonary vein and crossing
the diaphragm. Venous drainage is typically to the inferior
vena cava (IVC), but other systemic venous drainage is pos-
sible (including the renal vein).
• Conventional angiography may show an anomalous
systemic arterial supply, typically from the aorta or major
branches.
✔ Pearls & ✘ Pitfalls
✔
Embolization of the anomalous vein above the IVC has
been described if dual venous drainage to the left atrium
and IVC is documented by contrast study.
✔ Embolization of the anomalous systemic arterial supply
has been described.
✘ In adults with symptomatic scimitar syndrome, right-
to-left shunts such as ASD may be the primary cause of
dyspnea on exertion despite the presence of the anoma-
lous scimitar vein. Transesophageal echocardiography is
typically performed.
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149
Case 75
A
B
■
Clinical Presentation
A 37-year-old man presents to the clinic with a history of pelvic pain.
Further Work-up
C D
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