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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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50
RadCases Interventional Radiology
■
Imaging Findings
A
B
(A) Selected image from a non–contrast-enhanced computed tomographic (CT) scan of the abdomen
showing an enlarged left kidney with perirenal stranding ( arrow ). There is mild dilatation of the collect-
ing system. (B) Selected image from a non–contrast-enhanced CT scan of the abdomen at a lower level
showing multiple high-density images ( arrow ), suggestive of the presence of multiple calcifi cations
within the collecting system. A central high-density focal image central to the left kidney is suggestive
of a calcifi cation within the proximal portion of the left ureter.
■
Diff erential Diagnosis
• Obstructive pyelonephritis : An enlarged kidney and
perinephric stranding support this possibility. The clinical
information is also useful. This patient had fever, pain, and
a high white blood cell count of 19,000/mm
3
.
• Pyonephrosis: This diagnosis is diffi cult to make based
solely on the imaging fi ndings. A diagnosis of pyonephrosis
is supported by the aspiration of purulent material after
needle puncture of the collecting system.
• Staghorn calculi: The patient does have kidney stones, but
simple stone disease does not present with enlargement
and perirenal infl ammation.
■
Essential Facts
• Obstructive pyelonephritis is a grave condition. It is a
true emergency, and treatment should not be delayed.
• The morbidity and mortality rates of untreated obstructive
pyelonephritis or pyonephrosis are very high.
• These patients require emergent decompression of the col-
lecting system by either retrograde double-J stent place-
ment or percutaneous nephrostomy.
✔ Pearls & ✘ Pitfalls
✔
CT is the imaging method of choice for diagnosis.
✔ In most centers, percutaneous drainage of the collecting
system is preferred. The technical success rate is 95 to 98%.
✔ Twenty-fi ve to 40% these patients will require intensive
care.
https://t.me/med1917
51
Case 26
A
B
■
Clinical Presentation
Patient with an occluded transjugular intrahepatic portosystemic shunt.
https://t.me/med1917
52
RadCases Interventional Radiology
■
Imaging Findings
ABC
(A) Selected image from a direct portogram obtained through a transjugular intrahepatic portosystemic
shunt (TIPS). The angiographic catheter is in the main portal vein. The intrahepatic portal branches are
patent and readily opacifi ed. There is no fl ow through the shunt. The angiographic diagnosis is occluded
TIPS. (B) Selected image from a contrast injection within the occluded TIPS shows opacifi cation of a
tubular structure that corresponds to the biliary system ( white arrow ). (C) Direct portogram obtained
after stent-graft placement. The TIPS is widely patent. The fi stula is no longer demonstrated.
■
Diff erential Diagnosis
• TIPS-to-biliary fi stula with secondary TIPS occlusion
• TIPS occlusion: The shunt is occluded, but you should be
able to identify the biliary fi stula. The simple diagnosis of
TIPS occlusion would be incomplete in this case.
■
Essential Facts
• A fi stula between the TIPS and the biliary system has been
proposed as a cause of shunt stenosis and occlusion.
• A TIPS-to-biliary fi stula is diffi cult to demonstrate angio-
graphically; it is demonstrated in only 4 to 6% of occluded
shunts.
✔ Pearls & ✘ Pitfalls
✔
The incidence of TIPS-to-biliary fi stulas has decreased
signifi cantly with the use of stent-grafts.
✔ In a patient whose TIPS has been created with a bare
stent, early or midterm shunt occlusion associated with
sepsis or an infectious episode after TIPS placement
should raise suspicion of a fi stula to the biliary system.
• To demonstrate the fi stula, it is necessary to inject con-
trast directly within the occluded shunt.
• A fi stula to the biliary system may be suspected if a high
fever and elevated white blood cell count develop 2 to 3
weeks after placement of a TIPS.
https://t.me/med1917
53
Case 27
■
Clinical Presentation
The patient is a 72-year-old woman who is experiencing diffi culty swallowing.
https://t.me/med1917
54
RadCases Interventional Radiology
■
Imaging Findings
Selected image of a contrast-enhanced computed
tomographic (CT) scan of the chest at the level of
the aortic arch shows the origins of the right carotid
artery, left carotid artery, and left subclavian artery.
An additional vascular structure originates from the
medial aspect of the aortic arch ( white arrow ); it is di-
rected medially and to the right side and courses be-
hind the esophagus. This is the last branch of the arch
and is an aberrant right subclavian artery.
■
Diff erential Diagnosis
• Aberrant right subclavian artery with a left aortic arch
• There is really no good diff erential diagnosis.
■
Essential Facts
• This anomaly is seen in 1 to 2% of the population.
• In this usually isolated anomaly, the right subclavian
artery arises as the last branch of the aortic arch, courses
from the descending aorta to the right arm, and passes
behind the esophagus.
✔ Pearls & ✘ Pitfalls
✔
Aberrant right subclavian artery with a left aortic arch is
usually asymptomatic (this is not a true vascular ring);
however, symptoms may include dysphagia (so-called
dysphagia lusoria) and dyspnea.
✔ It may be associated with a “diverticulum of Kommerell,”
which is a diverticulum at the origin of the anomalous
vessel.
https://t.me/med1917
55
Case 28
■
Clinical Presentation
The patient is a 46-year-old woman with primary biliary cirrhosis.
https://t.me/med1917
56
RadCases Interventional Radiology
■
Imaging Findings
A
B
(A) Selected image from a digital subtraction arteriogram (DSA). The
tip of the angiographic catheter is within the lumen of the hepatic ar-
tery ( arrow ). The image shows contrast opacifi cation of the origin of
the superior mesenteric artery and faint opacifi cation of the abdominal
aorta. The intrahepatic arterial branches are also opacifi ed. The image
is consistent with catheterization of the hepatic artery during a trans-
jugular intrahepatic portosystemic shunt (TIPS) procedure. (B) Selected
image from a DSA study done before the TIPS procedure in the same
patient. The proper hepatic artery ( black arrow ) arises from the superior
mesenteric artery ( white arrow ). This is an unusual variant seen in
~
1 to
2% of the population.
■
Diff erential Diagnosis
• Hepatic arterial injury during TIPS procedure
• There is no diff erential diagnosis in this case. If the compli-
cation is not identifi ed and the operator proceeds with the
next step of the procedure, which is tract dilation and stent
placement, the hemodynamic outcome may be fatal.
■
Essential Facts
• Injury to the hepatic artery during a TIPS procedure is an
unusual complication seen in < 1% of cases.
• It is a potentially fatal complication.
✔ Pearls & ✘ Pitfalls
✔
Careful evaluation of all diagnostic images obtained dur-
ing a TIPS procedure is critical to identify complications.
✔ Entry into the hepatic artery should not be confused
with entry into the portal vein.
✔ Proceeding with shunt creation in this setting would
have devastating hemodynamic consequences.
✔ The recommended management of this complication is
to carefully withdraw the catheter from the artery and
embolize the tract.
✔ Access into the portal vein can again be attempted after
the complication has been addressed.
https://t.me/med1917
57
Case 29
■
Clinical Presentation
The patient is a 64-year-old woman who has undergone a liver transplant.
https://t.me/med1917
58
RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Selected image from a percutaneous cholangiogram shows a large fi lling defect within
the common bile duct ( arrow ). The fi lling defect conforms to the shape of the duct. No other
fi lling defects are identifi ed. (B) Digital subtraction over the wire cholangiogram via an access
sheath (not shown) after the percutaneous removal of biliary casts. The common bile duct is
now widely patent. No fi lling defects are identifi e d .
■
Diff erential Diagnosis
• Biliary cast syndrome in a patient with a liver transplant
• Biliary stones: These are usually smaller and have a better-
defi ned shape. Biliary casts usually conform to the shape
of the biliary ducts.
• Clots within the biliary system: This is a good possibility;
the clots usually change in size and shape over time, and
the patient may have clinical evidence of upper gastroin-
testinal bleeding.
■
Essential Facts
• Biliary cast syndrome is an unusual complication de-
scribed in patients with a liver transplant.
• The etiology of cast development is not known, but it ap-
pears to be related to the accumulation of biliary sludge.
Other predisposing factors include bile duct damage,
ischemia, and infection.
✔ Pearls & ✘ Pitfalls
✔
Management is diffi cult; therapeutic options include
endoscopic methods, surgical cast removal, and per-
cutaneous methods. Percutaneous cast removal can be
accomplished by pushing the casts into the intestine with
a Fogarty-type balloon catheter. This method has been
shown to be eff ective in some cases.
• The present case illustrates the successful management
of biliary cast syndrome with percutaneous techniques.
The casts were pushed into the duodenum with a 6F
Walrus balloon (Cook, Bloomington, IN).
https://t.me/med1917
59
Case 30
■
Clinical Presentation
The patient is a 67-year-old Hispanic man with liver cirrhosis and refractory ascites.
Further Work-up
A
B
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