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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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60
RadCases Interventional Radiology
■
Imaging Findings
AB C
(A) Selected image from a magnetic resonance imaging study, coronal
view, demonstrating a large amount of fl uid in the abdominal cavity.
The liver is small and located in the left upper quadrant. The stomach
is located in the right upper quadrant, indicating complete inversion
of organ distribution. (B) Selected axial image of a contrast-enhanced
computed tomographic (CT) scan. This study confi rms the inverse
distribution of the intra-abdominal organs and the large amount of
intra-abdominal fl uid. Note the aorta on the right side and inferior
vena cava on the left. The fi ndings are consistent with complete situs
inversus. (C) Selected image of a direct digital subtraction portogram
after completion of a transjugular intrahepatic percutaneous shunt
(TIPS) procedure in this patient with situs inversus.
■
Diff erential Diagnosis
• TIPS procedure in a patient with situs inversus
• There is no good diff erential diagnosis in this case. The
most important aspect of this case is to realize that situs
inversus is not a contraindication to a TIPS procedure.
■
Essential Facts
• The usual thoracic and abdominal visceral anatomy is
known as situs solitus. The complete reversal of the usual
anatomy is known as situs inversus totalis.
✔ Pearls & ✘ Pitfalls
✔
Careful planning of the procedure is important in cases in
which the patient has a variant or unusual anatomy.
✔ The operator should be prepared for unexpected fi ndings.
• Only two reports in the literature describe the creation of
a TIPS in a patient with situs inversus.
• The procedure is carried out in the usual fashion, with
the inverted anatomy kept in mind.
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61
Case 31
■
Clinical Presentation
This 57-year-old patient has undergone a liver transplant.
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62
RadCases Interventional Radiology
■
Imaging Findings
A
B
DC
(A) Selected image from a percutaneous cholangiogram.
Dual access has been obtained via the right and left ducts.
A large fi lling defect within the common bile duct is con-
sistent with a large biliary stone. The Roux-en-Y bilioen-
teric anastomosis is patent. (B) Selected image from an
over-the-wire cholangiogram obtained during balloon
angioplasty of the bilioenteric anastomosis. Angioplasty
was performed to allow passage of the stone through
the anastomotic site. (C) Single-shot image during stone
manipulation with an over-the-wire Fogarty balloon. The
stone was pushed through the bilioenteric anastomosis.
(D) Over-the-wire cholangiogram obtained 2 weeks after
stone manipulation shows no residual stone fragments
within the common bile duct.
■
Diff erential Diagnosis
• Biliary stone in a patient with a liver transplant
• Blood clot: The image is suggestive. Blood clots usually
change in size and shape after 24 to 48 hours. There may
be evidence of blood in the biliary drainage tube, or it may
present clinically as either hematemesis or melena.
• Air bubble: The fi lling defect seen is too large for an air
bubble. Usually, air bubbles are round and multiple, and
they lodge in the less dependent areas.
■
Essential Facts
• Retained biliary duct stones are associated with symptom-
atic acute cholangitis.
• The stones must be removed by surgical, endoscopic, or
percutaneous methods.
• In patients with intact anatomy, the method of choice is
the endoscopic approach.
• For patients with an inaccessible common bile duct by
endoscopy (diffi cult anatomy or Roux-en-Y bilioenteric
anastomosis), percutaneous manipulation of the stone is
preferable.
✔ Pearls & ✘ Pitfalls
✔
The percutaneous management of retained biliary stones
should be staged. Initially, the biliary system must be
decompressed with a percutaneous biliary drain. The
percutaneous tract must mature for 4 to 6 weeks before
manipulation is attempted.
✔ Stone manipulation can consist of percutaneous removal
with a retrieval basket. Alternatively, a Fogarty-type
balloon catheter can be used to push the stone through
either the ampulla or the surgical anastomosis.
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63
Case 32
A
B
■
Clinical Presentation
The patient is a 65-year-old woman with abdominal pain and gastrointestinal bleeding.
Further Work-up
C
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64
RadCases Interventional Radiology
■
Imaging Findings
AB
C
D
(A) Selected axial image from a delayed phase of a contrast-enhanced com-
puted tomographic (CT) scan of the abdomen showing a soft-tissue density
at the head of the pancreas ( arrow ). There is no distinct fat tissue plane
between this mass and the gallbladder. (B) Selected axial image from a con-
trast-enhanced CT scan, arterial phase, showing signifi cant contrast density
within the mass. The fi ndings are consistent with a pseudoaneurysm in the
region of the pancreatic head. (C) Image of a selective superior mesenteric
artery (SMA) injection showing that the pseudoaneurysm arises from a
small branch of the SMA, most probably from the pancreaticoduodenal
branches ( arrow ). Note the origin of a replaced right hepatic artery from
the SMA as an incidental fi nding. (D) Image of a selective SMA injection
after coiled embolization of the pseudoaneurysm shows complete oblit-
eration of the lesion.
■
Diff erential Diagnosis
• Pseudoaneurysm of a pancreaticoduodenal artery sec-
ondary to pancreatitis
• Saccular aneurysm of the superior mesenteric artery: The
arteriogram shows that this lesion does not correspond to
the SMA.
• Saccular aneurysm of the gastroduodenal artery (GDA):
Involvement of the GDA in pancreatitis is relatively com-
mon, but the angiographic images show involvement of
the pancreaticoduodenal arcade, not the GDA.
■
Essential Facts
• Vessel injury in acute or chronic pancreatitis is not uncom-
mon. The most frequently aff ected arteries are the splenic
artery (40%), gastroduodenal artery (30%), pancreaticoduo-
denal arteries (20%), and hepatic arteries (2%).
• If the condition is left untreated, the risk for rupture and
subsequent fatal outcome is high.
• Endovascular techniques have been useful in the man-
agement of these unusual cases.
• The embolization technique is usually with coaxial cath-
eter systems and microcoils.
• Alternatively, other agents, such as thrombin or Onyx
(formerly called Embolyx, MicroTherapeutics, Irvine, CA),
may be injected within the sac to occlude it. Thrombin
should be administered very carefully to prevent nontar-
get thrombin injection, which may have catastrophic side
eff ects.
✔ Pearls & ✘ Pitfalls
✔
These pseudoaneurysms should be embolized with the
“sandwich” technique, in which both the distal and prox-
imal segments of the artery feeding the pseudoaneurysm
must be embolized for the procedure to be successful.
✔ Isolated proximal embolization is associated with recur-
rence of the lesion via collaterals.
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65
Case 33
■
Clinical Presentation
A 57-year-old patient presents with shortness of breath.
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66
RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Anteroposterior chest fi lm showing large bilateral infi ltrates. The patient is intu-
bated, and the endotracheal tube is in a good position. (B) The tip of a left subclavian
catheter is located within the left innominate vein. There is a superior vena cava (SVC)
fi lter in a good position (arrows).
■
Diff erential Diagnosis
• Superior vena cava fi lter
• Migrated inferior vena cava (IVC) fi lter: This possibility
is remote. Usually, migrated IVC fi lters lodge in the right
atrium, the right ventricle, or rarely the pulmonary artery.
■
Essential Facts
• The placement of SVC fi lters was described in 1996 by
Ascher and colleagues.
• The incidence of clinically signifi cant deep vein thrombosis
in the upper extremities has risen as a consequence of the
increased use of indwelling central lines.
• Patients may require insertion of a central line after SVC
fi lter placement, and this may lead to complications such
as fi lter dislodgement or wire entrapment within the fi lter
during attempts at placing the central line. Thus, all cen-
tral line placements after SVC fi lter placement should be
performed under fl uoroscopic guidance.
• The SVC fi lter insertion technique includes a careful
superior vena cavagram.
• Probably the easiest access is via the femoral vein. For
insertion via the femoral route, a “jugular” fi lter should
be used; thus, the fi lter will be deployed “upside down.”
• Ideally, the fi lter legs should be deployed at the confl u-
ence of the innominate veins, and the fi lter cone should
be at the most central segment of the SVC without pro-
truding into the right atrium (Fig. B, arrows ).
✔ Pearls & ✘ Pitfalls
✔
Reported complications include dislodgement, aortic
perforation, and pneumothorax.
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67
Case 34
■
Clinical Presentation
The 65-year-old patient is undergoing a transjugular intrahepatic portosystemic shunt (TIPS) procedure.
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68
RadCases Interventional Radiology
■
Imaging Findings
Selected image from a digital subtraction wedge
hepatic venogram showing massive extravasa-
tion of contrast into the peritoneal cavity ( ar-
row ). This image is characteristic of capsular per-
foration during wedge hepatic venography.
■
Diff erential Diagnosis
• Capsular perforation during hepatic vein wedge injection
• There is no good diff erential diagnosis in this case, but this
complication must be identifi ed immediately and managed
promptly.
■
Essential Facts
• Capsular perforation during wedge hepatic venography
has been described as a fatal complication of either TIPS or
transjugular liver biopsy.
• Management options are limited and include embolization
of the tract, expedited completion of the TIPS procedure,
and supportive measures, including correction of coagu-
lopathy and close patient monitoring for the following 48
to 72 hours.
• The mechanism of injury may be related to the fast or
forceful distribution of either contrast or carbon diox-
ide within the liver parenchyma along the path of least
resistance to the edge of the liver, resulting in capsular
perforation.
• The best approach is to prevent the complication. Au-
thors have recommended gentle injection of 15 to 20 mL
of carbon dioxide; forceful injection must be avoided.
✔ Pearls & ✘ Pitfalls
✔
When the complication is identifi ed, the operator should
not ignore it, and the patient should receive full support-
ive measures and be monitored at least 24 to 48 hours
after the complication has occurred.
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69
Case 35
■
Clinical Presentation
The patient is a 30-year-old woman with a renal transplant.
Further Work-up
A
B
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