RadCases Q&A Interventional Radiology E-Book

Hector Ferral

• Herausgeber: Thieme Medical Publishers
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2018

Beschreibung

Cardiac Imaging, Interventional Radiology, Musculoskeletal Radiology, Neuro Imaging, Thoracic Imaging, Pediatric Imaging, Gastrointestinal Imaging, Breast Imaging, Nuclear Medicine, Ultrasound Imaging, Head and Neck Imaging, Genitourinary Imaging

Each RadCases title features 100 carefully selected, must-know cases documented with clear, high-quality radiographs. The organization provides maximum ease of use for self-assessment.

Each case begins with the clinical presentation on the right-hand page; simply turn the page for imaging findings, differential diagnoses, the definitive diagnosis, essential facts, and more.

Each RadCases title includes a scratch-off code that allows 12 months of access to a searchable online database of all 100 cases from the book plus an additional 150 cases in that book's specialty - 250 cases in total!

Learn your cases, diagnose with confidence and pass your exams. RadCases.

Interventional Radiology will enable you to diagnose the full range of vascular and nonvascular cases.

Features of Interventional Radiology:

• Numerous high-resolution 3-D radiographs demonstrating the mechanics of the vascular system
• A variety of common and uncommon presentations covering everything from acute lower gastrointestinal bleeding to superficial femoral artery stenosis
• Examples of critical cases that must be diagnosed immediately - to avert potential disaster in daily practice and on exams - such as traumatic injury of the aorta

Leseprobe

To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book.

RadCases Interventional Radiology

Second Edition

Edited by

Hector Ferral, MDSenior Clinician EducatorNorthShore University HealthSystemEvanston, Illinois

Jonathan M. Lorenz, MD, FSIRProfessor of RadiologySection of Interventional RadiologyThe University of ChicagoChicago, Illinois

Series Editors

Jonathan M. Lorenz, MD, FSIRProfessor of RadiologySection of Interventional RadiologyThe University of ChicagoChicago, Illinois

Hector Ferral, MDSenior Clinician EducatorNorthShore University HealthSystemEvanston, Illinois

477 illustrations

ThiemeNew York • Stuttgart • Delhi • Rio de Janeiro

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Director, Editorial Services: Mary Jo Casey

Production Editor: Teresa Exley, Absolute Service, Inc.

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Library of Congress Cataloging-in-Publication Data

Names: Ferral, Hector, editor. | Lorenz, Jonathan, editor.

Title: Interventional radiology / edited by Hector Ferral,

Jonathan M. Lorenz.

Other titles: Interventional radiology (Ferral) | RadCases.

Description: Second edition. | New York : Thieme, [2018] |

Series: RadCases | Includes bibliographical references and

index.

Identifiers: LCCN 2017057243| ISBN 9781626232822 |

ISBN 1626232822 | ISBN 9781626232839 (eISBN)

Subjects: | MESH: Radiography, Interventional—methods |

Diagnosis, Differential | Case Reports

Classification: LCC RC78 | NLM WN 200 | DDC 616.07/572—dc23

LC record available at https://lccn.loc.gov/2017057243

Copyright © 2018 by Thieme Medical Publishers, Inc.

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5 4 3 2 1

ISBN 978-1-62623-282-2

Also available as an e-book:eISBN 978-1-62623-283-9

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

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Contents

Series Preface

Preface

Acknowledgments

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 7

Case 8

Case 9

Case 10

Case 11

Case 12

Case 13

Case 14

Case 15

Case 16

Case 17

Case 18

Case 19

Case 20

Case 21

Case 22

Case 23

Case 24

Case 25

Case 26

Case 27

Case 28

Case 29

Case 30

Case 31

Case 32

Case 33

Case 34

Case 35

Case 36

Case 37

Case 38

Case 39

Case 40

Case 41

Case 42

Case 43

Case 44

Case 45

Case 46

Case 47

Case 48

Case 49

Case 50

Case 51

Case 52

Case 53

Case 54

Case 55

Case 56

Case 57

Case 58

Case 59

Case 60

Case 61

Case 62

Case 63

Case 64

Case 65

Case 66

Case 67

Case 68

Case 69

Case 70

Case 71

Case 72

Case 73

Case 74

Case 75

Case 76

Case 77

Case 78

Case 79

Case 80

Case 81

Case 82

Case 83

Case 84

Case 85

Case 86

Case 87

Case 88

Case 89

Case 90

Case 91

Case 92

Case 93

Case 94

Case 95

Case 96

Case 97

Case 98

Case 99

Case 100

Case Questions and Answers

Further Readings

Index

To Michelle, Manuel, and Emilio: Thank you for countless moments of happiness and thank you for giving me a reason to stay alive.

– HF

To my loving wife, Cynthia, and to my kids, Matthew and Anna: Every moment is precious.

– JML

Series Preface

As enthusiastic partners in radiology education, we continue our mission to ease the exhaustion and frustration shared by residents and the families of residents engaged in radiology training! In launching the second edition of the RadCases series, our intent is to expand rather than replace this already rich study experience that has been tried, tested, and popularized by residents around the world. In each subspecialty edition, we serve up 100 new, carefully chosen cases to raise the bar in our effort to assist residents in tackling the daunting task of assimilating massive amounts of information. RadCases second edition primes and expands on concepts found in the first edition, with important variations on prior cases, updated diagnostic and management strategies, and new pathologic entities. Our continuing goal is to combine the popularity and portability of printed books with the adaptability, exceptional quality, and interactive features of an electronic case–based format. The new cases will be added to the existing electronic database to enrich the interactive environment of high-quality images that allows residents to arrange study sessions, quickly extract and master information, and prepare for theme-based radiology conferences.

We owe a debt of gratitude to our own residents and to the many radiology trainees who have helped us create, adapt, and improve the format and content of RadCases by weighing in with suggestions for new cases, functions, and formatting. Back by popular demand is the concise, point-by-point presentation of the Essential Facts of each case in an easy-to-read, bulleted format and a short, critical differential starting with the actual diagnosis. This approach is easy on exhausted eyes and encourages repeated priming of important information during quick reviews, a process we believe is critical to radiology education. New since the prior edition is the addition of a question-and-answer section for each case to reinforce key concepts.

The intent of the printed books is to encourage repeated priming in the use of critical information by providing a portable group of exceptional core cases to master. Unlike the authors of other case-based radiology review books, we removed the guesswork by providing clear annotations and descriptions for all images. In our opinion, there is nothing worse than being unable to locate a subtle finding on a poorly reproduced image even after one knows the final diagnosis.

The electronic cases expand on the printed book and provide a comprehensive review of the entire specialty. Thousands of cases are strategically designed to increase the resident’s knowledge by providing exposure to a spectrum of case examples—from basic to advanced—and by exploring “Aunt Minnies,” unusual diagnoses, and variability within a single diagnosis. The search engine allows the resident to create individualized daily study lists that are not limited by factors such as radiology subsection. For example, tailor today’s study list to cases involving tuberculosis and include cases in every subspecialty and every system of the body. Or study only thoracic cases, including those with links to cardiology, nuclear medicine, and pediatrics. Or study only musculoskeletal cases. The choice is yours.

As enthusiastic partners in this project, we started small and, with the encouragement, talent, and guidance of Timothy Hiscock and William Lamsback at Thieme Publishers, we have further raised the bar in our effort to assist residents in tackling the daunting task of assimilating massive amounts of information. We are passionate about continuing this journey and will continue to expand the series, adapt cases based on direct feedback from residents, and increase the features intended for board review and self-assessment. First and foremost, we thank our medical students, residents, and fellows for allowing us the privilege to participate in their educational journey.

Jonathan M. Lorenz, MD, FSIRHector Ferral, MD

Preface

Our heartfelt appreciation goes out to the countless enthusiastic aspiring and practicing interventional radiologists (IRs) that have made RadCases Interventional Radiology an overwhelmingly popular educational resource for the past 5 years! The rich rewards we get from the ideas, encouragement, and successes of our trainees were the inspiration for our creation of the RadCases textbook series and our authorship of the first edition of 250 cases.

The first edition of RadCases Interventional Radiology provided a core source of concise, accurate, and comprehensive interventional radiology review materials. In this second edition, we have combined our continued passion for the education of IRs with your insightful feedback for the past 5 years to create 100 additional cases. The written content continues to support the knowledge base of residents facing written board exams, and the preservation of the case-presentation format supports practicing IRs and fellows, particularly those facing the oral exam for the certification of added qualifications. As with the first edition, the printed book provides a portable resource for the critical exercise of repeatedly priming core material, and all 350 interventional radiology cases are available in the electronic book to provide concise material, high-resolution images, and sort-ability to tailor your daily study sessions. We are confident this second edition expansion will help you achieve your goals!

Our cutting-edge practices and leadership roles in the local and national education of IRs served as a source of content for the second edition to grow and enhance RadCases Interventional Radiology to accommodate changes and advancements in interventional radiology, including thermal ablation applications, prostate embolization, and advancements in the management of conditions such as portal hypertension and vascular malformations. We continue to provide the gamut of vascular and nonvascular cases emphasizing both diagnosis and interventional management. As always, many thanks to our readers and supporters for their energy and dedication to our mutual passion—interventional radiology!

Case Authorship

Cases 1 to 50 were authored by Hector Ferral and cases 51 to 100 were authored by Jonathan M. Lorenz.

Acknowledgments

We would like to thank William Lamsback and Timothy Hiscock at Thieme Publishers for their guidance, encouragement, and expertise throughout the creation and preparation of RadCases, and we thank Owen Zurhellen for his expert technical assistance. We also thank Kenneth Schubach and Torsten Scheihagen for their fine work on the book manuscript.

Case 1

Clinical Presentation

A 42-year-old man, a marathon runner, presents with sudden onset of claudication.

Further Work-up

Imaging Findings

(A) A selected image from an MR angiogram (MRA) of the lower extremities. There is moderate irregularity of the lateral wall of the proximal popliteal artery (arrow). (B) An axial image from the MRA showing intense, irregular, cystic structures surrounding the right popliteal artery consistent with peri-arterial cysts (arrow).

Differential Diagnosis

• Cystic adventitial disease: An MR angiogram (MRA) shows peri-adventitial cysts, which confirm the diagnosis.

• Popliteal aneurysm: The findings in the present MRI scan do not correspond to aneurysm. Arteries have a normal wall and are not dilated.

• Popliteal entrapment: This is usually bilateral and is seen as a linear extrinsic compression of the popliteal artery or medial displacement of the popliteal artery. Provocative maneuvers (dorsiflexion/plantarflexion) may be necessary to demonstrate these changes.

Essential Facts

• Cystic adventitial disease may be difficult to diagnose.

• The cysts can be identified with ultrasound or MRI. The best diagnostic study is MRI.

• Patients are typically young and active and have no reason to have vascular disease.

Pearls and Pitfalls

Always look for the above-mentioned possibilities in any young patient with sudden onset of claudication.

The most important aspect is clinical suspicion.

MRI will be diagnostic.

Surgery is the treatment of choice.

Always evaluate distal arterial patency. This condition may also be associated with arterial thrombosis.

Cyst aspiration may work but is usually associated with recurrence. It is better to avoid aspiration.

Case 2

Clinical Presentation

A patient who had elective knee surgery presents for inferior vena cava (IVC) filter removal. You are asked to evaluate the diagnostic cavagram.

Imaging Findings

(A) The diagnostic cavagram immediately before removal attempt. The cavagram in the present case is normal, showing an intact inferior vena cava (IVC) filter with no tilting. (B) A sequence during removal. The filter cone has been captured with a snare, and then a 9-Fr sheath has been advanced to collapse the legs of the IVC filter. (C) A cavagram after filter retrieval. The image shows an intact IVC.

Differential Diagnosis

• Normal cavagram; straightforward removalof an inferior vena cava filter: The case shows a straightforward IVC filter removal. The cavagram is normal. The filter is not tilted and there is no thrombus within the cava.

• IVC thrombosis: No signs of thrombosis are identified.

• IVC filter complication: The image shows an intact IVC filter with no tilting and no fractures.

Essential Facts

• IVC retrieval has gained importance in clinical practice.

• When released, retrievable IVC filters were considered to be suitable for long-term insertion as permanent devices.

• Clinical practice has demonstrated that retrievable filters are associated with unexpected complications—mainly, fractures and leg penetration beyond the IVC wall.

• The U.S. Food and Drug Administration released a letter in 2010 indicating that retrievable filters should be removed as soon as they are no longer required.

Pearls and Pitfalls

Try to identify the type of filter before attempting removal. Each IVC filter has different optimal removal times.

A frontal KUB is the best imaging study to identify the filter and to evaluate for fractures.

CT and MRI are suboptimal studies to identify the type of filter or the presence of filter fractures.

If the diagnostic venogram shows thrombus within the filter cone, and if it occupies more than 25% of cone surface, consider avoiding removal.

Case 3

Clinical Presentation

A 58-year-old woman with a history of breast cancer presents, and a surveillance CT scan is performed.

Imaging Findings

(A) A selected axial image from a noncontrast CT scan of the pelvis that shows a lytic lesion of the right iliac bone. There is discontinuity of the cortex (arrow). There is no soft tissue swelling or stranding, and no fluid surrounding the bony structure. (B) A selected axial image obtained during bone biopsy. A 19-gauge guiding needle has been advanced into the right iliac bone, and a fine needle aspirate was obtained using a 22-gauge Franseen needle. The guiding needle was advanced through the area of cortex discontinuity.

Differential Diagnosis

• Metastatic breast carcinoma to the right iliac bone: The images show a lytic lesion with no soft tissue abnormalities. In a patient with history of breast cancer, this is the most likely diagnosis.

• Osteomyelitis: Osteomyelitis of this site is unusual in the absence of the history of trauma or penetrating injury.

• Osteoporosis: Very unlikely. The contralateral iliac bone is of normal density for the patient’s age. Focal osteoporosis is unlikely.

• Multiple myeloma: Other bones should be evaluated. Multiple myeloma usually affects multiple bones.

Essential Facts

• Bone biopsy is important in the work-up of metastatic disease.

• The procedure may be quite painful if the cortex is intact.

• Bone biopsies can be frustrating. If cortex is intact, expect lower diagnostic yield (70-80%).

• If cortex is affected and soft tissue mass is present, the yield approaches 100%.

Pearls and Pitfalls

Always evaluate the lesion to be biopsied. The key to planning the procedure is the status of the cortex. If the cortex is intact, you will need a bone biopsy system and most probably the patient will need to be sedated.

If the cortex is involved, then bone biopsies are relatively straightforward. In these cases, a small guiding needle and a fine needle aspirate will be diagnostic.

Bone biopsies may be associated with fracture of the biopsied bone. The site of biopsy needs to be carefully evaluated before proceeding.

Case 4

Clinical Presentation

A 40-year-old woman presents with dizziness and gait abnormality.

Imaging Findings

(A) A selected image from a right internal jugular vein digital venogram. The image shows a > 90% stenosis at the base of the right internal jugular vein. (B) A spot film obtained during balloon angioplasty of the right jugular vein. The balloon is fully inflated. (C) A selected image from the right internal jugular vein obtained immediately after angioplasty. The stenosis has been treated successfully.

Differential Diagnosis

• Right internal jugular vein stenosis: The patient presented here had multiple sclerosis. Her dizziness improved after angioplasty. The clinical entity affecting these patients has been termed “chronic cerebrospinal venous insufficiency” (CCSVI). This patient had no history of previous jugular vein catheterization.

• Catheter-induced venous stenosis: This patient had no history of previous catheter insertions.

• Extrinsic compression: This patient had no adenopathy and no history of malignancy.

Essential Facts

• CCSVI is a topic of great controversy. It has its supporters but it has many more detractors. To date, the existence of CCSVI has not been proved, but there is a large number of patients who have shown significant improvement in their symptomatology after balloon angioplasty of the jugular veins.

• In its original description, CCSVI was thought to be strongly associated with multiple sclerosis.

Pearls and Pitfalls

The best way to evaluate these patients is with a multimodal approach. No single imaging study has high sensitivity or specificity for the diagnosis of CCSVI.

If noninvasive studies are positive, then it is worthwhile to study the patient with an invasive venogram.

The existence of CCSVI has not been proved. All work on this topic is considered to be investigational and experimental at this point.

Case 5

Clinical Presentation

A 65-year-old woman with end-stage renal disease presents with an occluded arteriovenous graft. She has a severe allergy to iodinated contrast media.

Imaging Findings

(A) A selected digital subtraction image obtained during a declotting procedure with the use of carbon dioxide as a contrast agent. The outflow vein is shown. There is a patent, self-expandable metallic stent. (B) A selected digital subtraction image obtained during the same declotting procedure, clearly showing the inflow anastomosis and inflow artery. The inflow artery is patent, as well as the inflow anastomosis. (C) A selected digital subtraction image obtained at procedure completion. Carbon dioxide digital subtraction image shows a widely patent outflow vein and outflow anastomosis.

Differential Diagnosis

• Graft declotting using carbon dioxide: The current case illustrates the use of CO2 in a patient with history of severe iodinated contrast allergy. The procedure was completed without the use of non-ionic contrast.

• Graft declotting using iodinated contrast: The image definition of the iodinated contrast is different from that generated with the use of carbon dioxide. The image is sharper when iodinated contrast is used. Iodinated contrast dissolves in blood; carbon dioxide displaces blood. The mechanism of image acquisition is different.

Essential Facts

• Carbon dioxide has been used as a contrast agent for more than a century. CO2 was initially used in the abdomen and retroperitoneum. Beginning in the 1960s, CO2 was administered intravenously to identify pericardial effusions.

• Dr. Hawkins published the first report of the use of carbon dioxide for angiography in 1982. The use of CO2 as an arterial and venous contrast agent has expanded in recent years.

Pearls and Pitfalls

Carbon dioxide is nonallergenic and non-nephrotoxic.

It has very low viscosity, which allows injection via very small catheters.

Careful injection technique is essential for the safe use of CO2 in angiography.

At the present time, CO2 is contraindicated for arterial use above the diaphragm because of the risk of cerebral CO2 embolism.

Case 6

Clinical Presentation

A 40-year-old woman who refuses a pregnancy test.

Imaging Findings

A spot film obtained before an angiographic procedure in this woman. The image shows an Essure intratubal sterilization device (arrows).

Differential Diagnosis

• Essure intratubal sterilization device: The current case shows an Essure intratubal sterilization device (Bayer, Whippany, NJ).

• Malpositioned intrauterine device: This is a possibility; however, the location and appearance of the Essure device is quite characteristic. No other intrauterine device has this same appearance.

• Postsurgical foreign body: This is also a possibility; however, as mentioned previously, the Essure device has a characteristic appearance.

Essential Facts

• The Essure system was approved by the U.S. Food and Drug Administration for permanent sterilization in 2002.

• It is a nitinol coil that is implanted in the office, under hysteroscopy. The procedure is an outpatient procedure. The Essure device has a characteristic appearance on plain films.

Pearls and Pitfalls

The Essure system is designed to induce fibrosis and tubal occlusion.

Effective and complete tubal occlusion by this device needs to be confirmed by hysterosalpingogram 3 months after insertion.

Several complications have been described after Essure insertion, including incomplete tubal occlusion, tubal perforation, intractable pain, bleeding, and unintended pregnancies.

Case 7

Clinical Presentation

A 59-year-old diabetic man presents with lower back pain and fever.

Imaging Findings

(A) Selected sagittal image from a diagnostic, noncontrast MRI shows abnormal soft tissue bulging at the L5/S1 level. There is moderate compression of the thecal sac. (B) Selected axial image of the L5/S1 space during disk aspiration. The image shows an 18-gauge needle within the abnormal area.

Differential Diagnosis

• L5/S1 pyogenic diskitis: The abnormal bulging in the L5/S1 space is suggestive of a disk infection. The cultures were positive for Corynebacterium striatum. Disk aspiration is important for diagnosis.

• Spinal tuberculosis or fungal infection: These are strong possibilities. Differential diagnosis is established with cultures of the abnormal tissue.

Essential Facts

• The most common mechanism of vertebral osteomyelitis and diskitis is hematogenous spread from a distant site. Direct trauma and postsurgical complications could also be causes of spinal infection.

• Symptoms can be nonspecific, but a leading symptom is back pain.

• Cross-sectional imaging (CT or MRI) is useful to establish the diagnosis.

Pearls and Pitfalls

The most accurate method to establish etiology is image-guided needle aspiration (guidelines from the Infectious Disease Society of America).

CT is recommended for diagnostic aspiration of the lumbosacral area. Tilting the gantry is useful to guide the needle tract in the optimal angle (see image A, above).

Fluoroscopic guidance is useful for the thoracic spine and upper lumbar spine.

Needle aspiration is 90 to 95% sensitive for diagnosis.

Fluoroscopic guidance of the lumbosacral area is difficult and may result in a prolonged, unsuccessful procedure or complications.

Case 8

Clinical Presentation

A 52-year-old woman presents with left leg swelling. Venogram was obtained in a prone position.

Imaging Findings

(A) A venous digital subtraction angiogram (DSA) obtained in the prone position—the left common iliac vein shows a 95% stenosis immediately caudal to the junction with the inferior vena cava. (B) A selected image from a venous DSA obtained 24 hours after catheter-directed infusion of tissue plasminogen activator. The appearance of the vein has improved, but there is a residual 60 to 70% stenosis. (C) A selected image from a venous DSA after iliac vein stent placement. The left iliac vein is now widely patent.

Differential Diagnosis

• May–Thurner syndrome: The case is diagnostic. The stenosis within the left common iliac vein shows the characteristic signs of May–Thurner syndrome. This stenosis is caused by compression of the left common iliac vein by the right common iliac artery.

• Venous fibrosis: This is a possible diagnosis but in the absence of an underlying cause, this is low in the differential.

• Spontaneous venous thrombosis: Very rare in this location, especially in the absence of an underlying cause.

Essential Facts

• May–Thurner anatomy is the compression of the left common iliac vein by the right common iliac artery. This anatomic relationship results in left lower extremity swelling, pain, and venous thrombosis.

• The compression of the left iliac vein by the right iliac artery and its clinical consequences were identified and described by Virchow in 1851.

• Clinical presentation and history are essential components for diagnosis.

Pearls and Pitfalls

Cross-sectional imaging is the key to diagnosis.

Endovascular stent placement has been accepted as the treatment of choice for symptomatic patients who do not respond to conservative therapy.

For patients presenting with extensive iliofemoral deep venous thrombosis, catheter-directed thrombolysis followed by stent placement is an accepted therapeutic option.

Clinical suspicion is the key. Many patients with May–Thurner syndrome go undiagnosed.

Case 9

Clinical Presentation

A 62-year-old woman presents with gross hematuria.

Imaging Findings

(A) A selected axial image of a contrast-enhanced CT scan of the abdomen. The CT scan shows a saccular structure arising from the left renal artery (arrow). No extravasation is identified. (B) A selected image from a selective left renal artery digital subtraction angiogram (DSA). The image shows a complex left renal artery aneurysm. The artery has a beaded appearance. (C) A selected image from a selective left renal artery DSA after coil embolization of the aneurysm. Note preservation of flow to renal parenchyma.

Differential Diagnosis

• Aneurysm of the left renal artery; patient with fibromuscular dysplasia: Characteristic appearance by CT scan and arteriogram.

• Pseudoaneurysm of the renal artery: In the absence of a traumatic or inflammatory cause, this diagnosis is less likely.

• Renal cell carcinoma: Renal cell carcinoma is identified as a solid, hypervascular mass in the kidney parenchyma. On occasion, more central aneurysms may appear as solid masses.

Essential Facts

• Renal artery aneurysms are uncommon. The true incidence in the general population is unknown.

• Association between fibromuscular dysplasia (FMD) and renal artery aneurysms has been described.

• Symptoms include pain, hematuria, and hypertension.

Pearls and Pitfalls

Indications for treatment include symptoms (pain or hematuria), enlargement over time, or size larger than 2 cm.

Selective coil embolization is emerging as a suitable minimally invasive option.

Careful selective embolization with preservation of renal parenchyma is crucial.

Aneurysm should not be confused with a solid tumor/mass.

Case 10

Clinical Presentation

A 48-year-old man, who underwent laparoscopic resection of a left renal cell carcinoma 3 weeks prior, presents with hematuria and back pain.

Imaging Findings

(A) A selected axial image of a contrast-enhanced CT scan of the abdomen. A large saccular structure with avid contrast enhancement is identified in the mid-pole of the left kidney (arrow). (B) A selected digital subtraction angiography (DSA) image from a selective left renal arteriogram. The large saccular structure arises from a segmental branch of the lower pole (arrow). (C) A selected DSA image from a selective left renal arteriogram after embolization with direct injection of thrombin within the saccular structure and coil embolization of the supplying lower pole artery. Minimal parenchymal loss is noted.

Differential Diagnosis

• Iatrogenic pseudoaneurysm of the left kidney: This complication is increasingly reported in patients undergoing laparoscopic partial nephrectomy.

• Mycotic aneurysm of the renal artery: A good option if this patient did not have the surgical history. Spontaneous lesions like the one presented here are very unusual.

• Postsurgical hematoma: A strong possibility; however, in the absence of hemodynamic instability and perirenal soft tissue stranding, this option is less likely.

Essential Facts

• This is a rare complication, recently described after laparoscopic partial nephrectomy.

• Patients present with back pain, dysuria, and hematuria.

• Endovascular management of this complication is the first line of treatment.

• Coil placement on the end-artery should suffice to eliminate the lesion. Thrombin injection is optional and should be performed with extreme care.

Pearls and Pitfalls

Contrast-enhanced CT is the cross-sectional imaging method of choice for diagnosis.

In patients with borderline renal function, a color Doppler evaluation may be diagnostic.

High clinical suspicion is crucial.

Endovascular treatment may be associated with distal embolization or arterial dissection.

If treated with thrombin, this needs to be administered with extreme care and in increments of 100 units per injection.

Case 11

Clinical Presentation

A 58-year-old man underwent Whipple surgery for pancreatic cancer. Shortly after surgery, the patient presents with hemodynamic decompensation.

Further Work-up

Imaging Findings

(A) Selected axial image of a contrast-enhanced CT scan of the abdomen. The image shows extravasation of contrast anterior to the splenic artery and portal vein. There is compression and irregularity of the portal vein lateral to the site of extravasation. (B) Arteriogram shows an actively bleeding perforation of the splenic artery. (C) Digital subtraction angiogram obtained after successful coil embolization of the splenic artery. No further extravasation is demonstrated.

Differential Diagnosis

• Iatrogenic splenic artery laceration: This is demonstrated by active extravasation of the splenic artery on arteriogram. The CT angiogram was positive for a bleed, but the source could not be determined. Arteriogram demonstrated the injury to the splenic artery.

• Iatrogenic portal vein injury: Definitely an option, and the differential diagnosis from a cross-sectional imaging standpoint is extremely difficult. The arteriogram provides the answer.

Essential Facts

• Bleeding after pancreaticoduodenectomy occurs in 4 to 16% of patients.

• Endovascular evaluation of a patient with bleeding after pancreaticoduodenectomy is usually recommended if the patient is stable. If unstable, surgical revision is recommended.

Pearls and Pitfalls

Endovascular methods are useful in the evaluation and management of patients with bleeding after pancreatic surgery.

Stent graft placement is discouraged in patients with an active source of infection.

A vascular injury of the midsegment of the splenic artery can be treated with coil embolization. Flow to the spleen is provided by short gastric collaterals or collaterals from the gastroepiploic artery.

Even if the patient is stable, if CT findings are diagnostic of a vascular injury, an invasive evaluation should not be delayed.

Precise identification of the bleeding source may be difficult by cross-sectional imaging.

Case 12

Clinical Presentation

A 46-year-old woman with Crohn’s disease presents with fever, elevated white blood cell count, and pain.

Further Work-up

A transvaginal drain was performed. After drain removal, the patient had a massive transvaginal bleed. An arteriogram was performed.

Imaging Findings

(A) Transvaginal ultrasound image obtained during drainage procedure shows a bright echogenic image consistent with an acute bleed (arrow). The bleed was controlled by the drainage catheter. (B) Arteriogram after catheter removal shows a discrete irregularity within the left uterine artery consistent with a uterine artery laceration (arrow). (C) Arteriogram after coil embolization of the mid-uterine artery. Complete control of the acute bleed was achieved after embolization.

Differential Diagnosis

• Iatrogenic uterine artery laceration: There is no good differential. Both the images and the clinical course are diagnostic.