Disclosure:
Have acted as consultant for:SiemensBraccoLantheusNo bearing on the contents of this lecture
Some uses of devices shown are “off-label”
DISCLAIMER:VIR not the same as diagnosticWe are simple folkFocus on management, diagnoses straightforward
Key Points
NOTABLE:
more common in women, 65% bilateral
CLASSIC DESCRIPTOR:
“String of beads” appearance of renal artery
+/- webs
+/- stenosis
PEARL:
mid/distal renal artery vs. ostial/proximal 1/3
5 types, medial fibroplasia (type II) most common
1
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Key Points
TREATMENT:
endovascular preferred
angioplasty alone, no stent
1
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Differential Diagnosis
Vasculitis
Fibromuscular dysplasia
Congenital
2
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Atherosclerosis
Atherosclerosis
Atherosclerosis
Key Points2
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NOTABLE:
<10% cases of hypertension due to RAS
CLASSIC DESCRIPTOR:
Eccentric, ostial narrowing of renal artery with associated atherosclerotic aorta
PEARL:
>50% stenosis or >10% systolic pressure drop across lesion considered hemodynamically significant
Key Points
TREATMENT:
MEDICAL
endovascular treatment for:
failed medical therapy
renal salvage (ie. renal failure)
flash pulmonary edema
endovascular treatment is primary stent
balloon expandable for high radial force and accuracy of placement
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Differential Diagnosis
Atherosclerosis
Atherosclerosis
Atheroscelrosis(trauma/iatrogenic, vasculitis)
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Key Points3
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NOTABLE:
common cause of unilateral claudication
CLASSIC DESCRIPTOR:
focal, short, eccentric stenosis
PEARL:
best, most durable treatment for all iliac lesions is surgical bypass
Key Points
TREATMENT:
best treatment is surgical bypass
many patients not candidates
multiple comorbidities
best lesions for angioplasty
concentric
short
non-calcified
stenting in external iliac artery optional
self expanding stent best
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Key Points4
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NOTABLE:
iliac bifurcation lesions extension of aortic disease
CLASSIC DESCRIPTOR:
bilateral calcified narrowing of iliac bifurcation
PEARL:
Treatment is with “kissing” balloons or stents
Key Points
TREATMENT:Aortobiiliac or aortobifemoral bypass graft
most durableEndovascular
kissing stents/balloons for simultaneous treatment of both sides or to protect unaffected side from
occlusion/dissectionballoon vs. self expanding stents
higher radial force, precise position
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Differential Diagnosis
Atherosclerosis
Vasculitis
Extrinsic compression (not truly median arcuate ligament “syndrome”)
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Key Points5
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NOTABLE:
extrinsic compression of celiac axis by median arcuate ligament
CLASSIC DESCRIPTOR:
J-shaped appearance of proximal celiac artery
PEARL:
stenosis gets worse with expiration
treatment is conservative or surgical. Endovascular treatment not appropriate
Key Points – OPENING
Presentation Title - Subtitle
Not all lesions require treatment
Angioplasty is not the only treatment
Best lesions for angioplasty:
- short, concentric, non-calcified
Stenting for bailout, ostial lesions
Balloon expanding stents - ostial lesions
Self expanding stents – flexible/mobile anatomy
Diagnosis?
Treatment options?
What is the most devastating potential complication of endovascular treatment?
99
Differential Diagnosis
True aneurysm
Mycotic aneurysm
Arteriovenous fistula
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Key Points6
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NOTABLE:
Common complication of femoral artery complication.
Presents with bruising, palpable lump
CLASSIC DESCRIPTOR:
Yin-yang appearance. To-and-fro flow in neck.
PEARL:
Small (<2cm) pseudoaneurysms may resolve spontaneously
Key Points
TREATMENT:
expectant (for small lesions)
ultrasound graded compression
percutaneous thrombin injection
small needle
500-1000U thrombin
must have short neck, no AVF
surgical repair
stent graft
6
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Differential Diagnosis
Angiodysplasia
Neoplasia (polyp/carcinoma)
Colitis
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Key Points7
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NOTABLE:
divericulosis accounts for 65% of LGI hemorrhage
CLASSIC DESCRIPTOR:
extravasation of contrast, pooling on delayed phase, shape of diverticulum
PEARL:
do not image an unstable patient with lower GI hemorrage – take them straight to angio suite
Key Points
MANAGEMENT:
stabilize patient
if stable – image (CTA, Tc99 RBC scan)
if actively bleeding – to angio for diagnosis/treatment
treatment is embolization
superselective coil embolization
particles risk of ischemia
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Differential Diagnosis
Endoleak classification
Type I – inadequate seal proximally or distally
Type II – retrograde flow via collateral
Type III – graft failure, component separation
Type IV – porosity of graft
Type V - endotension
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Key Points8
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NOTABLE:
Type II endoleaks post EVAR are common and usually managed expectantly
Type I endoleaks more common in grafts without suprarenal fixation or in large/short necks
CLASSIC DESCRIPTOR:
contrast outside endograft, within aneurysm sac
PEARL:
Delayed imaging improves sensitivity for detection of endoleak
Key Points
TREATMENT:Type 1 endoleak
treated by extension of graft or buttress with balloon expandable stent
Type 2 endoleaktreated by embolizationdirect sac puncture vs. transarterial
Type 3 endoleaknew graft within old graft
Type 4 endoleak, usually intraoperative and resolve spontaneously
Type 5 endoleak – no treatment
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Differential Diagnosis
Secondary varicocele
- retroperitoneal mass
- renal vein/IVC occlusion
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Key Points9
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NOTABLE:
common cause of palpable scrotal mass
veins > 3mm on ultrasound are diagnostic
CLASSIC DESCRIPTOR:
“bag of worms” on ultrasound
PEARL:
most often “idiopathic”, look for a cause in cases of isolated right-side varicocele
Key Points
TREATMENT:
endovascular (embolization) vs. surgical (ligation)
both are “minimally invasive”
both have comparable outcomes
embolic material of choice is coils for large vessel occlusion
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Differential Diagnosis
Sarcoid/TB
Neoplasm
Airway trauma
Vasculitis
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Key Points10
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NOTABLE:
defined as >500cc hemoptysis in 24 hours
multiple causes, usually blood supply is by hypertrophied bronchial artery
CLASSIC DESCRIPTOR:
hypertrophied bronchial artery with abnormal parenchymal stain +/- shunting to pulmonary artery/vein
NB - active extravasation not commonly seen
PEARL:
mainstay of therapy is bronchial embolization – BEWARE THE ANTERIOR SPINAL ARTERY
Key Points
TREATMENT:
particle embolization of bronchial artery
no coils – won’t be able to treat recurrence
BEWARE THE ANTERIOR SPINAL ARTERYvariable bronchial artery anatomy
most commonly right intercostobronchial trunk, left bronchial artery
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Key Points - CLOSING
Sometimes surgery is the answer
Interventional options:
Embolization, covered stent, thrombin
Types of embolic agents:
permanent (PVA, glue, coils) vs temporary (gelfoam)
Coils are akin to surgical ligation
- “proximal” occlusion
- potential for collateral formation
Particles/glue
- “distal” occlusion, capillary/arteriolar level
- no collaterals, risk for ischemia
Presentation Title - Subtitle
Probable diagnosis?
Treatment options?
What kind of tube would you use for percutaneous intervention?
1212
Differential Diagnosis
Dysplastic nodule
Hemangioma
FNH-like lesion
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Key Points11
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NOTABLE:
Very common in far east, increased incidence in north america
CLASSIC DESCRIPTOR:
Arterially enhancing nodule with washout in cirrhotic liver
PEARL:
Any arterially enhancing lesion >2cm in a cirrhotic liver is HCC until proven otherwise
Only cure is liver transplantation
Key Points11
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TREATMENT:
Only curative treatment for HCC is transplant
Surgical resection for surgical candidates
RFA for non-surgical candidates
+/- lesions ≤ 2.5cm
chemoembolization
radiotherapy
sorafenib
Risks of RFA: hemorrage, infection, bile duct injury, needle tract seeding, colon/GB injury
Differential Diagnosis
Pancreatic adenoCa
Focal pancreatitis
Metastasis
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Key Points12
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NOTABLE:
most commonly present in pancreatic head.
CLASSIC DESCRIPTOR:
ill-defined hypoattenuating pass pancreatic head
PEARL:
Most unresectable
Key Points12
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PERCUTANEOUS BIOPSY:
ultrasound vs. CT guided
may go transgastric if needed
risks:
hemorrage
infection
tumour seeding very rare
bowel injury
coaxial technique
core biopsy preferred
Differential Diagnosis
Non-infected hydronephrosis
Pre-existing UPJ obstruction
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Key Points13
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NOTABLE:
99% of renal calculi depicted on non-contrast CT
Most calculi impacted at UVJ, UPJ or pelvic brim
CLASSIC DESCRIPTOR:
radioopaque calculus with associated renal enlargement, perinephric stranding, hydronephrosis/hydroureter
PEARL:
Infected calculi, hydronephrosis in solitary kidney or electrolyte disturbances are indications for urgent management
Key Points13
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TREATMENT:
renal decompression
urgently for sepsis, solitary kidney, electrolyte disturbance
options:
percutaneous nephrostomy/ nephroureterostomy
percutaneous JJ stent
cystoscopic JJ stent
risks of percutaneous therapy
worsening sepsis, hemorrhage/AVF, other organ injury
Differential Diagnosis
Perforated colon cancer
Abscess from inflammatory bowel disease
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Key Points14
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NOTABLE:
prevalence of diverticulosis @ 50% after age 70
complications include diverticulitis, fistula, muscular hypertrophy, lower GI bleed
CLASSIC DESCRIPTOR:
rim enahancing fluid collection in sigmoid mesentary, adjacent to inflamed diverticulum
PEARL:
always do elective sigmoidoscopy/colonoscopy to rule out underlying malignancy
Key Points14
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TREATMENT:
medical
antibiotics, often successful for small collections
surgery
two stage – hartman’s with colostomy, then reversal
percutaneous
definitive management
delay surgery to elective, 1-stage procedure
Key Points14
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PERCUTANEOUS TREATMENT:
US guidance – faster, safer
CT guidance – not all lesions can be seen by ultrasound
deep
gas obscuring view
Seldinger vs. Trochar
safer vs. faster, less painful
Tube size – 10 French or bigger for pus, thick bile, pleural fluid
Key Points14
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WHAT IS FRENCH SIZE?!?!?!:
Circumference of tube in mm
French size/3 = diameter
Eg. 8Fr tube is ~ 2.7mm
- suitable for simple fluid
Key Points15
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NOTABLE:
Hilar cholangiocarcinoma, known as klatskin tumour
Often unresectable
CLASSIC DESCRIPTOR:
Hilar soft tissue mass with bilateral biliary obstruction. Lack of communication of left and right sided ducts
PEARL:
Often require biliary drainage to restore bilirubin and allow safe administration of chemotherapy
Key Points15
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TREATMENT:
Medical
Surgical
Endoscopic
plastic stents
can’t be removed without endoscopy
limited access
more appropriate for low lesions
if the GB is distended – ERCP
Percutaneous
Key Points15
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PERCUTANEOUS TREATMENT:
Goal is to decompress as much liver as possible
Goal is internal drainage if possible
Internal/external biliary drainage catheter
minimize manipulation if cholangitis
Either side if right and left side communicate
Right side first vs. bilateral tubes if not
Key Points – NEEDLES/DRAINS
Presentation Title - Subtitle
Procedures are not without risk
Bleeding, infection, other organ injury
Internal drainage always desirable
US faster, safer when possible
Seldinger vs. trochar
- safer, slower, more painful