Transcript Lezioni di radiologia

Radiology course
PERIPHERAL VASCULAR
STENOSIS AND THROMBOSIS
Clinical cases
Istituto di
Radiologia
Ilaria Fiorina
Lower extremity deep-vein thrombosis
CASE 1
•
Patient presenting with sweeling in one leg, pain and
tenderness when standing or walking
• Discoloration of the skin
• Enlargement of the superficial veins
Lower extremity deep-vein thrombosis
•
Deep vein thrombosis is a blood clot that develops in a vein deep in the
body. The clot may partially or completely block blood flow through the
vein. Most DVTs occur in the lower leg, thigh or pelvis, although they also
can occur in the arm, brain, intestines, liver or kidney.
• Even though DVT
itself is not
life-threatening,
the blood clot has
the potential to
break free and
travel through the
bloodstream, where
it can become
lodged in the blood
vessels of the lung
(known as a
pulmonary embolism).
Case 1
• First study?
–
–
–
–
US lower extremity with Doppler
CT venography lower extremity with contrast
MR venography lower extremity without contrast
X-ray venography pelvis and lower extremity
Lower extremity deep-vein thrombosis
Us lower extremity with Doppler
•
•
•
•
Intramural thrombus
Incompressibility
> vein diameter
No flow with Doppler
• Second study?
– CT w contrast
– MRI w/o contrast
– X-ray venography
Lower extremity deep-vein thrombosis
CT venography with contrast
• Filling defect in the right popliteal vein
Role of Computed Tomography and Magnetic Resonance Imaging for Deep Venous Thrombosis and Pulmonary
Embolism. Circulation. 2004; 109: I-15-I-21
Lower extremity deep-vein thrombosis
MRI venography without contrast
(using TOF and phase-contrast technique)
Ovarian vein thrombophlebitis in a 44-year-old woman.
Role of Computed Tomography and Magnetic Resonance Imaging for Deep Venous Thrombosis and Pulmonary
Embolism. Circulation. 2004; 109: I-15-I-21
Lower extremity deep-vein thrombosis
How is DVT treated?
• Medications: anticoagulants (warfarin or heparin) to stop clots from getting bigger and to
prevent a blood clot from moving.
• Graduated compression stockings to reduce the chronic swelling.
• Elevation of the affected leg to improve circulation and decrease swelling.
DVT Treatment Procedure:
- Catheter-directed thrombolytic therapy
- Inferior vena cava filters
Inferior vena cava filters
Inferior vena cava filters are used when you cannot take any of the blood thinners, or if you
are taking blood thinners and continue to develop clots. The filter can prevent blood clots
from moving from the vein in your legs to the lung (pulmonary embolism). During a small
surgical procedure, the filter is inserted through a catheter (thin tube) into a large vein in the
groin or neck, then into the vena cava (the largest vein in the body). It can catch clots as they
move through the body to the lungs. This treatment will help prevent a pulmonary embolism.
Claudication
CASE 2
• Patient presenting with significant pain and discomfort
during walking, relieved by rest; lower extremity cramping
• Discolored skin
• Ulcerations, gangrene
Claudication
Claudication is most often a
symptom of peripheral artery
disease.
In
peripheral
artery
disease, the arteries that supply
blood to the limbs are damaged,
usually as a result of atherosclerosis,
that makes arteries hard and
narrow. That's because the arteries
get clogged with clumps of fat,
cholesterol and other material,
called atherosclerotic plaques.
These plaques can make arteries so
narrow that less blood can flow
through them.
Claudication
• First study?
–
–
–
–
US lower extremity with Doppler
CT angiography lower extremity with contrast
MR angiography lower extremity w/o contrast
X-ray angiography pelvis and lower extremity
Claudication
US arterial lower extremity with Doppler
• US to diagnose the location, degree and extent of the stenosis
• Doppler to analyze the velocity of blood flow
Claudication
CT angiography lower extremity
Right lower limb ischemia in a 57-year-old male patient
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A
C
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B
D
Case courtesy of Dr Roberto Schubert, Radiopaedia.org
Claudication
CT angiography lower extremity
3D reconstruction
MIP reconstruction
Case courtesy of Dr Roberto Schubert, Radiopaedia.org
Claudication
MR angiography lower extremity

Right lower leg and intermittent claudication (75-years-old)
Case courtesy of Dr Roberto Schubert, Radiopaedia.org
Claudication
How is Claudication treated?
Lifestyle changes, such as quitting smoking and participating in a
regular exercise regimen
Medications: aspirin or other medications to avoid blood clotting,
such as clopidogrel (Plavix), Additionally, if necessary, a cholesterollowering drug (statin) to lower cholesterol levels.
Angioplasty. This is a procedure that widens damaged arteries using a
narrow tube that travels through your blood vessels and has an
inflatable balloon on the end that can help improve circulation. A stent
is often implanted at the same time to keep the artery propped open
Vascular surgery
Angioplasty/ Stenting
Angioplasty/ Stenting
Renovascular hypertension
CASE 3
•
Patient (generally young woman) presenting with
hypertension refractory to antihypertensive medication.
• Diminished kidney function
Renovascular hypertension
FMD is a non-atherosclerotic, non-inflammatory
vascular disease that causes abnormal growth
within the vessel wall. It can involve the intima,
media or adventitia.
The medial type is characterized by thickening
of the media with collagen formation.
The causes of FMD are still unknown.
Some of the factors that may play a role
include:
Hormonal influences (most commonly in
women).
Genetics: About 10 percent of cases are familial
(inherited).
Internal mechanical stress, including trauma or
stress to the artery walls.
Loss of oxygen supply to the blood vessel wall
Renovascular hypertension
• First study?
–
–
–
–
Renal duplex US with Doppler
CT angiography with contrast
MR angiography w/o contrast
Renal angiography
Renovascular
hypertension
Renal duplex US with Doppler
Localized gross turbulence and increased peak systolic velocity in the proximal
right renal artery. Left renal artery has normal flow velocities.
Case courtesy of Dr O’Donnell, Radiopaedia.org
Renovascular hypertension
CT angiography with contrast
MPR
MIP
- multiple stenosis and the 'string-of-beads' appearance
Case courtesy of Dr O’Donnell, Radiopaedia.org
Renovascular hypertension
MR angiography w/o contrast
- multiple stenosis and the 'string-of-beads' appearance
Renovascular hypertension
How is renovascular
hypertension treated?
- Lifestyle changes: control high blood pressure, cholesterol, diabetes, and heart disease.
Imaging study (duplex ultrasound, MRA or CTA) performed at regular intervals, generally
every year, to monitor disease progression.
- Medications: antiplatelet (aspirin)
- Treatment procedures:
Percutaneous angioplasty of the renal arteries is recommended. Similar to the procedure
used to treat blockages in the heart arteries, renal angioplasty involves placement of a
balloon-mounted catheter inside the artery at the site of the narrowing or blockage. The
catheter is guided through the blood vessel with the aid of a special x-ray machine.
The balloon is inflated to re-open the blood vessel, and then the balloon and the catheter
are withdrawn.
Renal angioplasty
CAD/CAS
CASE 4
•
Patient presenting with TIA (Transient Ischemic Attack)
• Smoking, hypertension
• Diabetes, obesity
CAD/CAS
Carotid artery disease, also
called carotid artery stenosis,
is the narrowing of the carotid
arteries, usually caused by
atherosclerosis.
Plaque buildup can lead to
narrowing or blockage in the
carotid artery which, when
significant, can put an
individual at increased risk for
stroke.
CAD/CAS
• First study?
–
–
–
–
–
Carotid duplex US with Doppler
Cerebral CT without contrast
Cerebral CT angiography with contrast
Cerebral MR angiography w/o contrast
Carotid angiography
CAS/CAD
Carotid duplex US with Doppler
• US to diagnose the location, degree and extent of the stenosis
• Doppler to analyze the velocity of blood flow
CAS/CAD
Cerebral CT without contrast
Parietal calcifications in C4 segment of ICA
Case courtesy of Dr Di Muzio, Radiopaedia.org
CAS/CAD
CT angiography with contrast
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CTA: bilateral atherosclerotic mixed plaques on bulbs, with subocclusion of left ICA
Case courtesy of Dr Di Muzio, Radiopaedia.org
CAS/CAD
CT angiography with contrast (pre-op planning)
CTA: severe stenosis of left ICA, with non-circumferential calcification of plaque at bifurcation
Case courtesy of Dr Yang, Radiopaedia.org
CAS/CAD
Cerebral MRI with or without contrast
MRI showing multiple fresh infarcts
How is CAD/CAS treated?
- Lifestyle changes: quit smoking, control high blood pressure, cholesterol, diabetes,
and heart disease. Eat foods low in saturated fats, cholesterol, and sodium. Achieve
and maintain a desirable weight. Exercise regularly.
- Medications: antiplatelet (aspirin), statins
- Treatment procedures:
Carotid endarterectomy (CEA): traditional surgical treatment, under general
anesthesia, through an incision in the neck, the surgeon removes the plaque from the
artery and when the plaque removal is complete, the surgeon stitches the vessel closed.
Carotid angioplasty and stenting (CAS): During the procedure, a balloon catheter is
inserted through a sheath in a blood vessel. With X-ray guidance, the catheter is placed through
the blood vessel and directed to the carotid artery at the site of the blockage or narrowing. A
specially designed guidewire with a filter is placed beyond the area of blockage or narrowing.
Once in place, the balloon tip is inflated for a few seconds to open or widen the artery. The filter
(called the embolic protection device) collects any debris that may break off of the blockage. A
stent (a small mesh tube) is placed in the artery and opens to fit the size of the artery. The stent
stays in place permanently and acts as a scaffold to support the artery walls and keep the artery
open. After several weeks, the artery heals around the stent.
Carotid Artery Stenting
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Case courtesy of Dr Sorrentino, Radiopaedia.org
CMI
CASE 5
•
Patient presenting with abdominal pain after meals,
weight loss, fear of eating, nausea and/or vomiting
•
•
•
•
Smoking
Hypertension
Diabetes
History of cardiovascular disease
CMI
The primary vessels supplying the
mesentery are as follows:
- Celiac trunk - Foregut
- SMA - Midgut
- Inferior mesenteric artery (IMA) Hindgut
Chronic mesenteric ischemia (CMI)
usually results from long-standing
atherosclerotic disease of 2 or
more mesenteric vessels. Other
nonatheromatous causes of CMI
include the vasculitides, such as
Takayasu arteritis. Symptoms are
caused by the gradual reduction in
blood flow to the intestine.
CMI
• First study?
–
–
–
–
–
Gastrointestinal X-rays
GI duplex US
Abdominal CT with contrast
Abdominal MRI
Mesenteric angiography
CMI
GI duplex US with Doppler
• US to detect proximal arterial stenosis or occlusion
- Peak systolic velocity greater than 275 cm/sec
- End-diastolic velocity greater than 45 cm/sec
Duplex US findings in isolated
stenosis of the CA.
Lateral US image obtained in Doppler mode shows major
poststenotic turbulence and Doppler aliasing, which
indicate a stenosis of greater than 75%.
Chronic Mesenteric Ischemia: Imaging and Percutaneous Treatment. Radiographics, 2002
CMI
Abdominal CT with contrast
Chronic Mesenteric Ischemia: Imaging and Percutaneous Treatment. Radiographics, 2002
CMI
Abdominal MR angiography

CMI
How is CMI treated?
Anticoagulant medications, such as Coumadin (warfarin - a bloodthinner), to reduce the risk of blood clots.
Angioplasty and stenting: A balloon catheter is used to attempt to
open the artery and a small stent is placed inside the artery to
keep it open.
Surgery may be performed to remove plaque (endarterectomy),
bypass the blocked vessel to restore blood flow to the intestines,
or remove or repair an aneurysm. The surgeon may use autologous
bypass grafts (patient’s own blood vessels) or artificial grafts during
the bypass procedure.
CMI
Mesenteric angiography
Chronic Mesenteric Ischemia: Imaging and Percutaneous Treatment. Radiographics, 2002
Thank you