Cases vascular 2 Radiology Reporting Sample

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1. Vascular Cases 26-50

2. 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Case directory

3. Case 26

4. Scleroderma Case findings: Segmental occlusions of the lateral proper palmar artery digital arteries of the 2 nd – 5 th digits Inflammatory changes involving small vessels and capillary bed MC UE, including multiple focal stenoses and occlusions involving the ulnar, palmar, and proper digital arteries Radial artery and commonly digital arteries are rarely involved Collateral channels are sparse : indicating disease affecting the capillary beds Majority of theses patients experience Raynaud's phenomenon

5. Scleroderma DDX: Collagen vascular disease: Scleroderma SLE Occlusive arterial diseases: Atherosclerosis Buerger's disease (thromboangiitis obliterans) Thromboembolism Vasospastic diseases: Raynaud's disease Raynaud's phenomenon Case directory

6. Case 27 Early phase of aortogram

7. Late phase of aortogram

8. Hemangioendothelioma Case findings: Aortogram: prominent hepatic artery and diminution of the aortic caliber below the liver Late phase of aortogram: multiple large vascular spaces within the liver Benign capillary tumour almost exclusively found in children Diagnosed first few weeks of life Undergoes a rapid proliferative phase and then regression Complications during proliferative phase: High-output CHF Kassabach-Merritt syndrome: consumptive coagulopathy, anemia and jaundice Case directory

9. Case 28 Celiac arteriogram Arterial phase Venous phase

10. Insulinoma Case findings: Hypervascular mass overlying the region of the body of the pancreas DDX: Pancreatic neuroendocrine tumor: insulinoma, glucagonoma, gastrinoma, VIPoma, somatostatinoma Hypervascular metastasis: melanoma, RCC Hypervascular gastric tumor: leiomyoma, leiomyosarcoma

11. Multiple endocrine neoplasia MEN-I (Wermers syndrome): Pituitary adenoma Parathyroid hyperplasia / adenoma Pancreatic islet-cell tumor MC gastrinoma (ZE syndrome) 50% of Z-E ==> MEN-1 MEN-IIa (Sipples syndrome) Medullary thyroid carcinoma Parathyroid hyperplasia Pheochromocytoma (MC bilateral) Case directory

12. Case 29 Celiac arteriography Arterial phase Portal venous phase

13. Splenic vein occlusion Case findings: Arterial phase: normal anatomy and no discreet mass or hypervascular region PV phase: occlusion of splenic vein at its junction with SMV Large collateral (right gastroepiploic vein) drains the splenic vein, reconstituting the SMV and portal venous system Etiology: Pancreatic tumor Chronic pancreatitis Hypercoagulable state Cirrhosis Case directory

14. Case 30

15. Carotid body tumor Case findings: Hypervascular mass arising between the origins of the right internal and external carotid arteries Mass splays the bifurcation MRI: salt and pepper appearance, represent flow voids Carotid space contains: Carotid artery, jugular vein, CN X, lymphatic tissue DDX of carotid space mass: Vascular: aneurysm, jugular vein thrombosis Benign: carotid body tumor, schwannoma, neurofibroma Malignant: metastasis, lymphoma

16. Paraganglioma (glomus tumor, chemodectoma) Hypervascular tumor Originate from extra-adrenal neuroendocrine tissues: have a chemoreceptor function and are located near nerves and vessels Classified according to site of origin: Carotid body : CCA bifurcation Glomus jugulare : jugular foramen (presents with pulsatile tinnitus) Glomus tympanicum : cochlear promontory Glomus vagale : carotid space near nodose ganglion of vagal nerve Case directory

17. Case 31

18. Marfan’s syndrome Case findings: Aortogram: catheter is in true lumen Dissection flap initiating distal to LSA Incidentally notes is a bovine arch (common origin of innominate and LCA) Aortic root is dilated down to aortic valves Tulip bulb configuration of proximal aorta Involves sinuses of Valsalva and proximal aortic root Cystic medial degeneration: aortic dilation, AR, dissection Aortic dilation starts at aortic annulus

19. Marfan’s syndrome DDX ascending aorta aneurysm: Marfan's syndrome Ehlers-Danlos Syndrome, type IV Homocystinuria Isolated annuloaortic ectasia with dissection Sinus of Valsalva aneurysm Syphilitic aortitis: Spares annulus and aortic valves, tree-bark calcifications Case directory

20. Case 32

21. Choledochal cyst, type 1 DDX: Choledochal cyst Pancreatic pseudocyst Duplication cyst of the duodenum Duplicated gallbladder (rare)

22. Choledochal cyst Type 1: MC, fusiform dilatation of CBD Type 2: diverticulum of CBD Type 3: dilatation of intraduodenal portion of CBD ( choledochocele ) Type IV: Type IV-a: intrahepatic and extrahepatic ductal dilatation Type IV-b: extrahepatic ductal dilatation Type V: Caroli’s disease (MC intrahepatic ductal dilatation)

23. Choledochocele (choledochal cyst, type 3) Intra-duodenal segment of the CBD demonstrates a small focal bulbous dilatation Case directory

24. Case 33 ICA PSV: 370 cm/sec ICA EDV:180 cm/sec 80-99% stenosis

25. Carotid artery stenosis Criteria for CEA: Stenosis > 70% in symptomatic patients (PSV > 200 cm/sec) Normal PSV of ICA: < 100 cm/sec As stenosis increases, PSV increases as follows: % diameter stenosis PSV 0 - 15 <100 16 - 49 100 - 125 50 - 75 125 - 250 > 75 > 250 and/or 125 (EDV) Occlusion No Flow Case directory

26. Case 34

27. Middle aortic syndrome, NF Case findings (abdominal aortogram): Aorta is small in diameter 🡪 suggestive of diffuse hypoplasia Superior left RA has near occlusive ostial stenosis Middle right RA has a high-grade stenosis Other renal arteries are also affected High grade stenosis is present in a hypoplastic left common iliac artery with numerous transpelvic collaterals

28. Middle aortic syndrome, NF DDX: Severe progressive atherosclerosis Radiation arteritis Takayasu's arteritis Neurofibromatosis Williams syndrome Both Takayasu's arteritis and NF involve branch vessels such as the renal artery Case directory

29. Case 35 Portal venogram Early phase Delayed phase

30. Gastric and esophageal varices Case findings (portal venogram): Numerous tortuous, dilated vessels with retrograde flow in region of the gastric fundus and GEJ Large collateral vein extending inferiorly from splenic hilum to left renal vein Gastric and esophageal varices 🡪 due to portal hypertension with spontaneous splenorenal shunt

31. Gastric and esophageal varices

32. Colonic (hemorrhoidal) varices

33. Spontaneous splenorenal shunt

34. Recanalized umbilical vein Large series of abdominal wall collaterals, with a prominent vein the right upper quadrant Case directory

35. Case 36

36. Hypothenar hammer syndrome Case findings: Diminished ulnar artery flow with occlusion in the carpal area Caused by chronic trauma or vibration which causes intimal injury, aneurysm formation, emboli, and occlusion Damage to distal ulnar artery as it runs across the hook of the hamate Symptoms: digital ischemia, Raynaud’s, pulsatile mass Case directory

37. Case 37

38. Obstructive arterial disease of the hand Raynaud’s disease: Small artery disorder characterized by intermittent, reversible ischemia Secondary to vasoconstriction Buerger’s Disease (thromboangiitis obliterans): Inflammatory vasculitis of small and medium arteries Characterized by abrupt occlusions of distal arteries with normal intervening vessels and corkscrew , tortuous collaterals

39. Obstructive arterial disease of the hand Emboli: From cholesterol deposits, endocarditis, thrombosed hemodialysis grafts Diabetes or chronic renal failure: Leads to accelerated atherosclerosis of the arteries Trauma ( hypothenar hammer syndrome): Repetitive trauma Hypercoagulable conditions (e.g., malignancy) Collagen vascular disease: Scleroderma, RA, SLE Case directory

40. Case 38

41. Splenic artery aneurysm Risk factors: MC pregnancy, portal hypertension, FMD LC atherosclerosis Splenic artery pseudoaneurysm : May be due to pancreatitis , infection, surgery, or trauma Treatment: Embolization of the splenic artery both proximal and distal to the aneurysm Intra-aneurysmal packing with coils Perfusion to the splenic parenchyma is usually preserved due to collateral blood supply to the distal splenic artery More recent alternative to embolization is endovascular stent-graft repair using a covered stent 🡪 used in patients with favorable arterial anatomy

42. Case 39 Case directory

43. Traumatic transection of the right axillary artery Case findings: Arch aortogram: normal thoracic aorta with abrupt cutoff of contrast at the proximal right axillary artery Right subclavian arteriogram: Contrast is seen to the level of the proximal right axillary artery Evidence of extravasation at this level with possible pseudoaneurysm Faint reconstitution of the brachial artery from collaterals DDX arterial occlusion: Occluding intimal flap Spasm following complete trasection of the vessel Extrinsic compression of the vessel due to bone fragments or hematoma Thromboembolism

44. Angiography of arterial trauma Tears in the intima Extravasation of contrast Arterial occlusion Vasospasm Extrinsic compression Pseudoaneurysm A-V fistula Case directory

45. Case 40 What is the next step?

46. Traumatic splenic artery injury CT: splenic fracture involving the lower pole with active extravasation Celiac artery angiogram (not shown): pre-embolization show a small focus of extravasation in the lower pole of the spleen Splenic angiogram: post coil embolization with microcoils demonstrates successful embolization with preservation of greater than 75% splenic parenchyma

47. Embolization agents Metallic coils: permanent occlusion Placed quickly with a high degree of accuracy Best in single vessel injuries, available in a wide variety if sizes, diameters, lengths, and shapes Gelatin sponges: temporary occluding agents Best for single or multiple injuries of smaller arteries Useful when distal occlusion is necessary or when multiple collateral channels are present PVA particles Complications of splenic embolization: inadvertent non-target embolization, splenic infarction, splenic abscess

48. Organ injury scaling system Grade I Hematoma: subcapsular, <10% surface area Laceration: capsular tear, < 1cm parenchymal depth Grade II Hematoma: Subcapsular, 10-50% surface area Intraparenchymal, <5cm diameter Laceration 1-3cm parenchymal depth not involving a parenchymal vessel Grade III Hematoma: Subcapsular, >50% surface area or expanding Ruptured subcapsular or parenchymal hematoma Intraparenchymal hematoma >5cm Laceration: >3cm parenchymal depth or involving trabecular vessels

49. Organ injury scaling system Grade IV Laceration of segmental or hilar vessels producing major devascularization (>25% of spleen) Grade V Laceration: completely shattered spleen Vascular: hilar vascular injury with devascularized spleen Grade VI Injuries are by definition not salvageable by NOM (non-operative management) Advanced one grade for multiple injuries to the same organ Case directory

50. Case 41

51. Portal hypertension Portal pressure > 5-10 mm Hg Etiology: MC hepatic cirrhosis Presinusoidal: PV thrombosis, schistosomiasis Sinusoidal: cirrhosis Postsinusoidal: Budd-Chiari, HV or IVC obstruction

52. Portocaval shunt

53. Mesocaval shunt

54. Splenorenal shunt (proximal, Litton shunt)

55. Splenorenal shunt (distal, Warren shunt) Case directory

56. Case 42

57. Renal vein thrombosis Children: Dehydration Sepsis Maternal diabetes Adult: Glomerulopathies CVD Diabetes Trauma Thrombophlebitis

58. Renal vein thrombosis Case directory

59. Case 43

60. Duplicated IVC

61. IVC filter, Simon filter

62. IVC filter, Birdsnest filter

63. IVC filter, Greenfield filters Case directory

64. Case 44

65. Buerger's disease (thromboangitis obliterans) Case findings: Profunda femoris artery is hypertrophied Profunda femoris artery provides corkscrew collaterals to reconstitute the popliteal artery Corkscrew collaterals also reconstitute the posterior tibial artery Inflammatory arteritis of unknown etiology involving the small and medium-sized arteries of the extremities MC young males, associated with smoking Classic: Occlusion of the one or more arteries of the legs with normal iliac and femoral arteries Corkscrew collaterals In contrast to atherosclerosis, high incidence of UE involvement

66. Lower extremity veins

67. Lower extremity arteries Case directory

68. Case 45

69. Oncocytoma Case findings: Angiography: Central portion of tumor is relatively avascular Spoke-wheel pattern of hypervascularity that is most intense at the periphery of the mass CT: renal mass with central scar Oncocytoma: form of benign renal adenoma Well encapsulated with dense central fibrous scar DDX: renal cell carcinoma Case directory

70. Case 46

71. Popliteal artery entrapment syndrome Case findings: Smooth focal narrowing in mid portion of right popliteal artery No evidence of an aneurysmal or pseudoaneurysmal change Medial deviation of the proximal popliteal artery in the stress position Normal three-vessel runoff (not shown) in RLE DDX popliteal artery stenosis/occlusion: Premature accelerated atherosclerosis Adventitial cystic disease Entrapment syndromes: Adductor canal outlet syndrome Popliteal artery entrapment syndrome Collagen vascular disease Takayasu’s arteritis Thromboangiitis obliterans Thromboembolism

72. Popliteal artery entrapment syndrome Rare, but one of the MC cause of intermittent LE claudication in otherwise healthy young adults Medial deviation of the proximal popliteal artery in the stress position

73. Case 47

74. Persistent sciatic artery Case findings: Absent right external iliac artery Continuation of the internal iliac artery through the sciatic foramen

75. Persistent sciatic artery Uncommon, occurring in 1 in 1000 Embryologic sciatic artery remains dominant inflow vessel to the leg Due to superficial location in the ischial region, the sciatic artery is prone to intimal injury or aneurysm formation Aberrant vessel comes off internal iliac artery, passes through the greater sciatic foramen, and runs deep to the gluteus maximus Above the knee, joins the popliteal artery SFA is hypoplastic or absent

76. Case 48

77. SVC obstruction (secondary to fibrosing mediastinitis) Case findings: CT: Ill-defined soft-tissue mass encasing and obstructing SVC with extensive collaterals Superior vena cavogram (simultaneous contrast injection via both arms under fluoroscopy): Complete obstruction at the level of the brachiocephalic vein confluence with SVC as well as collateral vessels

78. SVC obstruction MC due to bronchogenic carcinoma Fibrosing mediastinitis: due to histoplasmosis Intraluminal thrombus from indwelling catheter

79. Case 49

80. Case 50