1

UW Radiology Review Course:

Vascular Diagnosis

Karim Valji, MD

Professor of Radiology

University of Washington

Seattle

Case 1A patient with this entity will likely suffer

from:

A. Leg ischemia

B. Hypertension

C. Hypotension

D. Chest pain

E. Boredom

2

Coarctation of the Aorta

• Bandlike narrowing near the attachment of the ligamentum arteriosum (postductal form). Distinguish from pre ductal fetal coarctation, which produces diffuse narrowing of the aortic arch and hypoplasia of left heart chambers

• Associated with bicuspid aortic valve, patent ductus arteriosus, ventricular septal defect, and Turner’s syndrome

• Blood flows from the anterior intercostal branches of the internal thoracic arteries retrograde into the posterior intercostal branches of the descending aorta. Enlargement and tortuosity of the intercostal arteries cause pressure erosion on the undersurface of the third through ninth ribs (“rib notching”).

• Imaging findings include severe, discrete narrowing around the aortic isthmus, dilation of the ascending aorta, and enlarged internal thoracic and intercostal arteries

• Treatment is surgical or endovascular

Case 2

3

Case 2Whom do you call?

A. CT tech

B. IR doc

C. Pulmonologist

D. Thoracic surgeon

Intravascular Foreign Body Retrieval

• Potential complications include clot formation and embolization, sepsis, cardiac dysrhythmias, and vascular or heart perforation with ensuing hemorrhage or cardiac tamponade

• When feasible, intravascular foreign body retrieval should be considered

• Long device dwell time itself is not a reason to avoid attempting removal

• Percutaneous retrieval is successful in greater than 95% of attempts

4

Case 3The most likely clinical situation is:

A. an elderly man with hypertension

B. an elderly woman with abdominal pain and sitophobia

C. a young thin woman with abdominal pain

D. an elderly man with weight loss

Median Arcuate Ligament Syndrome

• The median arcuate ligament connecting the crura of the hemidiaphragms drapes over the root of the celiac artery

• Mild to moderate compression causing superior extrinsic compression is a normal variant on imaging studies

• The syndrome is associated with abdominal pain and weight loss and typically seen in young asthenic women

• Compression is exaggerated during expiration.

• Symptoms are related to arterial ischemia or compression of the celiac neural plexus.

• Treatment is surgical. Stents are NOT advisable.

5

Case 4This patient most likely has:

A. wrinkles

B. long slender limbs

C. + VDRL test

D. just been hit by a car

E. been in and out of rehab

Thoracic Aneurysm in Marfan Syndrome

• Autosomal dominant disorder that affects the eyes, skeleton and muscles, and the cardiovascular system

• About 2/3 of cases due to mutation in the FBN1 gene that codes for fibrillin-1, resulting in structurally deficient microfibrils in the aortic media and activation of media-destroying metalloproteinases (MMP)

• CV involvement includes aneurysm or dissection of the proximal ascending aorta, aortic insufficiency, mitral valve prolapse or calcification, and pulmonary artery dilation

• Characteristic sinotubular ectasia with “tulip bulb” appearance

6

Classic Appearance of Thoracic Aortic Aneurysms

Type Features

Degenerative Fusiform aneurysm of the descending aorta

with atherosclerotic changes

Posttraumatic Saccular pseudoaneurysm at the aortic isthmus

Post-operative Saccular aneurysm at clamp site, suture line, or cannulation site

Bacterial Saccular, eccentric aneurysm at an unusual site

Marfan syndrome Aneurysm of aortic root and tubular segment

(sinotubular or annuloaortic ectasia)

Syphilitic Saccular ascending aortic or arch aneurysm sparing

the aortic root

Takayasu arteritis Wall thickening and enhancement (early)

Diffuse fusiform dilation of the aorta with branch stenoses or occlusions

Post-stenotic Dilation beyond an obstruction (e.g., aortic stenosis, coarctation)

Case 5This patient needs an IVC filter. What is

the next thing you will pick up?

A. Angled catheter

B. Guenther tulip filter

C. Bird’s nest filter

D. Telephone

7

Duplicated IVC

• Results from persistence of the inferior portion of the left supracardinalvein. Prevalence of this anomaly is 0.2% to 3%.

• The left IVC usually joins the right IVC at the level of the left renal vein. The right and left common iliac veins sometimes communicate in the pelvis.

• At venacavography, duplication may be suspected by the absence of an inflow defect from the left iliac vein and by the small caliber of the infrarenal IVC.

• However, it can go undetected on routine cavograms; if the initial study is suspicious, catheterization of the suspected duplication is advisable.

• Failure to detect this variant may leave patient unprotected from pulmonary embolism after filter placement.

8

Case 6

Case 6What is the most likely symptom?

A. Abdominal pain

B. Hypertension

C. Bleeding

D. Leg ischemia

E. Fever

9

Mycotic Aortic Aneurysm

• Disease is caused by seeding of an aortic lesion (e.g., plaque or aneurysm), septic embolization into the aortic vasa vasorum, transmural spread from an adjacent infection, or penetrating trauma

• Causative agents

– Bacteria (Salmonella species and Staph aureus)

– Mycobacterium tuberculosis (lympangitic or direct invasion)

– Syphilis

• For bacterial aortic aneurysms, typical scenario is IV drug user with fever ± pain, + blood cultures, and smooth uncalcified saccular aneurysm.

• Traditional treatment is antibiotics and aneurysm bypass , but stent grafts being used with greater frequency

Case 7

10

11

Case 7Best treatment for this disorder:

A. Anticoagulation

B. Vasodilator therapy

C. IVC filter

D. Thrombolysis

E. Surgery

Chronic PulmonaryThromboembolic Hypertension

• Occurs in < 1% of patients who suffer PE, developing years after the first episode, and causing exertional dyspnea and fatigue

• V/Q scan: multiple bilateral segmental mismatched defects

• CTA: vessel occlusion or narrowing, peripheral filling defects, diffuse wall thickening, webs or flaps, and a “mosaic” parenchymal pattern. Also, enlarged right heart chambers and central pulmonary arteries

• Disease is often progressive and lethal. Vasodilator therapy used in early stages. Definitive treatment is IVC filter placement and open thromboendarterctomy.

12

Case 8When does this patient most likely suffer

from leg pain?

A. Never

B. Night time

C. Day time

D. All the time

13

Popliteal Artery Entrapment Syndrome

• Chronic condition caused by an abnormal relationship between the artery and adjacent muscular bundles in the popliteal fossa

• Four distinct types. The most common form (type I) involves medial displacement of the artery from abnormal fetal migration of the gastrocnemius muscle.

• Bilateral in about one third of cases. Men are affected more often than women, and many of them are athletes or exercise regularly.

• Typical finding is narrowing and medial (or occasionally lateral) deviation of the midportion of the popliteal artery. The imaging study is then repeated with active, prolonged plantar flexion or passive dorsiflexion of the foot, which should provoke the compression.

• Treatment is surgical, NOT endovascular

Case 9With respect to treatment, what is the

magic number?

A. 1

B. 2

C. 4

D. 5

E. What???

14

Visceral Artery Aneurysms

True Aneurysms

Arterial dysplasia

Degenerative (atherosclerosis-associated)

High flow states (e.g., portal hypertension, hypersplenism)

Connective tissue disorders

Vasculitis

False Aneurysms

Inflammation

Pancreatitis

Infection (mycotic)

Trauma

Post-transplant

Dissection

Splenic Artery Aneurysms• Though uncommon, they are the most frequent visceral artery

aneurysms.

• True aneurysms usually small and asymptomatic and slow growing when detected, but lethal when they do rupture.

• Visceral artery pseudoaneurysms are slightly more common and typically symptomatic at presentation.

• Fluid or soft tissue adjacent to the lesion suggests an inflammatory pseudoaneurysm. Dyplastic visceral artery aneurysms often saccular, sometimes multiple, and may be calcified.

• Asymptomatic dysplastic splenic artery aneurysms larger than 2 cm in diameter warrant repair.

• Repair all aneurysms in women of child bearing age, all pseudoaneurysms, all symptomatic or rapidly expanding lesions, and all portal HTN related aneurysms in liver transplant patients.

15

Case 10Whom will you call next?

A. Thoracic surgeon

B. Pulmonologist

C. Primary physician

D. IR doc

Blunt Aortic Injury• Usually caused by a deceleration injury, with 80-90% immediately fatal

• Survivors typically have

– Contained pseudoaneurysm from mural tear

– Intimal tear

– Intramural hematoma

– Dissection

– Complete transection with thrombosis

• 75-90% occur at aortic isthmus

• Mortality rate without treatment is frighteningly high

• CT findings correspond to lesion morphology

• Use CT liberally in this trauma population

• Treatment is surgical or endovascular

16

Case 11What is the most likely clinical scenario?

A. Fell off the roof

B. Practices karate

C. Had an encounter with a cardiologist

D. Stabbed by “some dude” on the way to bible class

Hypothenar Hammer Syndrome

• Chronic, repetitive trauma to the hand (often from vibratory activity or repetitive pounding) may produce intimal damage and sometimes occlusion of palmar arteries.

• In particular, trauma to the distal ulnar artery as it runs across the hook of the hamate leads to this uncommon entity

• Disease spectrum runs from mild intimal injury to aneurysm formation, occlusion, and distal embolization

• Treatment is usually medical (e.g., anticoagulation) or surgical

17

Case 12How many congenital variants do you see?

A. 0

B. 1

C. 2

D. 3

E. 4

18

Multiple Aortic Branch Anomalies• Left vertebral artery origin from aortic arch

• Aberrant right subclavian artery

– reported frequency of 0.4% to 2.3%

– Originates from a dilated portion of the most distal remnant of the right aortic arch, the so-called diverticulum of Kommerell

– The right subclavian artery becomes the last branch of the aortic arch

– Vessel may indent the posterior surface of the esophagus, but patients rarely have symptoms

• Bronchial artery diverticulum

Case 13

19

Persistent Sciatic Artery

• Rare anomaly (about 0.1% of the population) in which the embryologic sciatic artery remains the dominant inflow vessel to the leg.

• The aberrant vessel arises from the internal iliac artery, passes through the greater sciatic foramen, and lies deep to the gluteus maximus muscle. Above the knee, it joins the popliteal artery. The SFA is hypoplastic or absent.

• The anomaly is occasionally bilateral.

• Because of its relatively superficial position in the ischialregion, the sciatic artery is prone to intimal injury or aneurysm formation.

20