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Sindromes Vasculares Compressivas
O documento discute síndromes compressivas vasculares. Ele se concentra na síndrome do ligamento arqueado mediano, descrevendo sua anatomia, fatores de risco, sintomas e achados de imagem característicos, como a compressão focal do tronco celíaco. O documento também discute o tratamento controversal da síndrome, incluindo opções cirúrgicas e endovasculares.
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Sindromes Vasculares Compressivas
- 1. SÍNDROMES COMPRESSIVAS VASCULARES BrendaNajat Boechat Lahlou Fellow de Radiologia Geral do Hospital Santa Casa de Misericórdia de São Paulo 21/09/2022
- 2. • Compressão extrínsecade vasos ou vísceras ocas por estruturas anatômicas adjacentes Síndromes Compressivas Vasculares
- 3. • Compressão extrínsecade vasos ou vísceras ocas por estruturas anatômicas adjacentes Síndrome de Compressão Vascular Achados anatômicos e morfológicos que predispõem Síndromes Compressivas Vasculares x
- 4. • Compressão extrínsecade vasos ou vísceras ocas por estruturas anatômicas adjacentes Síndrome de Compressão Vascular Achados anatômicos e morfológicos que predispõem • Presença de Sintomas • Pode ser achado incidental Síndromes Compressivas Vasculares x
- 5. • Compressão extrínsecade vasos ou vísceras ocas por estruturas anatômicas adjacentes Síndrome de Compressão Vascular Achados anatômicos e morfológicos que predispõem • Presença de Sintomas • Não é diagnosticado com achado radiológico isolado. • Pode ser achado incidental Síndromes Compressivas Vasculares x
- 6. • Compressão extrínsecade vasos ou vísceras ocas por estruturas anatômicas adjacentes • Sintomas vagos e inespecíficos e arrastados • Exame de escolha: Tomografia/ AngioTC • Informações hemodinâmicas: Venografia direta e Ultrassonografia Duplex Síndrome de Compressão Vascular Achados anatômicos e morfológicos que predispõem • Presença de Sintomas • Não é diagnosticado com achado radiológico isolado. • Pode ser achado incidental Síndromes Compressivas Vasculares x
- 7. • Compressão extrínsecade vasos ou vísceras ocas por estruturas anatômicas adjacentes • Sintomas vagos e inespecíficos e arrastados • Exame de escolha: Tomografia/ AngioTC • Informações hemodinâmicas: Venografia direta e Ultrassonografia Dupplex Síndrome de Compressão Vascular Achados anatômicos e morfológicos que predispõem • Presença de Sintomas • Não é diagnosticado com achado radiológico isolado. • Pode ser achado incidental Síndromes Compressivas Vasculares x
- 8. Síndrome de Nutcracker Estenosede Junção ureteropélvica Síndrome de May-Thurner Síndrome da artéria mesentérica superior Síndrome do ligamento arqueado Síndromes compressivas vasculares do ureter Biliopatia portal Síndromes Compressivas Vasculares
- 9.
- 10. • Síndrome deDunbar • Compressão da raíz do Tronco Celíaco pelo Ligamento arqueado mediano Síndrome do Ligamento Arqueado Mediano Ligamento Arqueado Mediano: Banda fibrosa “em arco” que conecta a crura diafragmática direita e esquerda no nível do hiato aórtico.
- 11. • Síndrome deDunbar • Compressão da raíz do Tronco Celíaco pelo Ligamento arqueado mediano • Fatores predisponentes: • Origem do tronco celíaco alta • Inserção do ligamento arqueado baixa • Aumento do efeito compressivo durante expiração Síndrome do Ligamento Arqueado Mediano
- 12. • Síndrome deDunbar • Compressão da raíz do Tronco Celíaco pelo Ligamento arqueado mediano • Farotes predisponentes: • Origem do tronco celíaco alta • Inserção do ligamento arqueado baixa • Aumento do efeito compressivo dourante expiração Síndrome do Ligamento Arqueado Mediano
- 13. • Síndrome deDunbar • Compressão da raíz do Tronco Celíaco pelo Ligamento arqueado mediano • Fatores predisponentes: • Origem do tronco celíaco alta • Inserção do ligamento arqueado baixa • Aumento do efeito compressivo durante expiração Síndrome do Ligamento Arqueado Mediano • Variante presente em 24 – 50% da população geral • 85% assintomático incidental
- 14. Quadro clínico: • Maioriaassintomático • Poucos casos são severos e levam a sintomas: • Dor epigástrica crônica (pode ou não ser pós-prandial) • Perda ponderal • Mais comum em mulheres jovens • Circulação colateral através da arcada pancreatoduodenal Síndrome do Ligamento Arqueado Mediano
- 15. Quadro clínico: • Maioriaassintomático • Poucos casos são severos e levam a sintomas: • Dor epigástrica crônica (pode ou não ser pós-prandial) • Perda ponderal • Mais comum em mulheres jovens • Circulação colateral através da arcada pancreatoduodenal Síndrome do Ligamento Arqueado Mediano
- 16. ACHADOS DE IMAGEM: •Redução focal do calibre do aspecto proximal do tronco celíaco • Em “gancho” • Mais pronunciado na fase final da expiração (pode fazer as 2 aquisições na suspeita) • Dilatação pós estenótica • Ausência de placa aterosclerótica (diferencial) • Vasos colaterais e aneurismas da arcada pancreatoduodenal. Síndrome do Ligamento Arqueado Mediano
- 17. Síndrome do LigamentoArqueado Mediano INS EX
- 19. Tratamento • Controverso • Tratamentocirúrgico • Paciente jovem com sintomas de dor pós-prandial e perda de peso > 20 kg • Transecção ligamentar com reconstrução celíaca • Cirurgia de bypass • Stent endovascular • Embolização endovascular dos aneurismas Síndrome do Ligamento Arqueado Mediano
- 20. Tratamento • Controverso • Tratamentocirúrgico • Paciente jovem com sintomas de dor pós-prandial e perda de peso > 20 kg • Transecção ligamentar cim reconstrução celíaca • Cirurgia de bypass • Stent endovascular • Embolização endovascular dos aneurismas Síndrome do Ligamento Arqueado Mediano
- 21. Síndrome de Nutcracker Estenosede Junção ureteropélvica Síndrome de May-Thurner Síndrome da artéria mesentérica superior Síndrome do ligamento arqueado Síndromes compressivas vasculares do ureter Biliopatia portal Síndromes Compressivas Vasculares
- 22.
- 23. • Compressão daVeia Renal Esquerda • Entre a Artéria Mesentérica Superior (AMS) e a Aorta • Se retroaórtica: Entre a aorta e corpo vertebral Síndrome de Nutcracker
- 24. • Compressão daArtéria Renal Esquerda • Entre a Artéria Mesentérica Superior (AMS) e a Aorta • Se retroaórtica: Entre a aorta e corpo vertebral Síndrome de Nutcracker
- 25. • Compressão daVeia Renal Esquerda • Entre a Artéria Mesentérica Superior (AMS) e a Aorta • Se retroaórtica: Entre a aorta e corpo vertebral • Fatores predisponentes: • Ângulo estreito entre AMS e Aorta • Curta distância entre AMS e Aorta Síndrome de Nutcracker Distância Aortomesentérica < 10mm (em geral 3 mm) Ângulo Aortomesentérico < 30(em geral 16)
- 26. Síndrome de Nutcracker •Compressão da Veia Renal Esquerda • Entre a Artéria Mesentérica Superior (AMS) e a Aorta • Se retroaórtica: Entre a aorta e corpo vertebral • Fatores predisponentes: • Ângulo estreito entre AMS e Aorta • Curta distância entre AMS e Aorta • Biotipo brevilínio • Perda rápida de peso e/ ou de gordura retroperitoneal • Ptose do rim esquerdo • Tecido fibroso pré-aortico • Interposição duodenal
- 27. A Síndrome • Ocorrequando há aumento da pressão da veia • Formação de colaterais intra e extrarrenais (em geral à esquerda) • Refluxo gonadal • Sintomas Síndrome de Nutcracker Quadro Clínico • Hematúria • Proteinúria ortostática • Dor em flanco (por coágulos) • Varicocele (♂) / varizes pélvicas e vulvares (♀) à esquerda • Sintomas de congestão pélvica (Dor crônica, dispareunia, disúria, dismenorreia)
- 28. Síndrome de Nutcracker ACHADOSDE IMAGEM • TC ou RM com contraste fase venosa • Sagital avalia ângulo e distância aortomesentérica • Coronal bom para avaliar varizes • US Duplex • Aumento da razão da velocidade de pico sistólico no ponto de compressão / velocidade na veia hilar (>4,7) • Venografia retrógrada - Diagnóstico definitivo • Gradiente de pressão renocaval > 3mmHg • Rede colateral • US transvaginal • Varizes pélvicas • Urografia excretora • Mostra indentações ureterais pelas varizes retroperitoneais
- 29. Ângulo Aortomesentérico >30 Distância Aortomesentérica > 10mm NORMAL:
- 30. Síndrome de Nutcracker ÂnguloAortomesentérico > 30 Distância Aortomesentérica > 10mm
- 31.
- 32.
- 33.
- 34.
- 35. Síndrome de Nutcracker Tratamento •Expectante - em pacientes jovens, magros ou com sintomas leves
- 36. Síndrome de Nutcracker Tratamento •Expectante em pacientes jovens, magros ou com sintomas leves • Intervenção em pacientes com sintomas severos • Transposição de veia renal esquerda ou veia gonadal para o aspecto inferior da VCI • Stent venoso externo • Stent endovascular • Bypass de veia renal esquerda com enxerto da Safena • Autotransplante renal para fossa ilíaca • Nefrectomia esquerda
- 37. Síndrome de Nutcracker Tratamento •Expectante em pacientes jovens, magros ou com sintomas leves • Intervenção em pacientes com sintomas severos • Transposição de veia renal esquerda para o aspecto inferior da VCI • Stent venoso externo • Bypass de veia renal esquerda • Autotransplante renal para fossa ilíaca • Nefrectomia esquerda. • Stent endovascular (em estudo)
- 38.
- 39. Síndrome de Nutcracker Estenosede Junção ureteropélvica Síndrome de May-Thurner Síndrome da artéria mesentérica superior Síndrome do ligamento arqueado Síndromes compressivas vasculares do ureter Biliopatia portal Síndromes Compressivas Vasculares
- 40. Síndrome da Artéria MesentéricaSuperior
- 41. • Síndrome decompressão duodenal aortomesentérica / Sd. De Wilkie • Ângulo aortomesentérico estreito • Distância aortomesentérica reduzida Síndrome da Artéria Mesentérica Superior 3ª L1 L3 Ângulo Aortomesentérico < 30 Distância Aortomesentérica < 10mm
- 42. • Ângulo aortomesentéricoestreito • Distância aortomesentérica reduzida • Cenários predisponentes: • Condições relacionadas a perda rápida de peso • Cirurgia corretiva de escoliose • Aplicação de pressão extraabdominal (imobilizações) • Variações anatômicas • Origem baixa da AMS • Inserção alta do ângulo de Treitz • Prevalência estimada em 0,1 – 0,3 % Síndrome da Artéria Mesentérica Superior
- 43. Quadro clínico • +Mulheres, 10 – 39 anos • Sintomas de obstrução duodenal • Dor epigástrica pós prandial • Empachamento, náuseas, vômito • Perda de peso • Refluxo gastroesofágico, gastrite e esofagite associada Síndrome da Artéria Mesentérica Superior
- 44. Síndrome da ArtériaMesentérica Superior ACHADOS DE IMAGEM • TC contrastada – Exame de escolha • Avalia anatomia vascular, compressão duodenal e dilatação proximal • Estudo radiográfico com Bário • Dilatação do estômago e duodeno proximal • Impressão extrínseca vertical sobre 3ª porção duodenal • Ondas antiperistálticas proximais • Retardo no esvaziamento gástrico • Alívio da obstrução com mudança postural (Prona e DLE) • Angiografia mesentérica • Ângulo aortomesentérico agudo (< 22°) e redução da distância aortomesentérica (< 8 mm)
- 45. Síndrome da ArtériaMesentérica Superior
- 46. Síndrome da ArtériaMesentérica Superior
- 47. Tratamento Tto conservador • Descompressãogástrica com sonda • Dieta por sonda nasoentérica • Suporte nutricional (para ganho ponderal e do tecido adiposo) Tto Cirúrgico se falha terapêutica: • Duodenojejunostomia • Gastrojejunostomia • Lise do ligmaento de Treitz (procedimento de Strong) Síndrome da Artéria Mesentérica Superior
- 48. Tratamento Tto conservador • Descompressãogástrica com sonda • Dieta por sonda nasoentérica • Suporte nutricional (para ganho ponderal e do tecido adiposo) Tto Cirúrgico se falha terapêutica: • Duodenojejunostomia • Gastrojejunostomia • Lise do ligmaento de Treitz (procedimento de Strong) Síndrome da Artéria Mesentérica Superior
- 49. Síndrome de Nutcracker Estenosede Junção ureteropélvica Síndrome de May-Thurner Síndrome da artéria mesentérica superior Síndrome do ligamento arqueado Síndromes compressivas vasculares do ureter Biliopatia portal Síndromes Compressivas Vasculares
- 50.
- 51. • Síndrome deCockett / Síndrome da compressão da veia ilíaca • Compressão crônica da veia ilíaca comum esquerda pelo cruzamento da artéria ilíaca comum direita e a 5ª vértebra lombar Síndrome de May-Thurner
- 52. • Síndrome deCockett / Síndrome da compressão da veia ilíaca • Compressão crônica da veia ilíaca comum esquerda pelo cruzamento da artéria ilíaca comum direita e a 5ª vértebra lombar • Estase venosa • Edema crônico de membro inferior • Trombose venosa profunda • Formação de “esporões” venosos Síndrome de May-Thurner
- 53. Quadro Clínico • Jovens/meia idade & + comum em mulheres • Assintomático • Edema de MIE • Por congestão • Por trombose • Varizes • Úlceras venosas Síndrome de May-Thurner • TEP • Flegmasia cerúlea dolens
- 54. Síndrome de May-Thurner ACHADOSDE IMAGEM • Tomografia contrastada • Avalia anatomia e compressão vascular, • Extensão da trombose • Colaterais venosas • Exclusão de diagnósticos diferenciais da compressão • Venografia por Ressonância magnética • Ultrassonografia Doppler • Avalia trombose • Fatores hemodinâmicos da compressão (velocidade) • Limitado na avaliação das ilíacas (sobreposição gasosa) • Venografia • Avalia compressão, gradientes de pressão intravascular e presença de colaterais atravessando a pelve • Invasivo, complicações e contraindicado em TVP extensa
- 58.
- 59. Tratamento • Trombólise guiadapor cateter + anticoagulação • Stent endovascular • Outros: • Transposição vascular • Bypass venoso • Venoplastia/ Ressecção de bandas intraluminais Síndrome de May-Thurner
- 60. Tratamento • Trombólise guiadapor cateter + anticoagulação • Stent endovascular • Outros: • Transposição vascular • Bypass venoso • Venoplastia/ Ressecção de bandas intraluminais Síndrome de May-Thurner Pré- Tto 24h pós trombólise Colocação do Stent
- 61. Síndrome de Nutcracker Estenosede Junção ureteropélvica Síndrome de May-Thurner Síndrome da artéria mesentérica superior Síndrome do ligamento arqueado Síndromes compressivas vasculares do ureter Biliopatia portal Síndromes Compressivas Vasculares
- 62.
- 63. • Obstrução funcionalou anatômica do trato urinário na junção ureteropélvica Estenose de JUP
- 64. • Obstrução anatômicado trato urinário na junção ureteropélvica • Cruzamento de vasos • Artéria ou veia que atravessa JUP (em geral artéria cruzando anteriormente) • Artéria polar inferior • Ramos da artéria e veia hilar • Vasos acessórios da aorta, artéria ilíaca ou veia cava inferior Estenose de JUP
- 65. • Obstrução funcionalou anatômica do trato urinário na junção ureteropélvica • Cruzamento de vasos • Artéria ou veia que atravessa JUP (em geral artéria cruzando anteriormente) • Artéria polar inferior • Ramos da artéria e veia hilar • Vasos acessórios da aorta, artéria ilíaca ou veia cava inferior Estenose de JUP
- 66. Quadro Clínico • Assintomático/incidental • Evolução progressiva • Dor lombar, hematúria, nefrolitíase, infecções Estenose de JUP
- 67. Estenose de JUP ACHADOSDE IMAGEM • Tomografia contrastada • Arterial / Venosa / Excretora - MPR e 3D • Dilatação pélvica e calicinal (Pelve “em gota”) • Ureter “Drapeja”/ “encaixa” na artéria polar • Ultrassonografia Doppler • US Doppler + Contraste endovenoso * • US Doppler endoscópico (endoureteral) • Urografia excretora ou retrógrada • Impressão extrínseca na JUP • Angiografia por catéter • Invasivo • Avaliação de anatomia venosa VPP de 100%
- 68.
- 69.
- 70. Tratamento • Depende dossintomas, grau da hidronefrose e função renal • Tto Cirúrgico: • Pieloplastia laparoscópica ou aberta* • Endopielotomia • Transposição dos vasos Estenose de JUP
- 71. Tratamento • Depende dossintomas, grau da hidronefrose e função renal • Tto Cirúrgico: • Pieloplastia laparoscópica ou aberta* • Endopielotomia • Transposição dos vasos Estenose de JUP
- 72. Síndrome de Nutcracker Estenosede Junção ureteropélvica Síndrome de May-Thurner Síndrome da artéria mesentérica superior Síndrome do ligamento arqueado Síndromes compressivas vasculares do ureter Biliopatia portal Síndromes Compressivas Vasculares
- 73.
- 74. • Compressão naintersecção do ureter com vasos retroperitoneais Síndromes Compressivas do Ureter
- 75. • Compressão naintersecção com vasos retroperitoneais • Veia ovariana • Veia testicular • Veia ilíaca comum • Aneurisma de artéria ilíaca comum • Ureter retrovascular (retrocaval ou retroilíaco) Síndromes Compressivas do Ureter
- 76. • Compressão naintersecção com vasos retroperitoneais •Veia ovariana • Veia testicular • Veia ilíaca comum • Aneurisma de artéria ilíaca comum • Ureter retrovascular (retrocaval ou retroilíaco) Síndromes Compressivas do Ureter Síndrome da Veia Ovariana: • Uropatia obstrutiva • Veia ovariana dilatada, aberrante ou trombosada • Comprime ureter no nível do anel pélvico • 95% à direita • + comum na gestação
- 77. Síndromes Compressivas doUreter ACHADOS DE IMAGEM • TC contrastada • Trifásico renal (arterial / venosa / excretora) ou Split bolus (+ fase sem contraste!) • Avalia ureter e sua relação com os vasos adjacentes • Urografia excretora / retrógrada • Impressão extrínseca oblíqua no ureter com hidroureteronefrose proximal. • Ureter retrocaval (circumcaval) – “J invertido” / “em gancho”
- 78.
- 79.
- 80.
- 81.
- 82.
- 83. Tratamento • Pacientes sintomáticos •Uretero-ureterostomia laparoscópica • Ligação cirúrgica ou embolização endovascular da veia ovariana Síndromes Compressivas do Ureter
- 84. Síndrome de Nutcracker Estenosede Junção ureteropélvica Síndrome de May-Thurner Síndrome da artéria mesentérica superior Síndrome do ligamento arqueado Síndromes compressivas vasculares do ureter Biliopatia portal Síndromes Compressivas Vasculares
- 85.
- 86. • Dilatação devias biliares por transformação cavernomatosa portal. Biliopatia Portal Saint (Epicolédoco) Petren (Paracolédoco) Biliopatia Portal Trombose crônica da Veia Porta Transformação Cavernomatosa • Plexo paracoledocal (de Petren) • Plexo epicoledocal (de Saint)
- 87. Saint (Epicolédoco) Petren (Paracolédoco) • Dilatação devias biliares por transformação cavernomatosa portal. Biliopatia Portal Biliopatia Portal Trombose crônica da Veia Porta Transformação Cavernomatosa • Plexo paracoledocal (de Petren) • Plexo epicoledocal (de Saint) Compressão extrínseca das vias biliares + Fibrose peribiliar (inflamação/ isquemia)
- 88. Dilatação de viasbiliares por transformação cavernomatosa portal. Quadro clínico • Assintomáticos • Minoria desenvolve colestase e icterícia crônica • 4 – 10% pode ter complicações Coledocolitíase, Colangite, Cirrose biliar secundária Biliopatia Portal
- 89. Biliopatia Portal ACHADOS DEIMAGEM • Ultrassom • Dilatação de ductos biliares intra e extra-hepáticos • Colaterais: Estruturas vasculares tortuosas junto ao ligamento hepatoduodenal e ao hilo hepático • Tomografia contrastada • Avaliar diagnósticos diferenciais (tumores biliares e pancreáticos) • Acotovelamento / “kinking” das vias biliares • Colangiorressonância • Indentações / ondulações nas paredes biliares. • Colangiopancreatografia Retrógrada Endoscópica (CPRE)
- 90.
- 91.
- 92.
- 93.
- 94. Tratamento • Pacientes sintomáticos •Radiologia Intervencionista • Colocação de stent biliar • Recanalização portal • Anastomose portossistêmica intra-hepática transjugular (TIPS) • Cirúrgico • Hepatojejunostomia • Coledocoduodenostomia Biliopatia Portal
- 95. Síndrome de Nutcracker Estenosede Junção ureteropélvica Síndrome de May-Thurner Síndrome da artéria mesentérica superior Síndrome do ligamento arqueado Síndromes compressivas vasculares do ureter Biliopatia portal Síndromes Compressivas Vasculares
- 96. Síndromes Compressivas Vasculares x SÍNDROMEDE COMPRESSÃO VASCULAR ACHADO ANATÔMICO EM EXAME DE IMAGEM
- 99.
- 100.
Notas do Editor
- #5 Variacoes anatomicas predisponentes.
- #7 ranging from vague abdominal pain, nausea and vomiting, loss of weight to acute abdominal hemorrhage, arterial ischemia and embolism or venous stasis and thrombosis, making the clinical diagnosis particularly challenging The combination of noninvasive imaging modalities, which allow the precise evaluation of anatomical structures, and invasive techniques, such as venography or arteriography that are useful for the direct measurement of pressure gradients, is helpful to establish the definitive diagnosis. However, the invasive procedures should be limited to the most doubtful cases or when the endovascular treatment needs to be performed
- #8 Elevated peak velocity of celiac artery during expiration> 2m/sec Contrast venography demonstrates left common iliac vein stenosis (arrow) due to compression by right common iliac artery or May-Thurner syndrome
- #10 Malignancies of the hematopoietic and lymphoid tissues include the lymphomas, leukemias, myeloproliferative neoplasms, mast cell neoplasms, plasma cell neoplasms, histiocytic tumors, and dendritic cell neoplasms. Multiple classification schemes have been employed for these diseases over the years. T
- #11 What is the crura of the diaphragm? The crus of diaphragm (pl. crura), refers to one of two tendinous structures that extends below the diaphragm to the vertebral column. There is a right crus and a left crus, which together form a tether for muscular contraction. They take their name from their leg-shaped appearance – crus meaning leg in Latin The median arcuate ligament is an archlike fibrous band connecting the right and left diaphragmatic crura at the level of the aortic hiatus, crossing the aorta anteriorly just superior to the celiac artery at the level of the first lumbar vertebral body
- #17 Alguns lugares fazem TC na inspiracao e aquisicao na fase expiratoria (apenas uma injecao de contraste) na suspeita de MALS. No entanto, alterações/ estenose presente apenas na fase expiratoria não tem significado clinico e não deveria ser valorizado. acquired in deep expiration in order to increase the proximal celiac trunk compression by the median arcuate ligament, followed by the portal venous phase in deep inspiration [9]. Severe stenosis of the celiac artery may be particularly relevant in patients undergoing pancreatic surgery with pancreaticoduodenectomy and it is a significant risk factor for upper abdominal organs infarction [11].
- #18 MALS in a 28-year-old man with chronic upper abdominal pain, postprandial nausea, loss of appetite, and a weight loss of 20 pounds over a 2-year period. (a)Midline sagittal reformatted MIP image from an abdominal CT angiographic study in deep inspiration shows a mild indentation on the superior aspect of the proximal celiac artery (arrow). (b)Midline sagittal reformatted MIP image in deep expiration shows a marked increase in the proximal celiac stenosis (arrow). The median arcuate ligament “tents” the superior aspect of the proximal celiac artery, resulting in the characteristic hooked appearance. In addition, mild poststenotic celiac dilatation is seen. A prominent pancreaticoduodenal collateral vessel (not shown) was also present. MALS in a 67-year-old man with chronic abdominal pain. (a)Midline sagittal reformatted MIP image from an abdominal CT angiographic study in inspiration shows severe (>90%) nonatherosclerotic narrowing of the proximal celiac artery (arrows) with a characteristic hooked appearance.
- #19 Incidentally detected proximal celiac stenosis in a 50-year-old man with advanced liver disease who was being evaluated for hepatocellular carcinoma. (b)Three-dimensional VR image shows a large, tortuous collateral vessel between the gastroduodenal branch of the celiac trunk and the splenic artery (white arrows). A large celiac artery–SMA pancreaticoduodenal collateral vessel is also present (black arrows). MALS in a 67-year-old man with chronic abdominal pain.c artery–SMA pancreaticoduodenal collateral vessel is also present (black arrows). (b)Coronal oblique MIP image shows a tortuous and hypertrophied pancreaticoduodenal collateral vessel (arrows) and a 3-cm true aneurysm in the pancreaticoduodenal arcade (arrowheads).
- #24 Veia renal esquerda retroaortica esta presente em 3% da populacao
- #25 “circumaortic venous ring”, is another anatomic variant characterized by the presence of two LRVs passing anteriorly and posteriorly to the aorta, respectively [17]. In bpatients with“renal collar” (0.3% to 16% of the population), the concomitant compression of the anterior LRV—between the abdominal aorta and SMA—and the posterior LRV—between the abdominal aorta and spine—is defined as “combined nutcracker syndrome” [15].
- #27 Nephroptosis, also known as a floating kidney and renal ptosis, is a condition in which the kidney descends more than 2 vertebral bodies (or >5 cm) during a position change from supine to upright. The condition is often treated with nephropexy, a surgical procedure that secures the floating kidney to the retroperitoneum
- #28 The most common symptom is hematuria resulting from the rupture of fragile varices into the collecting system. Conversely, nutcracker syndrome remains a very rare cause of hematuria
- #30 The perpendicular distance between the SMA and aorta was measured at the site where the duodenum crosses at three different levels: D1, D2, D3 (Figs. 1 and and2).2). D1 is the superior border, D3 is the lower border, and D2 is the midpoint of the duodenal loop which is crossing at that site. BMI was calculated for each patient as BMI = weight/(height)2.
- #31 The perpendicular distance between the SMA and aorta was measured at the site where the duodenum crosses at three different levels: D1, D2, D3 (Figs. 1 and and2).2). D1 is the superior border, D3 is the lower border, and D2 is the midpoint of the duodenal loop which is crossing at that site. BMI was calculated for each patient as BMI = weight/(height)2.
- #32 Nutcracker syndrome In a 22-year-old woman with progressive left lower quadrant pain and flank pain, as well as microscopic hematuria. (a)Axial CT image shows severe compression of the LRV (arrowhead) between the SMA (arrow) and the aorta. (b)Midline sagittal reformatted image shows steep angulation of the SMA (arrow) with compression of the LRV (arrowhead) in the narrowed aortomesenteric space.
- #33 A 50-year-old woman with anterior nutcracker syndrome C) Coronal reformatted CT MIP image shows marked dilatation of the left ovarian vein (arrows) Nutcracker syndrome In a 22-year-old woman with progressive left lower quadrant pain and flank pain, as well as microscopic hematuria. (c)Coronal reformatted image shows tortuous and dilated retroperitoneal varices (arrowheads) along the course of the left ureter. (d)Intravenous urographic (IVU) image shows multiple indentations on the left ureter (arrows) caused by retroperitoneal collateral vessels.
- #34 Nutcracker syndrome In a 22-year-old woman with progressive left lower quadrant pain and flank pain, as well as microscopic hematuria. (e)Axial CT image of the pelvis shows left-sided periuterine varices (arrow) A 50-year-old woman with anterior nutcracker syndrome. bCT image at the level of the pelvis demonstrates multiple pelvic varices (arrows). Left varicocele
- #35 Fig. 1. (Left) Preoperative abdominal CT scan showed the compression of the left renal vein (black arrow) between the superior mesenteric artery (white arrow) and the abdominal aorta. (Right) Left renal venography demonstrated periureteral venous collaterals (white arrow) with reflux into the gonadal and adrenal veins. The pressure gradient between the inferior vena cava and the left renal vein (black arrow) was 5 cm H2O. . Nutcracker syndrome. A: B-mode ultrasound showing left renal artery stenosis between the superior mesenteric artery and the aorta, with pre-stenotic ectasia. B: Doppler ultrasound showing an accentuated increase in velocity in the left renal vein immediately downstream of the stenosis. With spectral Doppler, it is possible to measure the post-stenotic peak velocity, which is normally above 100 cm/s(18).
- #37 The saphenous vein can be used to bypass the compressed segment of the left renal vein without the need for transection and transposition of the left renal vein Other less frequently used open surgical techniques include renal autotransplantation, transposition or bypass of the superior mesenteric artery and renopexy to treat renal ptosis.
- #39 Relationship between the LRV and the duodenum in the angle between the aorta and the SMA. (a)Drawing illustrates a normal AMA and AMD, which are promoted by the presence of retroperitoneal fat in the angle. (b)Drawing illustrates compression of both the LRV and the duodenum when the AMD is decreased, with an associated decrease in the AMA.
- #43 Conditions associated with rapid and severe weight loss, resulting in a loss of retroperitoneal fat, with resulting decreases in AMA and AMD and duodenal compression. These conditions include wasting conditions such as acquired immunodeficiency syndrome, malabsorption, cancer, and other conditions associated with cachexia; catabolic conditions such as burns and major surgery; eating disorders (eg, anorexia nervosa); drug abuse; and conditions following weight loss–related surgeries (eg, bariatric surgery) (22,23). Patients who have undergone corrective surgery for scoliosis, in whom lengthening of the spine is postulated to increase tension on the mesentery and thus decrease AMA and AMD A hip spica cast keeps your child's hips (pelvis) and one or both legs in the right position to heal. They will not be able to move their thighs or bend at the hips. A child gets a hip cast when they break a bone in the thigh or have hip surgery. It can only be put on in an operating room.
- #46 SMA syndrome in a 37-year-old woman with intentional weight loss, early satiety, and a 1-year history of epigastric pain. (c)Midline sagittal reformatted MIP image reveals steep angulation of the SMA (arrowheads) and a short AMD of 4 mm. (b)Axial CT image shows compression of the mid-transverse duodenum (black arrow) in the markedly narrowed space between the aorta and the SMA (white arrow). (a)Coronal reformatted image from an abdominal CT study shows a markedly dilated stomach.
- #47 Figure 2: Abdominal radiograph after one-hour demonstrate persistent contrast pooling in the proximal duodenum with an abrupt cut-off at its third part (arrows), coinciding with the superior mesenteric artery impression. (a) and (b) Dilation of the duodenum with abrupt cut-off at its third part, coinciding with the line of the SMA (red line).
- #53 Left common iliac vein compression by the right common iliac artery. Chronic changes in the left common iliac vein secondary to endothelial damage with (a) intraluminal spurs, (b) webs and (c) channels are depicted. References: Butros SR, et al.L. Venous compression syndromes: clinical features, imaging findings and management. Br J Radiol 2013;86:20130284.
- #54 Thrombus filled common and proximal external iliac vein longitudinal Phlegmasia cerulea dolens represents a rare and grave sequel of extensive iliofemoral vein thrombosis that is characterized by acute limb ischemia, which can progress to gang This latter is characterized by blue and painful leg, due to massive deep venous thrombosis combined with arterial occlusion determined by concomitant compartment syndrome [28]. Phlegmasia is a term that has been used to describe extreme cases of lower extremity DVT, which may progress to critical limb ischemia and potentially limb loss. This entity was first described by Fabricius Hildanius in the 16 century, and then in 1938, it was Gregoire who coined the term phlegmasia cerulea dolens translating to “painful blue inflammation,” differentiating it from the more commonly seen phlegmasia alba dolens or “painful white inflammation.”[3] PAD, also referred to as “milk leg,” references the early stages of this process due to compromise of arterial inflow secondary to extensive clot burden. PCD is a more advanced progression and is a precursor to venous gangrene.rene. The exact prevalence of MTS isnunknown, but it is assessed to occur in 2–5% of patientsnpresenting with lower extremity venous disorders Incidence of thrombosis is one to two out of every 1000 persons per year (37). A higher prevalence of thrombosis in the left leg (~60% of cases) than in the right leg (~40%) has been reported (37). May and Thurner (36) found a spurlike projection in the proximal left CIV in 22% of 430 cadavers. In later studies, the prevalence of venous spurs has been reported to be 49%–62% in patients with left iliofemoral thrombosis (38).
- #55 Thrombus filled common and proximal external iliac vein longitudinal Phlegmasia cerulea dolens represents a rare and grave sequel of extensive iliofemoral vein thrombosis that is characterized by acute limb ischemia, which can progress to gang Phlegmasia is a term that has been used to describe extreme cases of lower extremity DVT, which may progress to critical limb ischemia and potentially limb loss. This entity was first described by Fabricius Hildanius in the 16 century, and then in 1938, it was Gregoire who coined the term phlegmasia cerulea dolens translating to “painful blue inflammation,” differentiating it from the more commonly seen phlegmasia alba dolens or “painful white inflammation.”[3] PAD, also referred to as “milk leg,” references the early stages of this process due to compromise of arterial inflow secondary to extensive clot burden. PCD is a more advanced progression and is a precursor to venous gangrene.rene.
- #56 An 85-year-old man with May-Thurner syndrome. Coronal (a) and axial (b) contrast-enhanced CT images show thrombosed left common iliac vein (arrows) compressed between the right common iliac artery (arrowheads) and fifth lumbar vertebra
- #57 Drawing illustrating double May-Thurner syndrome. Coronal and sagittal views showing a compression ( * ) of left common iliac vein in two points respectively by the right common iliac artery (white arrow) and left common iliac artery (grey arrow) against the lumbar spine.
- #58 An 85-year-old man with May-Thurner syndrome. Coronal (a) and axial (b) contrast-enhanced CT images show thrombosed left common iliac vein (arrows) compressed between the right common iliac artery (arrowheads) and fifth lumbar vertebra CTAngiography.(A)Axialand(B)coronalMIPreconstructionimagesshowsubcutaneouscollateralveinswhich connectsRCFV(arrow) withLFCV(arrowhead). Time-resolved imaging technique depicting suprapubic, pre-sacral and abdominal wall collateral vessels (red arrows) associated with signs of left external iliac vein thrombosis (blue arrow).
- #59 Figure 1. Compression of the left common iliac vein (CIV) by the right common iliac artery (CIA) over the fifth lumbar vertebra (A). The vein velocity ratio is 5.8. Narrowing of the CIV is apparent with mosaic color due to aliasing from the high velocity. No flow is seen in the left CIV, whereas normal flow is observed in the right CIV (B). This is a less common type of compression where both the right and left CIA compress the left CIV.
- #60 Thrombus filled common and proximal external iliac vein longitudinal Phlegmasia cerulea dolens represents a rare and grave sequel of extensive iliofemoral vein thrombosis that is characterized by acute limb ischemia, which can progress to gang This latter is characterized by blue and painful leg, due to massive deep venous thrombosis combined with arterial occlusion determined by concomitant compartment syndrome [28]. Phlegmasia is a term that has been used to describe extreme cases of lower extremity DVT, which may progress to critical limb ischemia and potentially limb loss. This entity was first described by Fabricius Hildanius in the 16 century, and then in 1938, it was Gregoire who coined the term phlegmasia cerulea dolens translating to “painful blue inflammation,” differentiating it from the more commonly seen phlegmasia alba dolens or “painful white inflammation.”[3] PAD, also referred to as “milk leg,” references the early stages of this process due to compromise of arterial inflow secondary to extensive clot burden. PCD is a more advanced progression and is a precursor to venous gangrene.rene. The exact prevalence of MTS isnunknown, but it is assessed to occur in 2–5% of patientsnpresenting with lower extremity venous disorders Incidence of thrombosis is one to two out of every 1000 persons per year (37). A higher prevalence of thrombosis in the left leg (~60% of cases) than in the right leg (~40%) has been reported (37). May and Thurner (36) found a spurlike projection in the proximal left CIV in 22% of 430 cadavers. In later studies, the prevalence of venous spurs has been reported to be 49%–62% in patients with left iliofemoral thrombosis (38).
- #61 Thrombus filled common and proximal external iliac vein longitudinal Phlegmasia cerulea dolens represents a rare and grave sequel of extensive iliofemoral vein thrombosis that is characterized by acute limb ischemia, which can progress to gang This latter is characterized by blue and painful leg, due to massive deep venous thrombosis combined with arterial occlusion determined by concomitant compartment syndrome [28]. Phlegmasia is a term that has been used to describe extreme cases of lower extremity DVT, which may progress to critical limb ischemia and potentially limb loss. This entity was first described by Fabricius Hildanius in the 16 century, and then in 1938, it was Gregoire who coined the term phlegmasia cerulea dolens translating to “painful blue inflammation,” differentiating it from the more commonly seen phlegmasia alba dolens or “painful white inflammation.”[3] PAD, also referred to as “milk leg,” references the early stages of this process due to compromise of arterial inflow secondary to extensive clot burden. PCD is a more advanced progression and is a precursor to venous gangrene.rene. The exact prevalence of MTS isnunknown, but it is assessed to occur in 2–5% of patientsnpresenting with lower extremity venous disorders Incidence of thrombosis is one to two out of every 1000 persons per year (37). A higher prevalence of thrombosis in the left leg (~60% of cases) than in the right leg (~40%) has been reported (37). May and Thurner (36) found a spurlike projection in the proximal left CIV in 22% of 430 cadavers. In later studies, the prevalence of venous spurs has been reported to be 49%–62% in patients with left iliofemoral thrombosis (38).
- #64 Ureteropelvic junction obstruction in a 57-years-old man. Coronal MPR image from a CT angiography shows a crossing lower pole renal artery (arrowhead), branch of the main renal artery, causing a mild hydronefrosis. file:///C:/Users/wsrx02/Downloads/nrurol.2014.240.pdf
- #65 most commonly “crossing vessels” passing above the ureteric transition point. Particularly, the lower pole segmental renal vessels (artery or vein) may arise from the main renal artery or vein, or branch as accessory vessels directly from the abdominal aorta, iliac artery, or inferior vena cava [1]. Lower-pole segmental artery can bow anteriorly (Fig. 12) or posteriorly over the ureter. Lower pole crossing vessels are found in about 20% of healthy patients, while their incidence is up to 45% in patients with UPJO [35] Furthermore, UPJ obstruction also occurs in the absence of crossing vessels (62). Thus, the causal relationship between crossing vessels and UPJ obstruction remains controversial, with ongoing debate as to whether these are causative, aggravating, or incidental factors.
- #66 Drawings show left UPJO with hydronephrosis in which the dilated extrarenal pelvis and proximal ureter bow anteriorly (a) or posteriorly (b) over the lower-pole segmental artery. Note that, when there is significant hydronephrosis, the UPJO site is frequently more cephalad behind the overgrown pelvis. UPJ ureteropelvic junction.
- #69 UPJ obstruction in a 34-yearold man with right flank pain and hematuria. Coronal reformatted image from a CT urographic study shows an early branching right lower pole segmental artery (arrow) crossing the ureteropelvic transition. (b) Sagittal reformatted image shows a markedly dilated renal pelvis and renal parenchymal atrophy. The crossing vessel is also seen (arrow). (c) Three-dimensional VR image shows greater dilatation of the renal pelvis (arrowhead) compared with the intrarenal calices, a characteristic finding in UPJ obstruction. Note also the hooked appearance of the proximal ureter as it crosses over the artery UPJ obstruction in a 55-year-old man with a 2-year history of worsening postprandial abdominal pain. The patient had normal findings at urinalysis and no flank pain. Coronal reformatted image from an abdominal CT study shows severe right-sided hydronephrosis with cortical thinning and a decompressed proximal ureter (arrow). (b) Axial CT image shows an accessory right renal vein (arrowheads) draining into the IVC and crossing the UPJ. The accessory vein was believed to be the cause of the UPJ obstruction in this case.
- #70 Antegrade pyelogram showing typical appearance of an anterior crossing vessel causing UPJ obstruction with a patent UPJ, marked posterior angulation of the initial short ureteral segment, and an extrinsic compression of the obstructed ureter by the crossing vessel Crossing artery and vein at the UPJ. (a)Pyelo-gram obtained in a patient in the supineposition 30 minutes after the intravenousinjection of a contrast agent demonstrates UPJobstruction (arrow) with severe hydronephro-sis on the right side. (c)Longitudinalcontrast-enhanced CDI scan shows a markedincrease in the color Doppler signals, withdepiction of two vessels crossing anteriorly tothe UPJ. The artery is indicated by the solidarrows, and the vein is indicated by the openarrow.
- #75 Ureteropelvic junction obstruction in a 57-years-old man. Coronal MPR image from a CT angiography shows a crossing lower pole renal artery (arrowhead), branch of the main renal artery, causing a mild hydronefrosis. file:///C:/Users/wsrx02/Downloads/nrurol.2014.240.pdf
- #76 Ureteropelvic junction obstruction in a 57-years-old man. Coronal MPR image from a CT angiography shows a crossing lower pole renal artery (arrowhead), branch of the main renal artery, causing a mild hydronefrosis. file:///C:/Users/wsrx02/Downloads/nrurol.2014.240.pdf
- #77 It occurs most frequently during pregnancy due to the hormonal changes with ovarian vein dilatation, valvular incompetence, and decreased muscular ureteral tone [40]. OVS should be differentiated from pelvic congestion syndrome, which consists of the dilatation of the entire anastomotic pathway of the pelvic venous system (ovarian, uterine, iliac), frequently with caudal extension to the lower extremity veins [41].
- #78 Usually, a prior unenhanced study of the abdomen and pelvis in the form of a CT-KUB has been performed or undertaken before the split bolus component, excluding nephrolithiasis as the cause of the hematuria. Then, the patient receives 50 mL of IV contrast followed by an additional 50 mL eight minutes later. Images are then acquired 55 seconds following the second dose of IV contrast. In some centers the patient may be asked to lie in a prone position.
- #79 Fig. 1. A and B Illustration of the retrocaval right ureter in A. An excretory urographic image in B depicts a patient with a retrocaval ureter and distended proximal ureter.
- #80 Distal ureteral compression in a 39-year-old woman with hematuria. Threedimensional VR (a)and sagittal reformatted (b)images from a CT urographic study show a mild extrinsic indentation (arrowhead) on the distal right ureter resulting from its crossing over the right CIA (arrow in b), causing mild proximal hydroureter and hydronephrosis.
- #81 An 83-year-old man with ureteral vascular compression. Sagittal CT image on arterial phase shows right hydroureteronephrosis (arrow) secondary to compression by a saccular aneurysm (arrowhead) of the adjacent right common iliac artery
- #82 Proximal ureteral compression in a 57-year-old woman with left-sided abdominal pain, a sensation of flank fullness, and hematuria. Coronal reformatted (a)and 3D VR (b)images from a CT urographic study show mild proximal left hydroureter (arrowhead in b) and hydronephrosis, findings that are the result of extrinsic compression by a crossing left ovarian vein (arrow in a).
- #83 An 84-year-old woman with upper ureteral vascular compression. Coronal enhanced CT image shows the proximal ureter (arrow) compressed by a dilated ovarian vein
- #84 Ureteropelvic junction obstruction in a 57-years-old man. Coronal MPR image from a CT angiography shows a crossing lower pole renal artery (arrowhead), branch of the main renal artery, causing a mild hydronefrosis. file:///C:/Users/wsrx02/Downloads/nrurol.2014.240.pdf
- #91 Color Doppler ultrasound of the liver shows absent flow within the thrombosed main portal vein and adjacent collateralized flow (cavernous transformation of the portal vein). Note the presence of ascites. A: Ultrasound examination showing dilatation of the intrahepatic bile ducts; B: Doppler ultrasound examination demonstrating cavernomatous degeneration of the portal vein with hilar collateral circulation.
- #92 Figure 2 Magnetic resonance cholangiopancreatography. A: Coronal T2 weight Magnetic resonance indicates marked dilatation of the intra-and extra-hepatic bile duct (*), with presence of vascular structures with void flow that exert extrinsic compression (arrowheads), corresponding to the cavernoma. B: Coronal maximum intensity reconstruction shows the severity of the dilatation of the intra- and extra-hepatic bile duct (*) with notable narrowing of the distal common bile duct (arrow).
- #93 Figure 3 Pancreatic endoscopic retrograde cholangiopancreatography image indicates the site of stenosis of the bile duct (arrow) and a marked dilation of the biliary radicals.
- #94 Figure 3 Pancreatic endoscopic retrograde cholangiopancreatography image indicates the site of stenosis of the bile duct (arrow) and a marked dilation of the biliary radicals.
- #95 Colangiografia percutânea demonstrando dilatação das vias biliares até o duto biliar comum, com redução abrupta de calibre no terço médio do colédoco. B:Dreno tipo interno-externo na via biliar colocado percutaneamente. C:Ultrassom com Doppler evidenciando veia pericoledociana ao redor do dreno (seta) no hepatocolédoco.
- #97 ranging from vague abdominal pain, nausea and vomiting, loss of weight to acute abdominal hemorrhage, arterial ischemia and embolism or venous stasis and thrombosis, making the clinical diagnosis particularly challenging The combination of noninvasive imaging modalities, which allow the precise evaluation of anatomical structures, and invasive techniques, such as venography or arteriography that are useful for the direct measurement of pressure gradients, is helpful to establish the definitive diagnosis. However, the invasive procedures should be limited to the most doubtful cases or when the endovascular treatment needs to be performed
- #100 Malignancies of the hematopoietic and lymphoid tissues include the lymphomas, leukemias, myeloproliferative neoplasms, mast cell neoplasms, plasma cell neoplasms, histiocytic tumors, and dendritic cell neoplasms. Multiple classification schemes have been employed for these diseases over the years. T