肝内“假平行管征”的超声研究

目的：研究肝内“假平行管征”的超声表现及其临床意义。方法：检查正常成人214例,观察肝右后下静脉（IRHV）的超声表现,统计其显示率,并对10例肝动脉分支扩张的患者进行彩色多普勒和频谱多普勒超声检查。结果：IRHV的显示率为24％,在第一肝门水平注入下腔静脉,和门静脉右后叶支相伴而行,形成“平等管征”。肝内扩张的肝动脉分支在二维超声上与伴行门静脉分支亦构成“平行管征”,但彩色多普勒显示双管内均有血流信号,频谱多普勒分别探测动脉血流频谱和静脉血流频谱。结论：认识IRHV和肝内扩张的肝动脉分支有助于鉴别真假“平行管征”,有助于阻塞性黄疸的鉴别诊断。     

Laparoscopic surgery for the treatment of a ruptured aneurysm of the right gastric artery: a case report

Laparoscopic surgery for the treatment of a ruptured visceral artery aneurysm is recognized as a challenging procedure. Here, we describe our experience with laparoscopic surgery to treat a ruptured aneurysm of the right gastric artery. A 72‐year‐old woman was diagnosed with intra‐abdominal hemorrhage caused by a ruptured aneurysm of the right gastric artery. Transcatheter arterial embolization failed because the right gastric artery could not be cannulated. Therefore, we performed laparoscopic surgery. Using laparoscopy, we detected that the bleeding from the aneurysm had ceased; thus, the planned procedure was successful. The operative time and intraoperative blood loss were 100 min and 5 mL, respectively. The patient was discharged 7 days after surgery. Laparoscopic surgery after the failure of transcatheter arterial embolization is a suitable and safe procedure for ruptured visceral artery aneurysms, provided the circulatory dynamics are stable as a result of the temporary cessation of bleeding from the ruptured aneurysm.     

CT of agenesis and atrophy of the right hepatic lobe

Background: To identify and differentiate agenesis and severe atrophy of the right hepatic lobe on computed tomography (CT). Methods: The CT examinations of three cases of agenesis and 11 cases of severe atrophy of the right hepatic lobe were reviewed. We evaluated visibility of the three hepatic veins, the two main portal veins (including their branches if necessary), the dilated intrahepatic ducts, enlargement of the medial and lateral segments of the left lobe and caudate lobe of the liver, presence of a retrohepatic gallbladder, hyperattenuation of the atrophic liver parenchyma, posterolateral interposition of the hepatic flexure of the colon, and upward migration of the right kidney. Results: In the three cases of agenesis, no structure can be recognized as the right hepatic vein, right portal vein, or dilated right intrahepatic ducts. In the 11 cases of severe lobar atrophy, the right portal vein (or its branches) was recognized in eight cases, the right hepatic vein in four cases, and the dilated right intrahepatic ducts in 11 cases. The degree of enlargement of the lateral segment does not necessarily change inversely with the size of the medial segment and the caudate lobe. The retrohepatic gallbladder is present in eight cases (two in agenesis and six in atrophy). The phenomenon of hyperattenuation of the atrophic liver parenchyma was noted in six cases. Conclusion: Even though a retrohepatic gallbladder and a severely distorted hepatic morphology due to compensatory hypertrophy of the left and caudate lobes may raise a suspicion of agenesis of the right lobe of the liver, absence of visualization of all of the right hepatic vein, right portal vein and its branches, and dilated right intrahepatic ducts is a prerequisite of the diagnosis of agenesis of the right hepatic lobe on CT. In severe lobar atrophy, at least one of these structures is recognizable. Received: 1 March 1997/Accepted after revision: 25 June 1997     

A huge intrahepatic portal vein aneurysm

Portal vein aneurysm is an unusual vascular abnormality. We report a rare case of a huge intrahepatic portal vein aneurysm at the umbilical portion with hepatic encephalopathy. Abdominal contrast-enhanced dynamic computed tomography and angiography clearly showed a well-circumscribed, 50 x 40-mm portal vein aneurysm at the umbilical portion with portohepatic venous shunt. To our knowledge, this is the largest intrahepatic portal vein aneurysm ever reported.     

Pitfall: a pseudo tumor within the left liver lobe presenting with abdominal pain, jaundice and severe weight loss

A 51 year old male patient with a history of chronic alcohol consumption and recurrent pancreatitis was referred to our hospital with jaundice, epigastric pain, severe diarrhoea and weight loss of 28 kg within the last 12 months. A CT scan of the abdomen 4 months before admission had shown a pancreatitis with free fluid around the corpus and tail of the pancreas as well as dilated intrahepatic bile ducts and a cavernous transformation of the portal vein. Moreover, a tumor (3.5 x 3.0 x 3.6 cm) with irregular contrast enhancement was seen within the left liver lobe. The patient was referred to us for further evaluation and treatment. The initial B-Mode sonogram revealed a bull's eye like well defined lesion (8.1 x 7.5 x 7.0 cm) within the left liver lobe, consistent with a tumour or abscess. Prior to a diagnostic needle biopsy a PTCD was performed in this case presenting with dilated intrahepatic bile ducts and having a history of Billroth II operation. An additional colour coded Duplex Doppler ultrasonography demonstrated a visceral artery aneurysm and prevented us from performing the diagnostic puncture. The aneurysm was assumed to originate from a variant or a branch of the left hepatic artery. Angiography revealed a pseudoaneurysm of the pancreaticoduodenal artery and coil embolization was performed because of the increasing size and the risk of a bleeding complication. Postinterventional colour duplex ultrasound measurement showed no blood flow within the aneurysm. Retrospectively, the pseudoaneurysm must have led to a compression of the common bile duct, since the patient did not develop cholestasis after embolization and removal of the PTCD. Thus, a pseudoaneurysm of the pancreaticoduodenal artery must be included in the differential diagnosis of liver tumours in patients with chronic pancreatitis, despite its unusual localization near the liver. Therefore, we suggest that colour coded ultrasonography should be applied to any unclear, bull's eye like lesion, even though this method alone cannot exactly determine the origin of the pseudoaneurysm. Interventional angiography remains the gold standard for the diagnosis and therapy of visceral artery aneurysm.     

Acute rupture of an aortic false aneurysm treated with a stent-graft.

PURPOSE: To report the use of an aortic endograft to treat a ruptured false aneurysm at the anastomosis of an aortofemoral bypass graft. METHODS AND RESULTS: A 68-year-old man with a 30-year-old aorto-right femoral bypass and multiple comorbidities was admitted to the hospital complaining of acute abdominal pain. Imaging identified a 60-mm ruptured aortic false aneurysm with associated retroperitoneal hematoma, a 9-cm right femoral false aneurysm, and a calcified 23-mm left common iliac aneurysm. Two slightly overlapping Vanguard straight stent-grafts were implanted in the aorta and left common iliac artery in an emergency procedure owing to the patient's high surgical risk. The anastomotic false aneurysm and the bypass were excluded. A left-to-right femorofemoral bypass was performed to re-establish flow to the right femoral artery with ligation of the external iliac artery. The patient recovered uneventfully. He remained well with a successful repair until his death of a myocardial infarction 6 months after the procedure. CONCLUSIONS: Endovascular grafting can be used successfully for the urgent treatment of aortic false aneurysm rupture.     

Spontaneous rupture and thrombosis of an intrahepatic portal vein aneurysm

Aneurysm of the portal venous system, a localized fusiform or saccular dilatation, is a rare clinical abnormality. Most aneurysms are located in the extrahepatic segment and rarely in intrahepatic branches. Portal vein aneurysms are usually uncomplicated and asymptomatic and detected incidentally during diagnostic work-up. We describe a case of a bleeding intrahepatic portal vein aneurysm studied with ultrasonography, color Doppler, computed tomography, and percutaneous transhepatic portography in a noncirrhotic patient. Although there are 43 published cases of portal vein aneurysm in the English-language literature, neither rupture and spontaneous thrombosis of an intrahepatic portal vein aneurysm nor its nonsurgical conservative treatment has been reported.     

彩色多普勒超声对原位肝移植术后肝动脉血栓形成的诊断

目的评价彩色多普勒超声对原位肝移植患者术后肝动脉血栓形成的诊断价值.方法分析和总结6例原位肝移植后肝动脉血栓形成患者的彩色多普勒超声检查资料,6例患者均经手术或造影证实.结果 5例肝门和肝内门静脉周围均没见肝动脉血流信号,其中1例膈下动脉分支伸入肝内形成侧支循环, 另1例术后第3天肝动脉血流信号显示,术后第5天未见肝动脉血流; 6例均见门静脉流速增高;3例肝内见坏死灶;2例肝内胆管轻度扩张;2例Glisson鞘回声增强.结论彩色多普勒超声对肝移植后肝动脉血栓形成的诊断有重要作用.     

彩色多普勒超声对肝移植术后并发症的诊断价值

目的评价彩色多普勒超声对肝移植术后并发症的诊断价值。方法回顾性分析和总结26例肝移植术后并发症的彩色多普勒超声检查资料,检测指标包括肝动脉及左右分支的峰值速度（HAPV）、阻力指数（RI）、加速度及加速时间,门静脉平均流速,肝实质及胆管回声。结果6例经手术或造影证实为血管并发症（肝动脉血栓形成1例,肝动脉狭窄2例,肝动脉痉挛1例,门静脉狭窄2例）,彩色多普勒超声表现有肝动脉狭窄处的高速高阻血流并伴有湍流,而狭窄远端峰值速度〈40cm／s,RI〈0．5,加速时间〉0．08s,加速度〈300cm／s^2,1例肝动脉血栓形成肝门部无动脉血流信号;6例急性排斥反应,3例胆管结石并扩张。结论彩色多普勒超声对肝移植术后血管并发症的诊断具有重要的指导意义。     

Successful arterial embolization of arteriovenous fistula in the portal circulation

We successfully performed arterial embolization of an arteriovenous fistula between the left gastric artery and vein. The increased blood flow in the portal vein via the left gastric vein and the arteriovenous fistula induced severe portal hypertension. After obliteration of the left gastric artery, the arteriovenous fistula was not opacified on angiography and the portal hypertension improved.     

超声造影评估门静脉高压患者手术前后肝内血流动力学变化

目的 探讨应用CEUS评估门静脉高压患者术后肝内血流动力学变化的价值。方法 对接受手术治疗的17例门静脉高压症患者于手术前后均行CEUS检查, 记录肝动脉到达时间(HAAT)、门静脉到达时间(PVAT)及肝静脉到达时间(HVAT), 计算肝动静脉渡越时间(HAVTT)及门静脉-肝静脉渡越时间(PV-HVTT), 对手术前后各参数进行统计学比较。结果 门静脉高压症患者HAVTT及PV-HVTT在手术后较手术前明显延长, 差异有统计学意义(P均 <0.05)。HAAT、PVAT及HVAT手术前后的差异无统计学意义(P均 >0.05)。结论 CEUS参数中, HAVTT及PV-HVTT可用以较好地评估门静脉高压症患者肝内血流动力学变化, 为无创性评价门静脉高压患者术后近期疗效提供了新的方法。     

Endovascular management of a carotid aneurysm into the sphenoid sinus presenting with epistaxis

Non-traumatic cavernous internal carotid artery (ICA) aneurysms are rare, and favour the occurrence of massive recurrent epistaxis, which is associated with a high mortality rate. We report the case of a 67-year-old woman presenting a ruptured ICA aneurysm extending into the sphenoid sinus, revealed by epistaxis. Selective coil embolization of the aneurysm was performed. Flow-diverter stents were deployed in order to utterly exclude the aneurysm and prevent revascularization. Anti-platelet treatment was provided to lower the risk of in-stent thrombosis. A left frontal hematoma associated with a subarachnoid haemorrhage occurred at day 2. Outcome was favourable with no neurological sequelae, and no clinical recurrence of epistaxis occurred. A 4 months follow-up digital subtraction angiography showed a complete exclusion of the aneurysm. In addition, a magnetic resonance cerebral angiography at 16 months showed stable results. Thus, this two-stage endovascular procedure has proven its effectiveness in preventing epistaxis recurrence while preserving the ICA patency.     

Ruptured abdominal aortic aneurysm presenting as buttock pain

This is the first case report of a ruptured aortic aneurysm presenting with acute right buttock pain. The patient was an 80 year old man. A literature search revealed one report of ruptured internal iliac artery aneurysm presenting with acute hip pain and another of an unruptured aortic aneurysm presenting with chronic hip pain. Thus the present case is another unusual presentation of ruptured abdominal aortic aneurysm and highlights the importance of careful history taking and clinical examination. A high index of clinical suspicion of aneurysm rupture should be maintained in elderly patients presenting with a history of collapse.     

门静脉高压症介入治疗前后血流动力学变化分析

目的探讨肝炎后门静脉高压症的多重介入治疗方法的可行性.方法分析22例部分脾动脉栓塞术和12例行经颈内静脉肝内门体分流术并胃冠状静脉栓塞术患者的彩色多普勒检查资料.结果经颈内静脉肝内门体分流术并胃冠状静脉栓塞术后脾静脉、门静脉管径缩小(P<0.05),门静脉、脾静脉流速流量明显增加,呈高动力状态.部分脾动脉栓塞术后脾静脉、门静脉平均血流速度降低(P<0.05),血流量明显减少(P<0.01).结论经颈内静脉肝内门体分流术并胃冠状静脉栓塞术若与部分脾动脉栓塞术联合运用可缓解门脉系循环高动力状态、降低门静脉压力.     

Is positive end-expiratory pressure suitable for liver recipients with a rescue organ offer?

Purpose

Rescue organ offers may help to overcome the organ shortage. However, because of initial poor liver function, the recipient may develop a severe lung injury with the requirement for higher positive end-expiratory pressure (PEEP) levels to achieve adequate oxygenation. Positive end-expiratory pressure has been associated with perfusion impairment in the hepatosplanchnic area. We assessed the effects of increased PEEP levels on systemic hemodynamic and liver perfusion in liver transplantation (LT) patients with a rescue organ.

Methods

Twenty-four LT recipients of a rescue organ offer were enrolled. All patients were postoperatively mechanically ventilated with biphasic positive airway pressure, and 3 different PEEP levels (0, 5, 10 mbar) were randomly set within 4 hours after admission at the intensive care unit. Systemic hemodynamic parameters were recorded using a pulmonary artery catheter; and flow velocities of the hepatic artery, portal vein, and right hepatic vein were measured using Doppler.

Results

Positive end-expiratory pressure of 10 mbar did not impair the systemic hemodynamic. Flow velocities in the right hepatic vein, the portal vein, and the hepatic artery were not influenced by PEEP.

Conclusion

Our study demonstrates that PEEP up to 10 mbar did not impair the liver outflow in recipients with a rescue organ offer.     

Prenatal diagnosis of abnormal course of umbilical vein and ductus venosus agenesis: Report of three cases

Ductus venosus connecting the portal and embryonic venous circulation into the inferior vena cava has a crucial role in fetal circulation. The absence of ductus venosus is a rare anomaly, in which the umbilical vein connection to the venous system may be extrahepatic, bypassing the liver or intrahepatic via the portal venous system. We report three cases of ductus venosus agenesis with associated anomalies. In two of them the connection was directly to the right atrium, whereas the umbilical vein drained to the left internal iliac artery in the third case. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2012;     

Splenic artery aneurysms encountered in the ED: 10 years' experience

Objective

Our objective was to report 7 cases of splenic artery aneurysm (SAA) encountered in the emergency department (ED).

Methods

A retrospective survey of our ED database revealed 7 cases of SAA (6 men, 1 woman; mean age, 56 years) of 651 347 ED visits over the last decade. Their clinical and imaging features, management, and outcomes were evaluated.

Results

Splenic artery aneurysm in the ED was rare (prevalence, 0.011%). Common presentations included acute abdomen (n = 5) and shock (n = 2). Five cases had liver cirrhosis and portal hypertension. Abdominal radiographs (n = 7) revealed 2 atherosclerotic patients with SAA. Abdominal computed tomography (n = 7) depicted all SAAs (size, 1.5-8 cm; mean, 3.8 cm). Four ruptured SAAs were successfully managed with coils embolization. Among them, 1 patient with ruptured mycotic SAA also received surgery, but the patient died of Klebsiella sepsis 3 months later.

Conclusions

In the ED, ruptured SAA should be included as a rare differential consideration of acute abdomen, especially in middle-aged men with liver cirrhosis and portal hypertension. Although SAA may be an unexpected computed tomographic finding, once diagnosed, endovascular treatment is recommended.     

Thrombectomy of portal vein thrombosis in living donor liver transplantation

We describe a case of living donor liver transplantation where an intrahepatic portal vein embolism was detected by intraoperative ultrasonography after the completion of portal and arterial anastomoses. The recipient portal vein trunk was clamped and the ligature of the graft's right portal branch was released, thus maintaining the sole arterial supply. Backward flushing of the portal system was achieved, which removed the clot through the reopened right portal branch without the need for thrombectomy by Fogarty balloon catheter.     

肝硬化门脉高压患者入肝血流的超声评价

目的观测肝硬化门脉高压患者入肝血管(肝动脉、门静脉)血流动力学,探讨其与Child-Pugh肝功能分级、临床预后的关系.方法应用彩色多普勒超声分别检测35例正常健康人和37例肝硬化门脉高压患者的人肝血管的血流参数,分析肝硬化门脉高压入肝血管血流动力学参数与肝硬化分级关系.结果肝硬化门脉高压患者门静脉内径增宽,血流速度下降,充血指数增高,肝动脉血流阻力增高,与对照组有明显差异;肝硬化门脉高压患者Child-Pugh肝功能分级与门静脉内径无显著差异(P＞0.05),Child C级门静脉血流量显著减少,Child肝功能分级与门静脉的充血指数有关.结论测定入肝血管血流动力学参数有助于判断肝硬变门脉高压症的预后,为临床诊治提供依据.     

CT 和MR三维血管成像技术对于TIPSS的价值

目的 探讨CT血管造影及MR血管造影对门脉高压患者TIPSS治疗的价值。方法 TIPSS术前10例患者进行了三维MR血管造影，2例用MR团注技术测量门脉血流速度。60例进行了三维CT血管造影。所有病例经临床和DSA证实为肝硬化门脉高压，其中，68例行TIPSS治疗。MR血管造影使用西门子1．5T MR机，CT血管造影使用GE High Speed CT／i扫描机。结果 MR血管造影：10例患者均可见门静脉主干及其肝内分支扩张，但其中2例有布加综合征的表现。3例患者可见侧支循环及静脉曲张，表现为胃左静脉丛和左肾静脉曲张、脾肾分流。应用MR“团块追踪”技术测量了2例门脉主干的血流速度，分别为11．8cm／s和10．6cm/s。CT血管造影：准确地显示了60例患者的肝动静脉解剖、门脉主干扩张及其小血管分支，以及19例侧支循环及曲张血管。结论 CT血管造影和MR血管造影是一种无创性的检查方法，可充分显示肝静脉和门静脉解剖及变异，为TIPSS术前提供了重要信息。CT血管造影的空间分辨率优于MR血管造影。