Surgical Pathology & X-rays

for Medical Students

VASCULAR
 Index Aorto-iliac disease •Carotid stent
•Localized iliac disease
Angiographic anatomy •Carotid body tumour
•Fem-fem bypass
Types of angiography •Leriche syndrome Renal artery stenosis
Atherosclerosis •Aorto-bifemoral bypass DVT
Blue toe syndrome Femoro-popliteal disease •Phlegmasia & v. gangrene
Abdominal aortic aneurysm •Localized SFA disease •Diagnosis of DVT
•Autopsy specimens •Long SFA occlusion PE
•Imaging of AAA Infra-popliteal disease •Diagnosis of PE
•Complications of AAA Acute ischemia •Lung scan
•Operative repair of AAA Upper limb ischemia •Pulmonary angiography
Iliac aneurysm •Acute axillary embolism •CT pulmonary angiography
Femoral aneurysm •Burger’s & 2ry Raynouds •PE autopsy
Popliteal aneurysm •Pulseless disease •IVC filter
Brachial aneurysm •TOS SVC obstruction
Aortic dissection •Cervical rib Innominate vein occlusion
Chronic ischemia (grades) Carotid artery disease IVC obstruction
Treatment options •Internal carotid stenosis
2 © Vascular 2007

Balloon angioplasty •Carotid endartrectomy EXAMPLES

Angiographic anatomy
1. Lower abdominal
1 aorta
2 2. Common iliac
3. Internal iliac
4 3
4. External iliac
5. Common femoral
5 6. Superficial femoral
6 7 7. Deep femoral
The dotted yellow line is the inguinal ligament
3 © Vascular 2007
Index
Angiographic anatomy
1

1. External iliac
2
2. Common femoral
5 3. Superficial femoral
3 4. Deep femoral
5. Medial femoral
circumflex arteries
4 6. Perforating arteries

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Index
 Angiographic anatomy
of the tibial arteries

2
1. Popliteal
3
2. Anterior tibial
4
3. Peroneal
4. Posterior tibial
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Index
 Types of angiography
Conventional Digital CT MR
angiography subtraction angiography angiography

You can see the The bony 3D reconstruction is

bony skeleton skeleton is possible with spiral CT
subtracted
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Index
 Arterial atherosclerosis

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Index
Abdominal aorta opened – showing severe
atherosclerosis
Atherosclerosis usually affects large
and medium-sized arteries. The
process may begin in childhood and
often progresses when people grow
older. The damage begins in the
innermost layer of the artery
(endothelium)
Pathogenesis: Plaques (fats, cholesterol,
platelets, cellular waste products, calcium and
other substances) are deposited in the
damaged endothelium.
These deposits further stimulate the
cells in the artery walls to produce
factors that promote the proliferation of
smooth muscle cells and the
accumulation of lipids.
As a consequence, the artery is
progressively stenosed or occluded
© Vascular 2007
8
Index
Aorta opened, showing
atherosclerosis

Risk factors for

atherosclerosis are:
Hyperlipidemia
Hypertension
Diabetes mellitus
Smoking

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Index
 A diseased atherosclerotic aorta
may be the source for
athero-embolization to the lower
limbs. (Blue toe syndrome), were
the toes are cold, blue & iscemic
while the patient is having intact
pedal pulses

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Index
 Blue toe syndrome
Distal athero-embolism

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Index
 Abdominal Aortic Aneurysm
(AAA)
AAA

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Index
 Autopsy specimen
of abdominal aortic
aneurysm
The aneurysm is
below the renal
arteries
It does not involve
the iliac arteries
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Index
 A large abdominal
atherosclerotic aortic
aneurysm below the renal
arteries and above the
bifurcation
It is opened to reveal
layered mural thrombus
within the aneurysm
Mural thrombi can detach
14
and cause distal emboli
© Vascular 2007
Index
 Autopsy specimen showing:
Atherosclerotic abdominal
aorta (Opened)
Aortic aneurysm with a
mural thrombus

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Index
Infra-renal abdominal aortic
aneurism

This is a
postmortem
specimen
Note the
organized
laminated
thrombus
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Index
 Imaging for aortic aneurysm

Accidentaly discovered calcification on plane X-ray

U.S.
C.T.
Angiography
C.T. angiography with 3D reconstruction

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Index
 Plain X-ray
Calcifications in the wall
of AAA may be
accidentally discovered

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Index
Calcification within
the wall of the
abdominal aorta.
The lateral margin
of the calcification
is well to the left,
suggesting the
aorta is
aneurysmal.
The right iliopsoas outline
is obliterated, a sign of
leakage
19 © Vascular 2007
Index
US examination showing
abdominal aortic aneurysm When abdominal aortic
aneurysm is suspected
clinically (palpable aortic
pulsation on abdominal
examination),
ultrasonography should
be ordered as the first
investigation for
screening.
screening
US is noninvasive,
cheap & can determine
the diameter and
extension of the
aneurysm (relation to the
renal arteries)
20 © Vascular 2007
Index
CT scan showing AAA & mural thrombus
Aneurysm diameter is
directly proportionate to
incidence of rupture
Aneurysms with
diameter of 4cm or
more should be
operated upon because
they have a higher
0 1 2 3 4 5 incidence of rupture

The diameter of the aneurysm is measured & compared to the scale available

21 © Vascular 2007
Index
CT scan is the accurate
investigation to determine the
diameter of the aneurysm
CT accurately determines the
true extension of the aneurysm
•It is important to determine if
the upper limit of the aneurysm
is below, at, or above the
renal arteries because the
operative treatment is different
in each situation Ao

•It is important to determine if

the iliac arteries are also
aneurysmal K
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Index
Large AAA reaching the anterior abdominal wall
Clinical presentation: Visible pulsating abdominal swelling

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Index
Large AAA reaching the anterior abdominal wall
Clinical presentation: Visible pulsating abdominal
swelling

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Index
Abdominal aortic aneurysm Wall calcification

True lumen

Mural thrombus

Note
25 that the aneurysm is compressing the body of the lumbar vertebrae. ©
This patient
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presented with back pain.
Lateral view:

A large aortic aneurysm

with erosion of vertebral
bodies.
Note that inter-vertebral
discs are spared

Long standing back pain may be

the presenting symptom of AAA

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Index
An aortogram demonstrates aneurysmal dilatation of the
infrarenal portion of the aorta

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Index
Digital subtraction
angiography
showing:
Infra-renal
abdominal aortic
aneurysm
Angiography does NOT show
the true diameter of the
aneurysm. It only shows the
diameter of the patent lumen

CT scan showing © Vascular 2007

28
mural thrombus Index
CT angiography with 3D reconstruction
Infra-renal aortic aneurysm

Recently, CT angiography
with 3D reconstruction of the
arterial tree is gradually
replacing conventional CT
and angiography
It is more accurate than
older CT & less invasive than
angiography as the dye in
injected intravenously

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Index
 C.T. angiography
showing infra-renal aortic
aneurysm extending into
both iliac arteries

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Index
 Complications of AAA

Leak & rupture

Distal embilization (e.g. blue toe syndrome)

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Index
Leak & rupture

CT scan is the
investigation of
choice to
investigate
painful, ?leaking
or ruptured
aneurysm

Dye extravasation in the retroperitoneal space

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Index
 Leaking aortic aneurysm
The aneurysm wall is hazy, incomplete and the contrast
is seen outside the wall
Comments:
•Contained retroperitoneal
rupture is an extreme
emergency. It has a high
operative mortality (this the
reason way we prefer to
repair large (>4cm)
asymptomatic aortic
aneurysms as set
operations have much
lower mortality.
•Intraperitoneal rupture is
fatal. Patients usually don’t
reach hospital
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Index
 Ruptured (retroperitoneal) aortic aneurysm

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Index
CT showing ruptured aneurysm

Extravasation of
contrast
material
&hematoma

Anterior
displacement of
kidney

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Index
Distal embilization

Distal emboilsation of
cholesterol debris may
cause this picture
Cholesterol emboli
may occur
spontaneously (Blue
toe syndrome), or may
be iatrogenic during
surgery (Trash foot)

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Index
 Operative repair of AAA

Aneurysm
opened &
bifurcated
graft in
place

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AAA –operative view Bifurcated & straight grafts
Index
 Operative repair of AAA (another patient)

Aneurysm opened The bifurcated graft is first sutured

to the aorta from inside of the
Note the clots and
aneurysm
cholesterol debris.
In this patient, the 2 limbs of
These may cause distal
the graft are then sutured to
emblization
both iliac arteries

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Index
 Rt, common iliac artery aneurysm
Digital subtraction angiography: CT scan:

Note that the CT shows the true size of the aneurysm, while
angiography shows only the patent lumen
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The main complication of iliac aneurysm is rupture Index
Angiography showing a saccular aneurysm of the SFA
and relatively healthy arterial tree

This 23y old male gave past

history of two attacks DVT
He has recurrent oral &
genital ulcers

Diagnosis:
Behcet syndrome

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Index
Angiography showing Popliteal artery aneurysm
Common complications of
popliteal aneurism are:
Distal embolism with progressive
occlusion of the distal tibial
arteries (progressive chronic ischemia)
Acute thrombosis (acute ischemia)
Aneurysm rupture is a very rare
complication

N.B. The screening investigation for

suspected popliteal aneurysm is U.S. (not
angiography) because it is noninvasive &
shows the true diameter.

41 © Vascular 2007
Index
Post-traumatic
saccular aneurysm
of the popliteal
artery

Operative repair is
indicated in ALL saccular
aneurysms irrespective of
their diameter because
they all increase in size
and rupture by time
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Index
Post-traumatic false saccular
aneurysm of the brachial artery

Saccular Fusiform

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Index
Aortic dissection (post-mortem)

The dissection starts

from the ascending
aorta & extends into
the arch & descending
aorta
The extensively
dissected media is
filled with blood

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Index
Iliac artery dissection

Cross-sections of an iliac
artery into which dissection
had extended from the
True lumen False lumen
aorta. 
Note blood filling the false
lumen in the split media.
The true lumen is
compressed

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Index
 Aortic Dissection
Thoracic aorta

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Index
Aortic dissection

Notice the double lumen

The dissection extends into the celiac artery
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Index
Aortic dissection extending into the Lt. iliac artery

Notice the double lumen

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 Chronic Ischemia

Grade I Grade II Grade III Grade IV

Asymptomatic Claudication Rest pain (Rubber) Tissue loss

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Index
 Treatment options of chronic ischemia
Medical ttt

Active intervention

Balloon angioplasty (+/-

stent) For localized short lesions
Arterial bypass For diffuse long lesions
Extra-anatomical
bypass

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Index
Indications for balloon dilatation (with or without stenting)
Localized stenosis or occlusion
Good alternative in high risk patients

Localized Lt. common iliac PTA (percutanous

stenosis. transluminal angioplasty) &
Large collateral vessels stent placement
confirm hemodynamic
significance of the stenosis

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Localized SFA occlusion Index
 Aorto-iliac disease

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Index
Digital
subtraction
angiography:
Localized Lt.
common iliac
occlusion

Balloon angioplasty is the treatment of choice

53
in localized short stenotic lesions © Vascular 2007
Index
Digital subtraction angiography:
Localized Lt. common iliac severe stenosis –
ttt of choice is balloon angioplasty & stent

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 CT angiography
with 3D
reconstruction:
Left external iliac
artery stenosis

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Index
 Magnetic resonance
angiography (MRA)
Localized Lt. iliac stenosis
This patient underwent MRA
because he had an impaired
renal function and could not
tolerate injection of
conventional contrast material
MRA is accurate in the
diagnosis of proximal arterial
lesions (aorta, iliac & femoral)
First choice ttt: balloon angioplasty with
stent

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Index
Digital
subtraction
angiography
Showing

Healthy (normal)
aorto-iliac
bifurcation

Compare this image with the next slide

57 © Vascular 2007
Index
 Note that the aorta is dilated.
Digital This is a small aortic
subtraction aneurysm.
Asymptomatic aortic
angiography aneurysms discovered
accidentally are NOT operated
(note that the bone upon except if their diameter is
4cm or more because the
image is subtracted aneurysm rupture rate
from the film) becomes significantly more
than the operative mortality
C/O Lt. thigh
claudication
Diagnosis:
Lt. common
iliac stenosis
causing
chronic lower
limb ischemia
(Grade II) Index

The58 treatment of choice for this patient is percutanous balloon angioplasty (with or©without
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stenting) because the iliac stenosis is short & the rest of the iliac artery is relatively healthy
Lt. common iliac stent (The treatment of choice for localized,
short iliac stenosis or occlusion)

59 © Vascular 2007
Index
 Rt. common iliac
occlusion

This patient is having an

ischemic foot ulcer (Chronic
ischemia stage IV)
His cardiac function is
compromised, and thus is
considered a high operative risk.
What are the treatment
options?

The classical treatment option

for high risk patients with
unilateral iliac occlusion is
femoro-femoral bypass.
Balloon angioplasty with stenting is
another option although the
occlusion
60 here is relatively long © Vascular 2007
Index
Femoro-femoral crossover
(extra-anatomical) bypass

Arrows
demonstrate the
direction of blood
flow
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Index
 Digital
subtraction
angiography:
angiography
Lt. iliac axis
occlusion
treated by extra-
anatomical
femoro-femoral
bypass

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Index
 Leriche Syndrome
Infra-renal Aortoiliac Occlusive Disease

Buttock & thigh Bilateral absent

claudication femoral pulse

Impotence

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Index
Aorto-iliac occlusion
(Lerich syndrome)

The classical treatment for aorto-

iliac occlusion -in fit patients- is
aorto-bifemoral bypass

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Index
 Translumbar digital-
subtraction
aortography
Chronic occlusion of the
infrarenal aorta.
The intercostal arteries
(arrows) serve as major
collaterals

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Index
Aorto-iliac occlusion (Lerich syndrome)
Aorto-bifemoral Bifurcated
(dacron)
bypass (with a graft
bifurcated graft) is
the treatment of
choice for fit
patients with
diffuse aorto-iliac
disease
If the patient’s general condition is
unsuitable for aorto-bifemoral
bypass (e.g. compromised cardiac
functions), the alternative is an
extra-anatomical bypass (axillo-
bifemoral bypass)
66 © Vascular 2007
Index
 Angiogram of an
aortofemoral bifurcation
Dacron graft. (notice the
smooth outline of the graft)
The graft extends from the
infrarenal aorta to the
common femoral arteries

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Index
 Chronic
ischemia
Conventional
angiography

Notice:
Diffuse atherosclerosis of the aorta,
lilac and femoral arteries
Occlusion of the Lt. superficial femoral
artery
Refilling (run-off) of the popliteal and
68 © Vascular 2007
tibial arteries on both sides Index
 Femoro-popliteal disease

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Index
Lower extremity arteriogram at the level of the distal thigh

a b a. Mild diffuse
superficial femoral
artery disease
with focal severe
stenosis at the
adductor canal
b. Following
percutaneous
transluminal
balloon
angioplasty

70 © Vascular 2007
Index
 a b Digital subtraction
angiography
a. Diffuse insignificant
irregularity of the
SFA with short
occlusion at its distal
1/3
b. After angioplasty
Note: the shadow of the distal
half of the femur with an
inter-locking nail

71 © Vascular 2007
Index
 The classical
Rt. SFA occlusion treatment for
Lt. SFA diffuse disease patients with long
or diffuse SFA
disease is bypass
If the popliteal
artery is patent we
preferred femoro-
popliteal bypass
If the popliteal
artery is not patent
and the only
patent distal artery
is one of the
tibials, we can do
femoro-tibial
bypass Femoro-
The saphenous
popliteal
Rt. Lt. vein is always bypass
72
preferred over the © Vascular 2007
Index synthetic graft
C.T. angiography
Diffuse arterial tree disease
Bilateral SFA occlusion
Rt. anterior tibial occlusion
Lt. posterior tibial & peroneal occlusion

Comments:
•CT angiography provides a panoramic study,
yet, it is still less accurate than conventional &
subtraction angiography (the gold standard)
•In CT angiography, we inject IV contrast. It
can’t be used in patients with border line renal
function as an alternative to conventional
angiography
73 © Vascular 2007
Index
 Infra-popliteal disease
Infra-popliteal atherosclerosis (common in diabetics)
Thromboangitis obliterance (Burger’s disease)

74 © Vascular 2007
Index
Within normal Rt. SFA & popliteal arteries Diffuse tibial a. disease with corkscrew collaterals down
to the foot. No distal reconstruction of PT or DP arteries

Comments:
Typical angiographic appearance of Burger’s disease. The inflammatory nature of the arterial obstruction
starts distally and progresses proximally. As there is no named distal run-off patent artery, arterial bypass is
not possible.
75
Lumbar sympathectomy can help those patient only to improve skin blood flow to©heal painful
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superficial ulcers.
Index
 Angiography
Infra-
popliteal
occlusion

Index

Comments:
Infra-popliteal atherosclerosis is a common finding in diabetic patients. This variant of chronic ischemia can
threat the limb if complicated by foot infection.
If angiography
76 shows distal run-off filling of the posterior tibial, anterior tibial or dorsalis pedis arteries, bypass
© Vascular 2007
to these vessels is possible using the saphenous vein. This bypass can salvage the limb and prevent
 Digital subtraction
angiography showing infra-
1 3 popliteal disease
(atherosclerosis)
2
1. Occluded anterior tibial short
after its origin
2. Patent peroneal artery (inline
with the popliteal artery)
Posterior tibial is occluded & not
seen
3. Multiple collaterals compatible
with chronic ischemia
Infra-popliteal atherosclerosis
is common in diabetic patients
77 © Vascular 2007
Index
 Angiography:
This is an intra-operative
angiography showing the
saphenous vein (used as an
autogenous graft) & the distal
anastomosis with the posterior
tibial artery (the run-off artery)
The upper anastomosis (not shown
in this x-ray) is with the common
femoral artery
Intra-operative angiograms are sometimes
done after the arterial anastomosis is
finished to confirm its patency
78 © Vascular 2007
Index
64y old male presenting with short distance claudication >50m. Angio showing Lt. external iliac, common femoral & SFA
occlusion. Collaterals refill the deep femoral (profunda). The popliteal (not seen here) is refilling below the knee by collaterals

Comments:
•Although Ilio-popliteal is a
complete correction, it is not
needed except for limb
salvage when significant foot
infection & gangrene needs
high tissue O2 concentration
Lt. common iliac
•Half correction of the proximal
obstruction only is sufficient for
the treatment of claudication
•If both common iliac arteries
are within normal, femoro-
Deep
femoral crossover & ilio-
femoral femoral bypass are
artery comparable in patency
• Ilio-femoral bypass is more
anatomical but needs general
or epidural anesthesia
Life style limiting claudication is an indication for •Femoro-femoral cross over is
intervention if the general condition permits an extra-anatomical bypass, it
can be done under local
All the following are possible options for infiltration anesthesia. It is the
reconstruction: operation of choice in high
risk patients with unilateral
•Ilio-profunda femoris bypass
iliac occlusion
•Femoro-femoral
79
crossover bypass © Vascular 2007
•Ilio-popliteal bypass with possible relay in the profunda Index
 Acute ischemia
Acute Acute Post-
embolism thrombosis traumatic

80 © Vascular 2007
Index
 This is a 47y old patient
Acute embolic ischemia presented with acute Lt.
LL ischemia
Angiography was done
because there was NO
apparent source for
embolism
Angiography showed
the typical picture of
embolism (healthy
arterial outline, clot
silhouette in the iliac
artery, reversed
meniscus in the popliteal
artery)
ECG discovered a silent
recent myocardial
infarction. A mural
Popliteal embolism Lt. iliac embolism thrombus was the source
Reversed meniscus sign Clot silhouette of embolism
81 © Vascular 2007
Index
 Angiography of a patient with acute
ischemia showing acute popliteal occlusion
The patient gave past history of
claudication
The popliteal artery above the occlusion is
NOT very healthy
Notice well developed collaterals

This is possibly acute

thrombotic occlusion

82 © Vascular 2007
Index
Acute ischemia – popliteal
occlusion with no runoff - ?
embolic
Patient’s history is very
important
Age of the patient (young)
The sudden onset of pain (acute
occlusion with NO collaterals)
Known source of embolism (mitral
stenosis & AF)
No history of claudication
Intact pedal pulse on the other side
83 © Vascular 2007
Index
 30-year-old man in motorcycle accident with
diminished peripheral pulses in the Lt.lower extremity

A.P. Lateral

Plain X ray: Posterior knee dislocation

Angiography: Popliteal artery injury with
acute thrombosis.
Distal run-off refilling the anterior &
84 © Vascular 2007
posterior tibial arteries Index
 Upper limb ischemia

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Index
Angiography of the
Lt upper limb
(direct puncture of the
subclavian artery)
Acute occlusion of the
Lt. axillary artery
(possibly embolic)

86 © Vascular 2007
Index
 Radial a.
Secondary Raynaud's
syndrome in 36-year old
smoker with Buerger's
disease.
Arteriogram of forearm and
hand shows diffuse distal
disease with occlusion of
both palmar arches,
multiple digital arteries and
distal occlusion of the ulnar
artery .
87 © Vascular 2007
Index
 Buerger's disease

88 © Vascular 2007
Angiography of the aortic arch (arch aortoghraphy) in a
young girl with absent Lt. arm pulses

1. Aortic arch 3
4
2. Brachio-cephalic artery
(short stenosis)
3. Rt. common carotid artery
5 6
4. Rt. subclavian artery
2
5. Lt. common carotid artery
6. Lt. subclavian artery 1
(occluded)

Takayasu arteritis

89
“Pulsless disease” © Vascular 2007
Index
 Thoracic Outlet
O Syndrome
S
95% due to brachial plexus 5% due to venous or
arterial compression
compression

90 © Vascular 2007
Index
Digital subtraction
angiography of the Lt
upper limb with Arm elevation
thoracic outlet tightens the thoracic
outlet & may cause
syndrome external
Showing compression of the
structures passing
Compression of the between the clavicle
subclavian artery & the 1st rib.
with elevation of the In 95% of
arm symptomatic
patients, symptoms
The artery distal to the are due to brachial
stenosis may develop plexus compression
post-stenotic
In only 5% of
dilatation. A thrombus patients, symptoms
may be formed inside are due to
and cause distal compression of
embolism as seen in subclavian artery or
the 3rd film vein
91 © Vascular 2007
Index
A.P. view of the cervical spine
Please identify the 1st thoracic vertebra
and notice its attachment to the 1st rib

1. Bifid spinous process of C3

2. Superimposed articular
processes
3. Uncinate processes
4. Air filled trachea
5. Transverse process of C7
6. Transverse process of T1
7. 1st rib
8. Clavicle

Notice that the transverse process

of T1 is directed upwards ,while the
transverse process of C7 is
directed downwards

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Index
 Lt. cervical rib

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Index
 Carotid artery stenosis

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Index
The arch of the aorta and the vessels arising from it (postmortem)

The arch shows fatty streaking

and thickening.
The brachio-chephalic trunk is
blocked by a thrombus, 2 cm
in length, just above its origin.
The left common carotid artery
is mildly atheromatous and
exhibits a small area where
thrombus is deposited, but this
is not obstructing blood flow.

95 © Vascular 2007
Index
 This is an angiography of the Lt. extracranial carotid system.

Index
Try to identify
Common
carotid artery
Internal
carotid artery
External
carotid artery

96 © Vascular 2007
Note that: The internal carotid artery has no branches in the neck
 Digital subtraction angiography Internal carotid stenosis

Internal carotid
No branches
External
carotid

Common carotid
Atherosclerotic Internal carotid stenosis is an important cause of cerebral stroke & TIAs
Stenosis of 70% or more is an indication for intervention even in asymptomatic patient (prophylactic)
© Vascular 2007
97

The classical treatment is carotid endarterectomy Index

Digital subtraction
angiography
Showing

Internal carotid
artery stenosis
Internal carotid
External carotid artery artery stenosis
(notice branches)

Common carotid
artery

98 © Vascular 2007
Index
Operative pictures of carotid endartrectomy for internal carotid stenosis

Carotid 1 2
opened
showing
the
atheroma

End-
artrectomy
specimen

Smooth 3
lining after
end- 4
artrectomy
Note the
carotid
shunt.

Closure
with a
patch

99 © Vascular 2007
Carotid endartrectomy is the gold standard for treatment of significant carotid stenosis Index
One of the
treatment
options of carotid
stenosis is
carotid
stenting

A protection device
should be user to
protect the brain
from emboli that
may detach during Common carotid After balloon Stent
the procedure stenosis dilatation & stent

100 © Vascular 2007

Index
 Carotid body
tumor

Spiral CT with 3D reconstruction

Index
Note that carotid body tumor
101 is very vascular Digital subtraction angiography
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 Carotid body tumor

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Early phase Late phase Index
 Renal artery stenosis

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Selective Lt. renal angiography
Severe renal artery stenosis

Comments:
•The common
presentation is severe
hypertension in young
age
•If bilateral, it can result
in progressive renal
function deterioration
•The treatment to be
operative reconstruction
•The treatment today is
almost always by
balloon dilatation
(angioplasty) and
stenting under local
anesthesia.
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Index
MRA:
Bilateral renal
artery stenosis
Diffuse
atherosclerosis
of the aorta

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Aortography with selective injection in the
ostium of the Lt. renal artery

Severe renal artery stenosis

Abdominal
aorta

Unilateral renal artery stenosis

Severe stenosis of may present with hypertension
the renal artery In addition, bilateral renal
artery stenosis can present
with progressive renal function
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Index
 Deep Venous Thrombosis
&
Pulmonary Embolism

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 Phlegmasia

Venous gangrene

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Why is DVT more common on the Lt. side?
Postmortem to show anatomy
DVT is more
common on the
Lt. side
because of the
anatomical fact
that the Rt.
common iliac
artery crosses
over and
compresses the
Lt. common iliac
vein
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 Diagnosis of DVT
Coloured Duplex ultrasound:

Fresh thrombus
(no flow) in the
SFV with a floating
Venous tail
blood flow
in the SFV

Acute DVT of the superficial femoral vein

with a floating tail
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Index
 Ascending
venography

showing

acute DVT of the

Lt. common iliac
vein

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 Pulmonary embolism

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 Diagnostic modalities for PE
V

Ventilation-Perfusion (VQ) Scan:

Clots appear as perfusion defects, without corresponding
P defects on the ventilation scan 'mismatched defects'

Pulmonary
Spiral CT in a patient with PE: angiogram in a
patient with PE:
The clot appears as a filling defect
The clot appears
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Index as a filling defect
LUNG SCAN
This study is in two parts:
The ventilation scan studies the
distribution of air through the
lungs and the.
The image to the right shows a patient
undergoing a ventilation scan. The patient
inhales a radioactive labeled gas

Then the Perfusion scan studies

the blood supply to and within
the lungs . The patient is given a
IV injection of a radioactive
isotope. 

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Ventilation – perfusion scan (V/Q scan): is a radioisotope scan that can
measure and compare the amount of blood flow to each lung (perfusion)
and the amount of air that goes to each lung (ventilation)
In pulmonary embolism, the perfusion of a segment of the lung is impaired
(because the embolus occludes one of the branches of the pulmonary artery) while
the ventilation of the same segment is normal.
That is called, ventilation – perfusion mismatch

Normal pulmonary ventilation Abnormal pulmonary perfusion

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 Pulmonary
embolism
Pulmonary
angiography
showing
segmental
pulmonary artery
cutoff in the
lower Rt. lung
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 Pulmonary
angiography:
angiography
Filling defects of
pulmonary arteries
of left inferior lobe

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 Spiral CT

Normal CT pulmonary
angiography (3D reconstruction)
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Pulmonary embolism
wedged in a pulmonary artery
Cut section in the lung
bifurcation (post-mortem)

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IVC filter

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 SVC occlusion
SVC obstruction
extending into
the Lt
innomenate vein

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Digital subtraction
Basilic Vein
venography
Internal Index
Comments:
jugular vein
•This patient is under regular
dialysis for chronic renal
failure.
•He developed severe Lt.
upper limb oedema following
reconstruction of an arterio-
vennous fistula.
•A temporary catheter for
dialysis was inserted in his
Lt. subclavian vein several Axillary vein
months ago.
Lt. subclavian vein
•Subclavian, innominate &
SVC thrombosis is a known
complication of temporary
catheters used in dialysis if Lt. brachiochephalic (innomenate) vein occlusion
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left in place for a long time.
Inferior vena cava obstruction

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 IVC obstruction IVU
Notice the shadow of a calcified mass The same mass displaces the Lt. ureter

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Diagnosis: AAA © Vascular 2007
Index
 Examples

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1. What is the name of this investigation & what does it show?
2. If you are following up this patient:
Which of the following presentations is NOT related to the
pathology seen? (choose one)
a. Loin pain &
haematuria
b. Chronic lower
back pain
c. Acute
abdominal
pain & shock
d. The 2nd toe
became blue,
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Index
cold &©tender
Vascular 2007
A 60 year old diabetic patient presented with progressive Lt. LL claudication (now 30 meters)

1. What is this X ray & what does it show

2. What is the possible
etiology of this condition
Abdominal aorta
& what are the possible
risk factors (mention 3)
3. The 1st choice
treatment for this
condition is:
a. Endarterectomy
b. Balloon angioplasty
c. Arterial bypass
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Index
This 76 y old diabetic female
is complaining of rest pain of
one month duration. During
this period she developed this
slowly progressive change in
her foot.
O/E:
O/E the foot was warm
(except the big toe). Popliteal
pulse was felt but the pedal
pulses were absent
Management of this patient is:
a. Amputation of the big toe to avoid spread of gangrene
b. Antibiotics & vasodilators to improve foot circulation
c. Angiography & revascularization to improve foot circulation
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d. Lumber sympathectomy to improve foot circulation Index