Film Quiz R1 Kittipong Pooketkit

• Incidence 40-45% of people.

• Classic branching
• common hepatic artery from the celiac
Variation of artery
hepatic artery • proper hepatic artery into right and left
hepatic arteries to supply the entire
live
• 55-60% of the population.
 Terminology
• An accessory hepatic artery
is one which arises from an
anomalous origin and
supplies a portion of the
liver along with another

Variation of artery.

hepatic artery
• A replaced hepatic artery is
one which arises from an
anomalous origin and
supplies a portion of the
liver solely.
 • Right hepatic artery (RHA)
• from celiac artery: ~2.5% (range 1-4%)
• from SMA: ~12.5% (range 9-15%)
• accessory right hepatic artery from SMA: ~4%
Variation of (range 1-7%)
hepatic artery • Left hepatic artery (LHA)
• from left gastric artery (LGA): ~7.5% (range 4-
11%)
• accessory left hepatic artery from LGA: ~7.5%
(range 4-11%)
HN : 1503499
Persistent sciatic artery
• Rare vascular anomaly
• Etiology : persistence of the embryological axial limb artery,
normally regresses after week 12.
• Incidence is 0.05% of the population and
• Bilateral in up to 20% of cases
• Pathway
• representing a continuation of the internal iliac artery
• through the greater sciatic foramen
• alongside the sciatic nerve
• Join to popliteal artery
• Complication
• Aneurysm -> Ruptured
• Atherosclerosis
HN : 0865438
 Occlusion of the aorta distal to the renal arteries.

Common in the elderly with an advanced atherosclerotic disease.

Acute onset symptoms include the 6 Ps:

Aortoiliac • pain
• pulselessness
occlusive • pallor
• paresthesia
disease • paralysis
• Prostration

Chronic onset symptoms (Leriche syndrome ) may include

• Impotence
• claudication
• absence of femoral pulses

Blood supply to legs from “Collateral pathway”

 Systemic-Systemic :
Pathway of Winslow
Collateral
Pathways
Visceral-Visceral and
Visceral – Systemic
Collateral pathway Systemic-Systemic : Pathway of Winslow
Collateral pathway Systemic-Systemic : Pathway of Winslow
 Visceral-Visceral

Visceral – Systemic

Collateral pathway:Visceral – Visceral ,Visceral –Systemic

HN : 1155900
Abdominal
Aortic
Aneursym
•“Abdominal
aortic aneurysm”

• - Most are true aneurysm :

localized dilatation of aorta
• - Caused by weakening of its
wall (intima, media,
adventitia)
• - Diameter ≥ 3 cm
• - Ruptured AAA : 50% of
patients dying before reaching
hospital

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• Defined by its location relative to the renal
arteries.
• Suprarenal AAA
• involves the renal arteries and
extends superiorly
• SMA and celiac arteries arise from
the aneurysmal aorta
• Juxtarenalaneurysm
• extends to the renal arteries, with a
normal-sized aorta superiorly
• Infrarenal AAA
• arises at least 10 mm below the
renal arteries
Ruptured or
Impending rupture
Intramural
Luminal
Extraluminal
Intramural signs

20
 • 1. Increased aneurysm size
• Rupture risk

• 5-6 cm : 3-15% risk per year

• 6-7 cm : 10-20% risk per year

Intramural • 7-8 cm : 20-40% risk per year

signs • more than 8 cm : 30-50% risk per year

• Rapid enlargement rate : more than 10 mm per

year à indication for surgical repair

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RadioGraphics 2007; 27:497–507 ● Published online 10.1148/rg.272065026 22
 • 2. Focal wall discontinuity

Many aneurysm lined with circumferential

Intramural •

wall calcifications
signs • Focal discontinuity of intimal calcifications à
indicate rupture site
• Most common at posterolateral wall

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RadioGraphics 2007; 27:497–507 ● Published online 10.1148/rg.272065026 24
 • 3. Hyperattenuating crescent sign

• - Intraluminal blood dissects into thrombus à

Intramural contact weakened aortic wall à increased risk of
rupture
signs
• CT findings : A well-defined peripheral crescent
of increased attenuation within thrombus.

Insights Imaging (2014) 5:281–293 DOI 10.1007/s13244-014-0327-3 25

RadioGraphics 2007; 27:497–507 ● Published online 10.1148/rg.272065026 26
 4. Draped aorta sign
• Seen in contained AAA ruptures when rupture

site is posterior and sealed by adjacent

Intramural vertebral body
signs • Loss of fat plane between aneurysm and

vertebra
• Chronic : smooth vertebral erosions

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RadioGraphics 2007; 27:497–507 ● Published online 10.1148/rg.272065026 28
Luminal signs

29
 • 1. Aortoenteric fistulas

• Primary : complication of atherosclerotic aortic

aneurysm
• Secondary : complication of aortic reconstructive
surgery
Luminal signs • Most involve third to fourth part of duodenum
• CT findings :
• - Intraluminal or periaortic extraluminal gas
• - Contrast extravasation to bowel lumen

30
RadioGraphics 2007; 27:497–507 ● Published online 10.1148/rg.272065026 31
 • 2. Aortocaval fistulas

• - Rare findings (1% of AAAs, 2-4% of ruptured aneurysms)

Luminal signs • CT findings :

• - Obliterate fat plane AAA and IVC
• - On arterial phase : AAA and IVC enhancement

32
 33
Insights Imaging (2014) 5:281–293 DOI 10.1007/s13244-014-0327-3
Extraluminal signs

34
 • 1. Periaortic fat stranding

Extraluminal • - Frequently observe in impending rupture

signs • - May be earliest sign before complete AAA
rupture

35
 36
Insights Imaging (2014) 5:281–293 DOI 10.1007/s13244-014-0327-3
 • 2. Contrast extravasation

• - Most specific sign of complete AAA rupture

Extraluminal CT findings :
signs
•

• - On arterial phase : contrast material from

lumen through retroperitoneal
• - Venous phase : expanding pool of contrast
material
•

37
RadioGraphics 2007; 27:497–507 ● Published online 10.1148/rg.272065026 38
 • 3. Retroperitoneal hemorrhage

• - Most common sign of ruptured AAA

• - Usually rupture at posterior and posterolateral
walls
Extraluminal
signs • CT findings :
• - Acute : high-attenuation fluid collection ( >
30 HU)
• - Multiple compartments : perirenal, anterior
and posterior pararenal spaces, along psoas
muscle

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Insights Imaging (2014) 5:281–293 DOI 10.1007/s13244-014-0327-3 40
Conclusions
Location Findings Complete Impeding
rupture rupture
Increased aneurysm size - +

Focal wall discontinuity + +

Intramural
Hyperattenuating crescent - +
sign
Draped aorta - +
Aortoenteric fistula + -
Luminal
Aortocaval fistula + -
Periaortic stranding - +
Extraluminal Contrast extravasation + -
Retroperitoneal hemorrhage + - 41
 References.

42
Indication for repair AAA

Large (Size ≥5.5 cm in diameter

or ≥5 cm in marfan syndrome)

Fast-growing (grows ≥1
cm/year)

Symptomatic patient

Rupture or impending rupture

• Surgical repair
• Open repair: Artificial/biologic/tissue grafts
• Closed repair: Endovascularstent graft
Thoracic endovascularaortic repair (TEVAR)
Endovascularaneurysm repair (EVAR)
• Complications
• Endoleaks
• Limb Thrombosis
• Stent-Graft
Migration
• Sac Enlargement
and Rupture
HN : 1643027
Acute Aortic
Syndrome
IMH PAU

Incomplete
Sp ectrum
Acute aortic syndrome
Dissection

- Acute aortic dissection

- Intramural hematoma (IMH)
Classic - Penetrating atherosclerotic
Dissection ulcer (PAU)

Aortic

Rupture

Emerging concepts in intramural hematoma imaging, Radiographics2016

 Sp ectrum
AAD PAU
Intima and inner layer of aortic media Intima, media

IMH
Rupture of vasa vasorum to media

without intimal tear

 Risk Factors
Long-standing arterial Iatrogenic factors
hypertension *** ●Catheter/instrument
●Smoking, dyslipidemia, intervention
cocaine/crack
● Valvular/aortic surgery
Vascular inflammation ●Side or cross-clamping/
● Giant cell arteritis aortotomy
● Takayasu arteritis ● Graft anastomosis
● Behcet’s disease ● Patch aortoplasty
● Syphilis
● Ormond’s disease
●Aortic wall fragility

Connective tissue disorders Deceleration trauma

● Hereditary vascular disease ● Car accident
● Marfan syndrome
● Fall from height
●Vascular Ehlers-Danlos
syndrome (type 4)
● Bicuspid aortic valve
● Coarctation of the aorta
AAD
Acute aortic dissection
 Aortic

Dissection Stanford Classifications

Treatment options§
Stanford Type A: surgery or
endovascular therapy§
Stanford Type B: medically

Type A Type B
 CXR Investigation

• 10 – 40 %Normal

• Widening mediastinum
• Abnormal cardiac contour

• Displaced calcification

• Opaque AP window
CTA

• Blood on both sides of an intimal flap (imaging hallmark of dissection)

• Internal displacement of intimal calcification
• 2 distinct lumina with interposed intimal flap
• False lumen: Larger cross-sectional area, beak sign, cobweb sign, thrombosis,
and delayed enhancement
• True lumen: Continuity with undissected portion of aorta and smaller cross-
sectional area
 Aortic
Dissection CT features
Contrast-enhanced CT
intimal flap that separates the true and false lumen
CT features
Beak sign
CT features

Cobweb sign
 Aortic
Dissection
Complication

• Aortic regurgitation

• Aortic branch obstruction

• Pericardial tamponade

• Myocardial infarction

• Aortic rupture
 Dynamicand staticobstruction
Dynamic

Static
Treatment
• Stanford Type A: surgery orendovascular therapy
• Stanford Type B: medically
• Indications for immediate surgery or endovascular stent placement
• Ruptured aorta (38.5% mortality risk)
• Hemodynamic instability
• Descending aortic diameter greater than 6 cm
• Poor perfusion of the thoracoabdominalaorta
• Mesenteric, renal, and extremity ischemia causing secondary compression of the
true lumen by the expanding false lumen
• Pseudocoarctationsyndrome with uncontrolled hypertension
• Distal embolization