Incidental Findings for the Vascular Technologist Richard C. Pennell, MD, FACS Chief, Division of Vascular Surgery Mercy Hospital St. Louis Clinical Professor of Surgery St. Louis University School of Medicine Disclosures Charles Claude Guthrie’s 2 Headed Dog Three Headed Dogs Some Cases Provided By • International Man Of Mystery • Master Vacuum Cleaning specialist • Oil Change Grandmaster • Microwave repair • Free style and break dance teacher • Sexiest tractor Driver Award in 2010 Patrick A Washko BSRT,RDMS,RVT Technical Director Rex Hospital - UNC Healthcare Vascular Diagnostic Center [email protected] What is an incidental finding? Carotid Duplex • Thyroid masses – Cysts – Solid • Cervical lymphadenopathy • Carotid body tumor • Jugular vein thrombophlebitis Thyroid Cysts • Usually benign • Easy to see • Worth noting although may not require treatment Thyroid Mass-Solid • Benign – Thyroid AdenomaUsually peripheral vascularity – Multinodular goiter • Malignant thyroid cancer-Diffusely vascular Cervical lymphadenopathy Benign LN Malignant LN Metastatic nodes are more vascular! Carotid Body Tumor Paraganglioma • • • • • Slow growing Usually benign Occasionally bilateral-5% Malignant 5-10% Sx’s of Cranial nerve palsy in 10% • Resection for sx’s or enlargement Carotid Body Tumor Carotid Body Tumor Jugular Vein Thrombophlebitis Incidental Abdominal Findings • Gallstones • Retro-aortic left renal vein • Nutcracker Syndrome • Renal Masses – Cysts – Renal cell Ca • Renal Vein Thrombosis • Inflammatory AAA Gallstones Gallstones Gallstones Retro-Aortic Left Renal Vein • Occurs in 2.1% of pts • Can be associated with hematuria & flank pain • Increases risk of varicocele • Increases risk of renal vein injury with open AAA repair Retro-Aortic Left Renal Vein Nutcracker Syndrome • Caused by left renal vein compression by the SMA • Presents with flank pain & hematuria • Treatment ranges – Renal vein stent – Renal vein transposition – Nephrectomy Nutcracker Syndrome Renal Masses • Cystic – Usually benign – Polycystic Kidney disease – Single vs. multiple • Solid – Often malignant – Renal Cell Ca – Can be associated with tumor extension into renal vein and IVC Solid Renal Masses Renal Cell Carcinoma • Notorious for growth of tumor out the renal vein and up the vena cava • Surgery often involves removal of the tumor from the vena cava • May see some flow around the tumor Resection of Tumor in renal vein and IVC • Tumor can be limited to renal vein • Extension into IVC is common • Can extend up to right atrium Portal Vein Imaging • 72 y/o woman underwent Whipple procedure for pancreatic CA 3 days ago • Study done due to sepsis and shock Duplex Imaging of Portal Vein Gas Renal Vein Thrombosis • Can be caused by nephrotic syndrome or dehydration • Often seen in pts with membranous glomerulonephritis • Dx usually confirmed by CTA/CTV Inflammatory AAA • Occurs in 5% of AAA’s • Manifested by markedly thickened adventia of aortaup to 2.5cms • Duodenum becomes adherent to aorta • May see ureteral entrapment/hydronephrosis • Higher open operative complication rate – Duodenal injury – Difficulty with proximal clamping • Suggested by triad of – Elevated sed rate – Wt loss – Back/Abd pain • Resembles retroperitoneal fibrosis pathologically Inflammatory AAA Incidental findings in lower extremity imaging • Inguinal Adenopathy • Lymphocele-usually postop or post traumatic • Baker’s cysts • AV fistulas • Incidental arterial stenosis seen on venous exam Inguinal Lymphadenopathy • Etiology – Inflammation • Ulcers/Infection of extremity – Malignancy • May resolve spontaneously with Rx of inciting infection Incidental Findings During Venous Duplex Lymphocele Lymphoceles • • • • • Usually seen in post op or post trauma pts Caused by lymphatic injury Groin area is most common Can be treated by drainage if early Chronic lesions develop a “rind” or “capsule” and require excision or they will recur Baker’s Cyst Incidental Findings During Venous Duplex • Baker’s Cyst can mimic DVT – Leg Swelling – Pain • Can be differentiated due to bruising at ankle/foot because of bleeding Ruptured Hemorrhagic Baker’s Cyst AV Fistulas • Usually traumatic – Post Cardiac cath – Peripheral angio – Complication of femoral line insertion • Usually asymptomatic Incidental Arterial Stenosis Femoral Vein Femoral Artery SFA Aneurysm SFA Aneurysm Incidental Findings During Venous Duplex 10-1-2012 7:30am Incidental Findings During Venous Duplex Incidental Findings During Venous Duplex Extrinsic Compression lymphadenopathy in the right inguinal region 10-1-2012 9:30am • • • • • • 38 year old male Left lower extremity edema PMH MVA 6 years ago pelvic fracture at that time Small rural hospital Arkansas “You ain’t a looking where it hurts” Left External Iliac -CFV Augmentation Abnormal Response To Augmentation normal Response To Augmentation Left Gluteal Region Incidental Findings During Venous Duplex Left Buttocks Area Venography Occlusive Disease of the Popliteal Artery • 63 y/o male with claudication • ABI= 0.65 • Able to walk during golf • Arterial duplex to consider for angioplasty • Dx: Thrombosed Popliteal aneurysm Adventitial Cystic Disease of the Popliteal Artery • Classic radiographic finding is Scimitar sign or “birds beak” • Caused by Embryonic “rest” of synovium in arterial wall • Essentially a ganglion cyst of popliteal artery • Can be treated by unroofing the cyst or bypass graft Adventitial Cystic Disease Angiogram Right Leg Left Leg Adventitial Cystic Disease Surgery Adventitial Cystic Disease Conclusions • • • • Expect the unexpected Listen to the patient and look “where it hurts” Take time and optimize your images Understand the potential adjacent pathology in the area you are working • Try to explain unusual findings if possible • Look at each case as a Christmas present-you don’t know what you will find until you open it