Vasküler stent/greft oklüzyonu, tromboz ve restenoz BT bulguları

Özet

Önceden periferik arter stenti ya da bypass grefti bulunan hastada yeni ekstremite ağrısı, soğukluk veya nabız kaybı geliştiğinde lümen açıklığı hızla değerlendirilmelidir. Arteriyel faz BT anjiyografi, stent/greft boyunca kontrast geçişini, oklüzyon seviyesini, kollateralleri ve distal damar yatağını hacimsel olarak gösterir. Spektral rekonstrüksiyonlar ve yüksek çözünürlüklü ince kesitler, metal ve kalsiyum kaynaklı blooming artefaktını azaltarak stent içi lümenin gerçek değerlendirmesini sağlar. Akut oklüzyonun veya distal iskemi bulgularının atlanması uzuv perfüzyon kaybının yaygınlığını olduğundan az gösterebilir.

Faz ve pencere

BTA tanısal: Arteriyel kontrastlı incelemede stent/greft lümeni boyunca kontrast dolumu, dolum kesintisi ve distalde yeniden doluş izlenir; eksantrik ya da konsantrik düşük atenüasyonlu materyal trombüsle uyumlu olabilir. Görüntüleme zamanlaması yetersizse tüm distal damar yatağındaki zayıf opaklaşma gerçek tıkanıklığı taklit edebilir.
Gecikmiş: Arteriyel BT anjiyografide distal damar yatağı yaygın ve yetersiz opaklaşıyorsa, gerektiğinde gecikmiş görüntüde geç doluş olup olmadığı incelenir; tüm ağaçtaki yavaş akım ile stent içindeki fokal dolum kesintisini ayırmaya yardımcı olabilir.

Önerilen pencereler: Anjiyo (G 600 / M 150), Yumuşak doku (G 400 / M 40).

BT bulguları

Stent içi dolum defekti — kontrastlı lümen içinde duvara komşu ya da santral düşük atenüasyonlu materyal trombüsü düşündürür.
Tam lümen kesintisi — stent/greft segmentinde opaklaşmanın aniden sona ermesi ve distalde kollateral ya da yeniden doluş paterni.
İn-stent restenoz — stent iç çapının fokal veya uzun segmentli daralması; damar eksenine dik kesit ve stent içi lümenle kıyaslanır.
Greft anastomoz darlığı — greftin doğal artere birleştiği bölgede lümen daralması görülebilir.
Stent deformasyonu veya ayrışması — metal strutların hizasında kesinti, üst üste binme, bükülme ya da segmentler arasında açıklık.
Distal perfüzyon azalması — tıkanıklığın ötesinde arterlerin daha geç veya daha silik opaklaşması; karşı ekstremiteyle ve kollaterallerle karşılaştırılır.
Akut ekstremite iskemisi — kas gruplarında ödem veya azalmış kontrastlanma eşlik edebilir; bu bulgular tek başına kas nekrozunu kanıtlamaz.

Normalde

Aynı düzeydeki açık arter stentinde kontrast sütunu metal strutların içinde kesintisiz izlenir ve stent uçlarında damar kalibresi ani basamak yapmadan devam eder. Karşı tarafın aynı arter segmentiyle lümen genişliğini ve distal dalların opaklaşmasını karşılaştır; bypass greftinde proksimal ve distal anastomozları ayrı ayrı izle.

Normal BT ile kıyasla

Aynı bölgenin, kaynak veri setinde patoloji içermediği belirtilen bir BT incelemesini kesit kesit kaydırın; organ sınırlarını açarak anatomiyi hasta görüntüsüyle karşılaştırın. Küçük rastlantısal bulgular tümüyle dışlanmamıştır.

Kaynak: TotalSegmentator v2.01 veri seti (Wasserthal ve ark., Radiology: Artificial Intelligence 2023), CC BY 4.0, vaka s0685; organ sınırları veri setinin otomatik segmentasyonundan, birleştirilerek sadeleştirildi. Görüntüler 2,5 mm kesit aralığına yeniden örneklendi.

Ayırıcı tanı

Akım gecikmesi: opaklaşma tüm distal ağaçta zayıftır; gecikmiş görüntüde yaygın dolum artışı ve keskin bir stent içi kesinti olmaması bunu destekler.
Metal blooming: strut çevresinde parlak kenarlar lümeni yalancı dar gösterir; dik kesit ve alternatif rekonstrüksiyonlarda açık kontrastlı merkez seçilebilir.
Kalsifiye plak: damar duvarına yapışık çok yüksek atenüasyonlu plak lümeni daraltır; stent içi yumuşak doku trombüsünden farklı olarak kalsiyum dansitesi verir.
Akut emboli: stent dışında, çoğunlukla bifurkasyonda ani intralüminal dolum kusuru oluşturur; stent boyunca kronik daralma eşlik etmeyebilir.
Diseksiyon: intimal flap, korunmuş gerçek lümeni belirgin bir yalancı lümenden ayırabilir.

Tuzaklar

Distal arterlerdeki yetersiz kontrast dolumu, bolus zamanlaması veya düşük debi kaynaklı akım gecikmesinin göstergesi olabilir; gerçek oklüzyondan ayırmak için gecikmiş fazlardaki opaklaşma değerlendirilmelidir.
Metal strut veya yoğun kalsiyumun oluşturduğu blooming gerçek stenozu abartabilir; stenozu stent eksenine dik ince kesitlerde doğrula.
MIP görüntüsü kalsiyum ve metal örtüşmesi nedeniyle rezidüel lümeni saklayabilir; kaynak aksiyel kesitleri ve damar boyunca CPR/MPR görüntülerini kontrol et.

Kendini dene

Yüzeyel femoral arter stentinde kontrast sütunu aniden kesiliyor; popliteal arter kollaterallerle yeniden opaklaşıyor. En uygun yorum nedir?
Cevabı göster
Stent oklüzyonu. Stent boyunca ani dolum kesintisi ve daha distalde kollateral yeniden doluş oklüzyonu destekler. Farklı fazlardaki arteriyel opaklaşma düzeyleri karşılaştırılabilir; diseksiyonda intimal flap gerçek lümeni yalancı lümenden ayırabilir.
Stent lümeni çok dar görünüyor; parlak metal kenarlarının arasında ince kontrast çizgisi seçiliyor. Hangi taklitçi olasıdır?
Cevabı göster
Metal blooming. Metal strutların blooming artefaktı rezidüel lümeni olduğundan dar gösterebilir; dik kesit ve damar boyunca rekonstrüksiyonla kontrol edilir. Emboli çoğunlukla stent dışında ani kusurdur; enfeksiyon için çevre inflamatuvar bulgular, venöz tromboz için venöz anatomide dolum kusuru aranır.

İlgili konular

Kaynaklar

Bu sayfadaki 38 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 8 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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