Popliteal anevrizma trombozu ve distal embolizasyon

Özet

Popliteal anevrizma trombozu akut ekstremite iskemisiyle, distal embolizasyon ise birden fazla tibial runoff damarının oklüzyonuyla birliktelik gösterebilir. BTA'da tanı, genişlemiş popliteal dış konturu, trombüsle daralmış ya da kapanmış rezidüel kanalı ve diz altındaki embolik dağılımı birlikte göstermeye dayanır. Sadece popliteal arterdeki akım kesilmesine odaklanmak, mural trombüs nedeniyle kısmen gizlenmiş anevrizma kesesinin çapını veya distaldeki çoklu krural oklüzyonları kaçırabilir. Distal runoff'un gerçek durumunu belirlemek için her iki bacağın opasifikasyonu karşılaştırılmalı; anterior tibial, posterior tibial ve fibular arterler ayrı ayrı izlenerek kesilme düzeyleri kaydedilmelidir.

Faz ve pencere

BTA tanısal

Arteriyel kontrastta popliteal arter dış çap artışı içinde eksantrik veya çevresel kontrastlanmayan mural trombüs, hilal biçimli rezidüel lümen ya da tam kontrast kesilmesi aranır. Anterior tibial, posterior tibial ve fibular (peroneal) krural arterlerde bir veya birden fazla ani kapanma/yeniden doluş kaydedilir; şiddetli iskemi veya bolus zamanlama sorunu distal kontrastı azaltabilir.

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

BT bulguları

• Genişlemiş popliteal dış kontur — trombüs lümeni doldursa bile anevrizma kesesinin toplam dış çapının korunması.
• Mural trombüs — patent kontrast kanalını çevreleyen hilal biçimli veya tabakalı kontrastlanmayan materyal.
• Kritik daralmış rezidüel kanal — tromboze kese içinde ince kontrast şeridi ve azalmış distal krural opasifikasyon.
• Tam popliteal tromboz — anevrizmatik segmentte kontrastla dolan lümenin kaybı ve distal runoffun azalması ya da kaybı.
• Çoklu krural embolizasyon — anterior tibial, posterior tibial veya fibular (peroneal) arterlerde ayrı ani kesilme odakları.
• Krural çıkış damarlarında akım kaybı — anterior ve posterior tibial arterlerin açık olup olmadığı, fibular arterin izlenebilen distal kesimi ve ayak dolaşımıyla devamlılığı ayrı ayrı değerlendirilir; fibular arterin ayak bileğine ulaşması şart değildir.
• Kas iskemisi bulguları — etkilenen baldırda şiddetli hassasiyet, yükselen kreatin kinaz düzeyleri ve kompartman sendromu riskini gösteren şişlik.

Ölçütler ve sınıflamalar

SVS kılavuzunda popliteal arter anevrizması tanımı

SVS kılavuzlarına göre popliteal arter anevrizmasında elektif tedavi indikasyonu çapın ≥20 mm olması veya mural trombüs ile distal oklüzyon riskidir.

Normalde

Normal dallanma paterninde popliteal arter proksimal baldırda anterior tibial arteri verir ve tibioperoneal gövde olarak devam eder; bu gövde posterior tibial ve fibular (peroneal) arterlere ayrılır. Etkilenen bacakta anevrizmanın dış çapını ve kalan lümeni ölçün; kontralateral popliteal arteri ve aortayı eşlik eden anevrizma açısından değerlendirmek amacıyla inceleyin. Dallanma varyantı varsa ayrıca tanımlayın.

Ayırıcı tanı

İzole popliteal emboli

dış çapı normal popliteal arterde keskin lümen kapanması görülür; anevrizma kesesi ve mural trombüs yoktur.

Kronik PAH

yaygın femoropopliteal plak, uzun segment kapanma ve gelişmiş kollateraller distal çoklu embolizasyon olmadan görülebilir.

Popliteal arter psödoanevrizması

duvar hasarı/iletişim boynu ve çevre hematom gerçek anevrizmatik genişlemeden ayırır.

Baker kisti ile arter basısı

arter dışındaki kistik kitle komşu damarı iter veya daraltır; intraluminal trombüs görünümü yoktur.

Kontrast bolusunun distal damarlara ulaşmaması

her iki bacakta tibial arterlerin kontrastlanmasının yaygın biçimde zayıf olmasına yol açar; bu bulgu tek başına çok düzeyli emboli olarak yorumlanmamalıdır.

Tuzaklar

• Tromboze anevrizma kontrastla dolmadığı için normal çaplı oklüzyon gibi görünebilir; popliteal damarı proksimalden distale izleyip dış konturu kaynak kesitlerde arayın.
• Mural trombüs, popliteal anevrizma kesesi içinde kontrastlanmayan trombüs olarak değerlendirilir; BT anjiyografide anevrizma içinde trombüs ve arterde darlık görülebilir.
• Tibial damarlardaki kontrast kaybını emboliye bağlamadan önce kontrastın alt ekstremite damarlarına ulaştığını ve karşı bacak arterlerinin kontrastlanmasını kontrol edin.
• Anevrizma trombozunda distal emboli tek bir tibial arterle sınırlı olmayabilir; yalnız en iyi opaklaşan dalı izleyip diğer runoff damarlarını atlamayın.

Kendini dene

1. Soğuk ve soluk ayakta BTA'da neredeyse tamamen tromboze popliteal anevrizma ve distal runoff yokluğu görülüyor. En uygun tanı hangisidir?

   • Tromboze popliteal anevrizma
   • Üç damarlı açık tibial runoff
   • Tromboze popliteal ven anevrizması
   • Popliteal kist
   Cevabı göster

   Tromboze popliteal anevrizma. BTA'da neredeyse tamamen tromboze popliteal anevrizma ve distal runoff yokluğu tarif edilir.

2. Popliteal arter dış çapı genişlemiş, ancak kontrastla dolu kanal yok; distal runoff kayıp. En önemli yorum nedir?

   • Tam tromboze anevrizma
   • Normal popliteal varyant
   • Baker kisti
   • Venöz faz artefaktı
   Cevabı göster

   Tam tromboze anevrizma. Anevrizmanın neredeyse tamamen trombozu ve distal damar yatağında akımın kaybolması, tromboze popliteal anevrizmayla uyumludur.

Kaynaklar

Bu sayfadaki 38 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 14 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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