Posttrombotik venöz stenoz ve kronik oklüzyon BT bulguları

Özet

Önceden derin ven trombozu geçiren, bacakta kalıcı şişlik veya venöz kladikasyon gelişen hastada iliak venler ve vena cava inferior (VKI) kronik çıkış engeli açısından incelenir. Venöz fazlı BT, tıkalı segmentin uzunluğunu, kalan lümeni, trombüs sonrası damar duvarı değişikliklerini ve alternatif akım yollarını haritalar. Organize trombüs zamanla fibrotik bantlar, düzensiz daralma ya da tam tıkanıklık bırakabilir; bu görünüm akut trombüsle aynı değildir. Tıkanıklığın ve kollateral yolun atlanması, venöz hipertansiyonun yaygınlığının ve girişim planlaması için gereken anatomik bilginin eksik kalmasına yol açar.

Faz ve pencere

Portal tanısal: Kronik posttrombotik venöz obstrüksiyonda iliak venografi, tıkalı segmentleri ve eşlik eden kollateral damarları gösterebilir.
Gecikmiş: Venöz dolum zamanlamasının yetersiz olduğu incelemelerde arteriyel fazdan geç venöz faza uzanan çok fazlı görüntüleme, zamanlama kaynaklı yanlış yorumları azaltabilir.

Önerilen pencereler: Anjiyo (G 600 / M 150), Batın (G 400 / M 50), Yumuşak doku (G 400 / M 40).

BT bulguları

Kronik kalibre kaybı — iliak ven veya VKI'nin kısa ya da uzun bir segment boyunca incelmesi, eski trombozun bıraktığı fibrotik yeniden şekillenmeyi destekler.
İntralüminal sineşi ve trabekülasyon — lümen içinde ince septalar, ağsı bantlar veya çok kanallı rekanalizasyon görünümü kronik organize trombüsü düşündürür.
Kronik venöz oklüzyonda BT venogramda beklenen opasifikasyonun kaybı oklüzif trombüsle uyumlu olabilir.
Kollateral yeniden yönlenme — genişlemiş yükselen lomber, paravertebral, presakral veya yüzeyel epigastrik venler, akımın tıkalı iliokaval segment çevresinden dolaştığını gösterir.
Posttrombotik rekanalizasyonda, etkilenen segmentten bir miktar venöz akım geçişi sürebilir; bu durum tam oklüzyondan farklıdır.
Posttrombotik venöz obstrüksiyonun değerlendirilmesinde iliak venler ve ortak femoral ven birlikte incelenebilir.

Normalde

Normal venöz fazlı BT'de ortak iliak venler birleşerek sağda, aortanın sağında seyreden kesintisiz VKI'yi oluşturur; lümen benzer biçimde kontrastlanır ve çevresinde belirgin genişlemiş lomber ya da presakral kanallar bulunmaz. Aynı seviyede karşı taraf veninin çapını, lümen konturunu ve iliokaval birleşim devamlılığını kıyaslayın; kronik hastalıkta karşı tarafın normal olması tek başına hastalıklı tarafın oklüzyonunu kanıtlamaz.

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 s0119; organ sınırları veri setinin otomatik segmentasyonundan, birleştirilerek sadeleştirildi. Görüntüler 2,5 mm kesit aralığına yeniden örneklendi.

Ayırıcı tanı

Akut iliokaval tromboz: genişlemiş ven içinde daha homojen dolum defekti ve çevresel yumuşak doku ödemi görülebilir; kronik küçülme ve yerleşik kollateraller daha az belirgindir.
Kontrast karışımında opaklaşmamış kanın kontrastlı damara girmesi dolum defektini taklit edebilir; çok fazlı görüntüleme zamanlama kaynaklı yanlış yorumları azaltabilir.
Ekstrinsik pelvik kitle basısı: ven kitle tarafından dıştan yassılaşır veya yer değiştirir; kitle yumuşak doku penceresinde seçilir ve lümen içi sineşi beklenmez.
VKI tümör trombüsü, komşu tümörden damar lümenine kesintisiz uzanım gösterebilir; damar genişlemesi tümör trombüsünü düşündürebilir.
Doğuştan VKI kesintisi: beklenen segment yokluğu ve azygos/hemiazygos devamlılığı ile seyreder; tek başına önceki tromboz öyküsünü veya posttrombotik lümen bantlarını açıklamaz.

Tuzaklar

Venöz BT'de erken faz veya asimetrik dolum trombozu taklit edebilir; çok fazlı görüntüleme zamanlamaya bağlı yanlış yorumları azaltabilir.
Kronik venöz trombozda kısmi rekanalizasyon etkilenmiş segmentten bir miktar venöz akım geçişini sürdürebilir; bu bulgu tam oklüzyonla eşdeğer değildir.
Geniş kollateraller kronik çıkış engelini destekler ama hangi damarın tıkalı olduğunu tek başına göstermez; ana iliak damarları ve VKI'yi ayrı ayrı haritalayın.
Kronik posttrombotik kalınlaşmayı komşu retroperitoneal fibrozis sanmayın; fibrozis damar dışı dokuda plak veya çevreleyici yumuşak doku oluşturur.

Kendini dene

Eski DVT öyküsü olan hastada iliak ven küçülmüş, lümen içinde ince kontrast kanalları ve belirgin paravertebral venler var. En uygun yorum nedir?
Cevabı göster
Posttrombotik kronik obstrüksiyon. Küçük, düzensiz lümen; içinden geçen rekanalizasyon kanalları ve yerleşik kollateraller kronik posttrombotik yeniden şekillenmeyi birlikte destekler. Akut trombüs çoğu kez genişlemiş damarda görülür; leiomyosarkom lümen içi kitle dokusu, lenfadenopati ise damar dışı nodal yapılar oluşturur.
Kronik iliokaval ven obstrüksiyonlu hastalarda 3 boyutlu BT venografisi ile altın standart kabul edilen IVUS arasında minimal lümin alan ölçümleri açısından nasıl bir ilişki saptanmıştır?
Cevabı göster
Yüksek pozitif korelasyon. Kaynaklara (S10) göre 3D CTV ile IVUS arasında CIV, EIV ve CFV segmentlerinde yüksek Pearson korelasyonu (r=0.89, 0.77, 0.69) saptanmış; 3D CTV'nin stent çapı ve uzunluğunu tahmin etmede güvenilir bir araç olduğu gösterilmiştir.

İlgili konular

Kaynaklar

Bu sayfadaki 34 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 11 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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