Ekstremite damar yaralanması

Özet

Künt veya penetran ekstremite travması arter duvarında yırtılma, diseksiyon, tromboz, psödoanevrizma ya da arteriyovenöz fistül oluşturabilir. Ekstremite BTA yaralanmanın seviyesini, lezyon tipini, distal akımı ve kemik-yumuşak doku eşlikçilerini gösterir. Akım kesisi veya devam eden kanamanın atlanması ekstremite perfüzyonunu ve doku canlılığını tehdit edebilir.

Okuma sırası

1. Yaralanma seviyesindeki ana arter. BTA'nın koronal MIP görüntüsünde travma hattına girin; yaralı ekstremitenin ana arterini proksimalden distale izleyip ani kalibre veya opaklaşma değişimini bulun.
2. Arter lümeni ve damar dışı odak. Şüpheli noktayı aksiyel kesitlerde açın; lümen içinde flep mi, damar dışında kontrast mı, yoksa arterle boyun üzerinden bağlı bir kese mi olduğunu ayırın.
3. Distal arter ağacı. Lezyonun distalindeki radial-ulnar ya da tibial-peroneal dalların opaklaşmasını izleyin; kesilme sonrası kollateral yeniden dolumun başladığı seviyeyi not edin.
4. Yumuşak doku, komşu ven ve kemik. Yara yolu ve kas hematomunu, komşu venin arteriyel fazdaki dolumunu ve eşlik eden kırığı göstererek kanama, fistül ve iskelet hasarı birlikteliğini tamamlayın.

Faz ve pencere

BTA tanısal

Arteriyel kontrastla dolan ekstremite damarları boyunca ani kesilme, lümen daralması, intimal flep, trombüs, damar dışı kontrast, sakküler kese ve yaralanma yerinde erken venöz opaklaşma araştırılır; distal arterlerin dolumu kesintisiz izlenir.

Gecikmiş tanısal

Zamanla büyüyen şüpheli ekstravazyon aktif kanamayı düşündürür; psödoanevrizma ise arterle bağlantılı sınırlı bir kontrast kesesi olarak izlenir ve çevresinde aktif kanama olmayabilir. Proksimal oklüzyon veya yavaş akımlı yaralanmalarda kollateral dolaşımın sağladığı distal yeniden dolam, limb kurtarma açısından kritik olabilir.

Önerilen pencereler: Anjiyo (G 600 / M 150), Yumuşak doku (G 400 / M 40), Kemik (G 1800 / M 400).

BT bulguları

• Damar kesisi veya oklüzyon — arter kontrast dolumu bir noktada aniden sonlanır; distal damarlar dolmuyorsa tromboz veya tam kesilme düşünülür.
• İntimal flep — lümen içinde ince duvar parçası, eksantrik daralma veya kısmi dolum kusuru oluşturur.
• Aktif ekstravazasyon — BTA'da damar dışı aktif kontrast ekstravazasyonu arteriyel yaralanma bulgusu olarak izlenebilir.
• Travmatik psödoanevrizma — arter lümeniyle bağlantılı, sınırlı kontrast kesesi ve komşu yumuşak doku hematomu görülür.
• Arteriyovenöz fistül — yaralanma çevresindeki venin arteriyel fazda erken opaklaşması, bazen eşlik eden arter kesesiyle birlikte izlenir.
• Distal yeniden dolum — ana arter trombozu veya kesisi sonrasında kollateral yollarla distal arter dalları kontrastlanabilir; bu distal dolam, proksimaldeki tam kan akışı kesintisini maskeleyebilir ve doku perfüzyonunu sürdürebilir.
• Perivasküler hematom veya yara kanalı — kanama ve penetran travmanın seyri damar yaralanma bölgesine yaklaşabilir.
• İskelet-kas eşlikçisi — kırık, kas içi kanama, kompartıman çevresinde şişme veya yabancı cisim damar lezyonunun düzeyiyle eşleşebilir.

Normalde

Normal ekstremite BTA'da damarların normal anatomisi ve sık görülen varyantları dikkate alınır. Ekstremite BTA'da damar açıklığı ve düzensizliği değerlendirilir; anatomik ayrıntılar ve olası varyantlar dikkate alınır.

Ayırıcı tanı

Vazospazm, ekstremite iskemisine yol açabilen damar patolojileri arasındadır.

Psödo-oklüzyon veya zayıf bolus

ekstremite BTA'sında bolus zamanlaması, damar anormalliğini taklit edebilen ya da maskeleyebilen teknik bir tuzak olarak dikkate alınmalıdır.

Arteriyel varyant

beklenmeyen damar seyri başka kesitlerde anatomik devamlılıkla izlenir ve çevresinde travma odağı yoktur.

Travmatik psödoanevrizma

sınırlı kontrast kesesiyle seyreder; aktif kanama gibi hematom içinde ilerleyici yayılım oluşturmaz.

Venöz yaralanmalar (tromboz, diseksiyon) akut dönemde arteriyel faza göre geç evre BT anjiyografide daha belirgin olabilir.

Tuzaklar

• Ekstremite BTA'da teknik tuzaklar veya artefaktlar damar anormalliğini taklit edebilir ya da maskeleyebilir; görüntüler bu olasılık gözetilerek değerlendirilmelidir.
• Ağır kırık veya metal parçanın yanındaki çizgi artefaktı damarı örtebilir; farklı düzlem ve pencerede, artefakttan uzak segmentleri izleyin.
• Distal yeniden dolum — ana arter trombozu veya kesisi sonrasında kollateral yollarla distal arter dalları kontrastlanabilir; bu distal dolam, proksimaldeki tam kan akışı kesintisini maskeleyebilir ve doku perfüzyonunu sürdürebilir.
• Arteriyel fazda erken venöz opaklaşma AV fistül düşündürebilir ancak hiperemi veya diğer nedenlerle de görülebilir; kesin tanı için klinik ve radyolojik değerlendirme gereklidir.

Kendini dene

1. Bacağın BTA'sında popliteal arter ani kesiliyor, distal tibial dallar daha aşağıda yeniden opaklaşıyor. En olası açıklama nedir?

   • Arter kesisi ve kollateral dolum
   • Yalnız damar spazmı
   • Venöz psödoanevrizma
   • Normal arter varyantı
   Cevabı göster

   Arter kesisi ve kollateral dolum. Fokal ani arter kesintisi ve distal yeniden dolum, proksimal yaralanma sonrasında kollateral akımı düşündürür; distal opaklaşma lezyonu dışlamaz. Spazm genellikle düzgün daralma yapar, diğer seçenekler bu arteriyel örüntüyü açıklamaz.

2. Kol travması BTA'sında yaralanma yakınındaki ven arteriyel fazda erken kontrastlanıyor. Hangi bulgu öncelikle aranır?

   • Arteriyovenöz fistül
   • Arter oklüzyonu
   • İntimal kalsifikasyon
   • Kemik iliği ödemi
   Cevabı göster

   Arteriyovenöz fistül. Yaralanma odağına yakın venin erken opaklaşması arteriyovenöz bağlantıyı destekler. Oklüzyon arter dolumunun kesilmesidir; kalsifikasyon kronik duvar bulgusudur; kemik iliği ödemi damar şantını göstermez.

İlgili konular

• Aktif kontrast ekstravazasyonu
• Travmatik psödoanevrizma
• Abdominal aorta ve visseral damar yaralanması

Kaynaklar

Bu sayfadaki 38 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 12 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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