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Abdominal Vascular Syndromes: Characteristic Imaging Findings* Síndromes Vasculares Abdominais: Achados De Imagem Característicos

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Abdominal Vascular Syndromes: Characteristic Imaging Findings* Síndromes Vasculares Abdominais: Achados De Imagem Característicos Cardarelli-LeitePictorial L et al. / AbdominalEssay vascular syndromes Abdominal vascular syndromes: characteristic imaging findings* Síndromes vasculares abdominais: achados de imagem característicos Leandro Cardarelli-Leite1, Fernanda Garozzo Velloni1, Priscila Silveira Salvadori1, Marcelo Delboni Lemos1, Giuseppe D’Ippolito2 Cardarelli-Leite L, Velloni FG, Salvadori PS, Lemos MD, D’Ippolito G. Abdominal vascular syndromes: characteristic imaging findings. Radiol Bras. 2016 Jul/Ago;49(4):257–263. Abstract Abdominal vascular syndromes are rare diseases. Although such syndromes vary widely in terms of symptoms and etiologies, certain imaging findings are characteristic. Depending on their etiology, they can be categorized as congenital—including blue rubber bleb nevus syndrome, Klippel-Trenaunay syndrome, and hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome)—or compressive— including “nutcracker” syndrome, median arcuate ligament syndrome, Cockett syndrome (also known as May-Thurner syndrome), and superior mesenteric artery syndrome. In this article, we aimed to illustrate imaging findings that are characteristic of these syndromes, through studies conducted at our institution, as well as to perform a brief review of the literature on this topic. Keywords: Gastrointestinal tract; Venous thrombosis; Arteriovenous fistula; Hemangioma. Resumo As síndromes vasculares abdominais englobam doenças raras, com sintomas e causas diversas, mas com achados de imagem carac- terísticos. Dividem-se em dois grupos distintos, a depender de sua origem, que pode ser congênita (síndrome de blue rubber bleb nevus, síndrome de Klippel-Trenaunay e telangiectasia hereditária hemorrágica/Rendu-Osler-Weber) ou compressiva (síndrome do “quebra- nozes”, síndrome do ligamento arqueado, síndrome de Cockett ou May-Thurner e síndrome da artéria mesentérica superior). Neste artigo, o nosso objetivo é ilustrar achados de imagens determinantes dessas doenças, por meio de estudos adquiridos em nossa insti- tuição, associando uma breve revisão da literatura. Unitermos: Trato gastrintestinal; Trombose venosa; Fístula arteriovenosa; Hemangioma. INTRODUCTION tomical structures or by compression of hollow visceral or- gans by vessels. Compressive syndromes lead to major he- The use of imaging methods to evaluate abdominal dis- modynamic alterations, such as ischemia and thrombosis, eases has been discussed in a series of recent articles in the primarily in young, healthy patients(12,13). radiology literature of Brazil(1–10). Abdominal vascular syn- dromes, although rare, are relevant because they can often CONGENITAL VASCULAR SYNDROMES represent a diagnostic challenge for the attending physician. It is important for radiologists to identify imaging find- Such syndromes have varied clinical presentations and dis- ings as part of a single syndrome, dispelling diagnostic tinct causes. Nevertheless, their imaging findings are char- doubts and contributing to treatment planning. The main acteristic and must be recognized by radiologists(11). symptom is bleeding, occult or overt, leading to anemia and Abdominal vascular syndromes can be divided in two consumption of coagulation factors in the most severe major groups, according to their origin(12): congenital or cases(12). Congenital vascular syndromes can be classified compressive. Congenital syndromes include several types of as low-flow or high-flow. To differentiate between those two low-flow or high-flow vascular malformations, which can types, it is recommended that, in addition to a physical exam, result in hemorrhagic complications. Compressive syndromes Doppler ultrasound, magnetic resonance imaging (MRI), and are caused by compression of the vasculature by adjacent ana- angiography be employed(12). Classifying the flow allows a more precise diagnostic assessment and contributes to de- * Study conducted in the Department of Diagnostic Imaging of the Escola Paulista fining the most appropriate treatment strategy(12,14). de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil. 1. MD, Radiologist in the Department of Diagnostic Imaging of the Escola Paulista Low-flow type de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Low-flow congenital vascular syndromes predominantly Brazil. 2. Tenured Associate Professor in the Department of Diagnostic Imaging of the originate from a malformation of the venous system and Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), present multiple phleboliths as a common imaging charac- São Paulo, SP, Brazil. teristic. Among such syndromes, we describe the blue rub- Mailing address: Dr. Leandro Cardarelli-Leite. Departamento de Diagnóstico por ber bleb nevus and Klippel-Trenaunay syndromes. Imagem – EPM-Unifesp. Rua Napoleão de Barros, 800, Vila Clementino. São Paulo, SP, Brazil, 04024-002. E-mail: [email protected]. Blue rubber bleb nevus syndrome – This syndrome Received July 7, 2015. Accepted after revision October 30, 2015. is characterized by vascular malformations which mainly Radiol Bras. 2016 Jul/Ago;49(4):257–263 257 0100-3984 © Colégio Brasileiro de Radiologia e Diagnóstico por Imagem http://dx.doi.org/10.1590/0100-3984.2015.0136 Cardarelli-Leite L et al. / Abdominal vascular syndromes affect the skin and the gastrointestinal system. On the skin, Klippel-Trenaunay syndrome – A diagnosis of this syn- there are typically dark blue lesions, with an elastic consis- drome, as manifested in a lower limb (Figure 3), can be made tency, measuring up to 5.0 cm(11). if at least two of the following criteria are met(11): lateral Barium radiography of the gastrointestinal tract shows giant varices; bone and soft tissue hypertrophy; and port-wine polypoid filling defects. Computed tomography (CT) shows stains. In the gastrointestinal tract, Klippel-Trenaunay syn- multiple phleboliths, representing cavernous hemangiomas, drome mainly affects the distal colon and rectum, although most commonly in the colon, rectum, and liver (Figure 1). it can extend to the genitourinary structures in the pelvis. On MRI, the venous malformations are well defined, with The main imaging findings, as depicted in Figure 4, include isointense signals on T1-weighted images, hyperintense sig- phleboliths, varices showing enhancement (in the later stages) nals on T2-weighted images, and progressive, homogenous after the use of intravenous contrast medium, and increased uptake of intravenous paramagnetic contrast medium (Fig- soft tissue mass in the lower limb(11). The differential diag- ure 2), from which the low-flow nature of the syndrome can noses include other diseases that cause gigantism of the limbs be inferred(11). and vascular anomalies, such as the Proteus, Parkes-Weber, Bannayan-Riley-Ruvalcaba, and Maffucci syndromes, al- though only Klippel-Trenaunay syndrome causes venous malformations that present as “Port wine” stains(15). Figure 1. Blue rubber bleb nevus syndrome. Axial CT scan showing a calcified hepatic nodule (arrow), suggestive of hemangioma. Figure 3. Klippel-Trenaunay syndrome. Axial maximum intensity projection CT reconstruction showing large caliber gluteal collateral circulation (arrow). Figure 4. Klippel-Trenaunay syndrome. Axial maximum intensity projection CT Figure 2. Blue rubber bleb nevus syndrome. Sagittal T2-weighted MRI scan show- reconstruction showing multiple phleboliths distributed throughout the bladder and ing circumferential thickening of the rectum (asterisk) with high signal intensity. rectum walls, which are thickened, indicative of cavernous hemangiomas. 258 Radiol Bras. 2016 Jul/Ago;49(4):257–263 Cardarelli-Leite L et al. / Abdominal vascular syndromes High-flow type in up to 30% of patients. Such involvement manifests as large High-flow congenital vascular syndromes are predomi- vascular bundles resulting from arteriovenous, arterioportal, nantly of arterial origin, the main example being hereditary or portovenous shunts (Figure 5). Those shunts can result hemorrhagic telangiectasia, also known as Rendu-Osler- in major clinical complications such as portal hypertension, Weber syndrome(16). ascites, hepatic encephalopathy, heart failure, and biliary (16,17) The diagnostic criteria for high-flow congenital vascu- necrosis . Other findings include an increase in the cali- lar syndromes include recurrent episodes of epistaxis; mul- ber of the hepatic artery (> 1.0 cm) and telangiectasia, which tiple vascular dilatations on the lip, palate, hands, or nose; is characterized by small hypervascular subcapsular nodules, arteriovenous malformations; and fistulas in organs such as less than 1.0 cm in diameter (Figure 6). It is noteworthy the lungs, liver, brain, and bone marrow. Telangiectasia mainly that the prevalence of focal nodular hyperplasia is 100 times involves the gastroduodenal mucosa and is generally limited, higher in these patients with hereditary hemorrhagic telang- which hinders evaluation with radiological methods(16). iectasia than in the general population, information that can (16,17) Hereditary hemorrhagic telangiectasia (Rendu- limit the number of unnecessary liver biopsies . Osler-Weber syndrome) – In this disease, the main find- COMPRESSIVE VASCULAR SYNDROMES ing on imaging exams is hepatic involvement, which is present In general, compressive vascular syndromes occur when the vascular structures in the abdomen and pelvis compress or are compressed by adjacent anatomical structures. Com- pression of the celiac trunk, left iliac vein, or renal
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