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Upright renal arteriography and renal hypertension
Upright Renal Arteriography Renal Hypertension CHESTER C. WINTER, M.D., From tbe Division of Urology, Department of Surgery, Obio State University College of Medicine and University Hospital, Columbus, Obio.
o KNOWLEDGE,the use of the upright T position of the patient for abdomina1 OUR
aortography and concomitant renaI arteriography is a recent innovation. Our experience with it persuades us to consider it worthy of emphasis, and we are presenting a cIinica1 case in some detai1 because it so we11iIIustrates the value of the new technic. Kaufman [I] reported his experiences with the method among hypertensive patients at the CIeveIand meeting in October 1962 of the Cooperative Study of RenovascuIar Hypertension (NationaI Institutes of HeaIth). He aIso commented on apphcations of the procedure in two Ietters of the UroIogists’ Correspondence CIub [2,3] in 1962. According to his account, a catheter was threaded percutaneousIy into the aorta, either by the femora1 arteria1 route or by the axiIIary artery. The patient stood upright before a rapid cassette changer and a series of flms was exposed. An automatic injector was used. The advantages of ahowing gravitationa force to straighten the renaI artery and its branches are seIf-evident, since occasionaIIy narrow Iesions may be hidden by a coi1 in the renaI artery and overlap of its branches. It seems especiahy suitabIe in female patients in whom there is a high incidence of ptosis of the right kidney [a]. This articIe describes the effective use of an upright renaI arteriogram performed in a hypertensive patient immediateIy fohowing a routine transmmbar aortogram. The transIumbar needIe was retained in pIace for the upright x-ray exposure, which was the onIy roentgenogram made fohowing manua1 injection of the contrast materia1.
and
Columbus, Ohio
CASE REPORT
M. E., a white woman, fifty-four years oId, was referred for further study because of a constant ache in her right flank of one year’s duration. She worked as a clerk in a department store, remaining on her feet for many hours severa days a week. She noted that by the end of a working day her pain increased to the point where she obtained reIief onIy by Iying down upon reaching her home. Concomitant with this complaint, her family physician noted that she had mild systoIic and diastoIic hypertension. An excretory urogram reveaIed ptosis of both kidneys, but of significant degree onIy on the right side. She also had a moderate right hydronephrosis which appeared to be secondary to a stricture at the ureteropelvic junction. The ureter had a high origin from the renaI peIvis. There was delayed drainage from the right kidney, whiIe the left pyeIogram appeared normaI.
FIG. I. Fifteen minutes foIIowing aortography, the excretory urogram shows a normal pattern for the Ieft kidney but a moderate hydronephrosis is present on the right. The right ureter appears to be joined to the renaI petvis at a high point and to be obstructed at this junction.
Upright
Rena1 Arteriography
I
I~___~ i
I _-i-FIG. 2. The Icft rcnogram and bIood cIearance curve are normal. The right kidney has a norma functional scgmcnt, but n marked obstructive pattern is seen in the terminal phase in the upright position.
(Fig. I.) The initia1 urinaIysis showed pyuria for lvhich she received chemotherapy; the urinary sediment returned to normal. InitiaI uroIogic examination reveaIed the patient to have palpable right and Ieft kidneys upon assuming the upright position. There were no other abnormal findings referabIe to the back or abdomen. The results of pelvic and recta1 examinations wcrc nor remarkabIe. The patient did not admit to increased flank pain upon drinking copious amounts of fIuids or using diuretic agents. Initial bIoot1 pressures taken in the upright position 15616o/q8-102 mm. Hg. \vere Radioisotope renograms [j] showed an abnormality compatible with the excretory urogram. The initia1 Ieft renogram performed with the patient upright proved to bc normal but the drainage pattern was markcdly delayed on the right side, aIthough here the \-ascular and functional segments were normal (Fig. 2.) The test was rcpcated with the patient in the prone position. A dl-amatic change then appeared in the right renogram in that the drainage pattern reverted toward normal whiIc the Ieft renogram and the remainder of the right rrnogram wcrc unchanged. (Fig. 3.) It was aIso noted that
FIG. 3. With the patient prone, the Ieft renogram remains normal whiIe the right shows an improvement in the drainage pattern over that in Figure 2.
the supine position led to a lower blood pressure which subsequently returned to normal in the hospital, where she was admitted January 4, 1963, for further investigation. The resuIts of another series of rcnograms simuIated the original findings. TransIumbar aortography was performed with the use of local anesthesia and sedation with secobarbito1 and morphine. A preliminary fiIm after injection of 5 ml. of 50 per cent sodium diatrizoatc (IIypaquc”) showed the necdIc inferior to the renal arteries to bc in good position, and the main stem artcrics to each kidney were outlined in an adequate fashion. KO lesions were noted. The principal test series was conducted uith IO ml. of 50 per cent sodium diatrizoate administered by an automatic pressurr injector (3.5 kg. per cm.2 = 48 Ib. per in.2). Nine films wcrc cxposcd at a rate of three per second, and two additional roentgenograms were made during the seventh and tenth seconds to depict the nephrogram phase. SeIected Mms from this aortogram series arc shown in Figures 4, 5 and 6. Examination showed no artery crossing the region of the urctcropelvic junction, although there did appear to be an accessory artery to the superior pole of the right kidney. The examiner considered the possibiIity that this vessel, because of its Iocation and size, might be suppIying an adrena tumor. such as a pheochromocytoma.
Winter
FIG. 4. In the first second of the (prone) aortogram series, the main renaI artery trunks appear normaI and an accessory artcry is seen on the right (arrow). It couId either suppIy the upper pole of the right kidney or Iead to an adrena tumor.
FIG. 5. In the second second of the aortogram, the intrarenal branches of the renaI arteries are shown. The area suppEed by the accessory artery (right, upper arrow) is stiII uncertain. Note the Iower branch ofthe right renal artery (lower arrow) does not cross the ureteropelvic junction in the patient’s prone position. FIG. 6. The nephrogram
phase of the aortogram
is usefu1 for comparative
renaI measurements
and densities.
FIG. 7. The upright aortogram cIearIy shows the accessory artery (I) to suppIy the upper poIe of the right kidney and not a tumor of the adrena gIand. The right renaI artery is uncoiIed and its inferior branch (2) now appears to cross the ureteropeIvic junction, which couId account for the hydronephrosis, hypertension and decreased drainage on the upright renogram. Having knowIedge of Kaufman’s report on upright renaI arteriography, the aortographist judged the patient to be an appropriate candidate for such a maneuver. Since the tabIe over the cassette changer was not rotational, the patient was transferred by cart to an adjacent room, where a tabIe containing a cassette would tilt into an upright position. The transIumbar needle was Ieft in pIace during this transportation period. An upright roentgenogram of the renaI areas was then obtained, foIIowing manuaI injection of 8 mI. of 50 per cent sodium diatrizoate. (Fig. 7.) The patient withstood the entire two stage aorto-
graphic procedure without any discomfort or complications and had no sequeIae. SeveraI new facts were discIosed by the appIication of this nove1 technic to the aortographic examination of the patient. The right accessory artery was found definiteIy to supply the superior poIe of the right kidney, rather than to lead to an adrena tumor. The marked ptosis of the right kidney was again noted. The inferior branch of the right renaI artery was shown to cross the ureteropeIvic junction and thus couId account for obstruction of the right ureter onIy when the patient was in an upright position. 818
Upright RI,.SUJ.TS
TABLE I OF INDIVIDUAL RENAL
Tests
Right Kidney
Patient upright Urine volume (ml./min.).’ 1.4 Creatinine (mg. Per cent). 10.0 Sodium (mg./L.). / 30.0 Osmolality (mOsmj.. 98.0 Pntieot supine Urine volume. 1.; Crcntinine. 13.4 Sodium.. . 48.0 Osmolalltyv. 141 .o Indigo carmine Appearance time. . 7 min. ID set Initial concentration ~ trace Late concentration, . 2 plus
FUNCTION
-
Renal Arteriography
TESTS
Left Kidney
I 6 1I.O 30.0 98.0 I.4 34.3 99 5 330.0
Blndder
0.1
0.2
min. 45 sec. 4 plus 4 PIUS
Because of these observations, individua1 renaI function tests were thought to be indicated and were performed under IocaI anesthesia. One hundred mg. of intramuscuIar meperidine and 300 mg. of oral sodium secobarbito1 were given for sedation. She was then given 500 ml. of water oraIIy for hydration and maintained in an upright position. LocaI urethral anesthesia was initiated by instiIIing I per cent Xylocaine@ jelly. An intravenous infusion of 300 ml. of 3 per cent sodium chloride was administered during a thirty minute period. The patient was pIaced in the Iithotomy position and cystoscopy accompIished immediateIy with a No. z I Fr. Brown-Buerger instrument. The bladder and uretera orifices appeared normaI. Both ureters were intubated with No. 5 Fr. whistIetipped nyIon catheters. Urine, coIIected from each renaI pelvis, represented the effect of the water diuresis in the upright position. The patient was then aIlowed to remain supine for thirty minutes and continue water imbibition. CoIIection of urine from each kidney was repeated. The rates of urine excretion and urine concentrations of creatinine, sodium and osmoIaIities, and indigo carmine resuits with the patient in two positions are presented in TabIe 1. The patient was kept supine for severa hospita1 days with compIete reIief of her flank discomfort, and bIood pressure measurements were normaI. On the sixth hospita1 day, biIatera1 renaI expIoration was carried out through an upper abdomina1 midTine incision. BIood from the right renaI vein was coIIected, frozen and stored for subsequent assay for renin and angiotensin. The right renal arteries and branches were identified and found to conform to the aortographic findings. The inferior branch of the right renaI artery couId be we11 separated from the ureteropelvic junction. Thr right renal p&is was fiIIed with normal saIine soIution which entered into the ureter through a combination of peristaIsis and manipuIation after
FIG. 8. The right upright renogram is returning normal on the sixth postoperative day.
toward
the ureteropeIvic junction was dissected cIeanIy from surrounding tissue. It was elected, therefore, not to open the ureter or renaI pelvis. Both kidneys were pIaced in their norma anatomic positions and nephropexies accompIished by means of catgut sutures through their inferior capsuIes to the psoas muscles. The patient continued supine for five days postoperativeIy and was then aIIowed gradua1 ambuIation. The renogram on the sixth postoperative day showed drainage returning toward norma for the first time whiIe the patient was in the upright position. (Fig. 8.) The upright renogram on the ninth postoperative day indicated that renaI function and drainage were compIeteIy normaI. (Fig. 9.) BIood pressures continued to be norma and the patient was discharged on the sixteenth hospita1 day. The excretory urogram was almost norma by the fourth postoperative week. (Fig. IO.) COMMENT
Upright
aortography
is an additiona way especiaIIy if renaI The renaI arteries and
to evaIuate renaI vascuIature, ptosis
is
present.
Winter
FIG. IO. The upright excretory urogram is norma months postoperativcIy. Compare with Figure 7.
FIG. g. The right upright renogram norma on the ninth postoperative pressure is normat aIs0.
two
Erect aortography is not aIways indicated or feasibIe and patients shouId be seIected for this variation in technic. Those with renaI ptosis or in whom standard aortograms are unsatisfactory because of coiIed or overIapping renaI arteries wouId fuIfiI1 the prime requirements for the erect position. Since the cooperation of the patient seems essential, IocaI anesthesia is advocated and the pediatric age group wouId therefore be eIiminated from seIection. FinaIIy, a patient with vasomotor instabiIity, as reffected by a history of vertigo, syncope, orthostatic hypotension or excessive apprehension, should not undergo upright aortography. Kaufman used the transfemora1 and transaxiIIary catheter technics, which seem more suitabIe for this method than the transIumbar route, aIthough experience with the Iatter in the case herein reported was quite satisfactory. The resuIts of individua1 renaI function tests in this patient deserve brief comment. Their vaIues were unexpected, unusua1 and diffIcuIt to interpret. It was postuIated prior to their performance that in the upright position a pattern of right renaI ischemia wouId be obtained, that is, a Iower sodium concentration and a sIower rate of urine excretion. However, the vaIues for a11 of the tests were equa1 on the two sides, but quite Iow. When the tests were repeated with the patient in the supine position and unobstructed right renal drainage, the resuIts were again unexpected. The Ieft renaI
has returned to day. The bIood
branches are straightened by gravitationa factors and can be visuaIized in their entirety more readiIy. Narrow constrictures or those hidden by overIapping vesseIs are exposed. The reIationship of arteries to the ureters and renaI peIves in the erect position is eIucidated. The vaIue of such information, especiaIIy in renaI hypertension [dJ, was demonstrated in this patient. Some pathoIogists beIieve that mura1 hyperpIasia begins as a seque1 to trauma to the intima of the renaI artery. The “accordionpIeating” of such renaI arteries has been viewed by Kaufman [I] as possibIe evidence that renaI ptosis has produced such vascuIar insuIt because of the accordion-Iike action of an eIongated renaI artery. AIthough ptosis and mura1 hyperplasia are frequentIy associated and more common in young women and on the right side, they have been observed in maIes and on the Ieft side. a20
Upright:
Renal
Arteric-jgraphy described. Upright aortographyis chpccially adaptabIe to the examination of t.hr hj,pcrtensive patient or one who has renal ptc& with ureteropelvic junction obstruction. Certain contraindications are to be observed.
tests were normal but the right renaI functions, ;ncluding the sodium concentration, remained depressed. The rate of urine excretion from both sides continued equal. The tests were not in conformity with an ischemic Iesion of the right kidney. Rather, they were compatibIe with depressed right kidney function secondary to chronic obstruction. The espIanation for hypertension of renaI origin is diffIcuIt to make from the resuIts of the divided renaI tests. However, obstructive uropnthy and, rareIy, ptosis are known to be causes of renal hypertension.
REFERENCES
I. LI~I;K~Y, J. J. Upright angiogram. Coop. Study of Hyperten., CleveIand, Ohio, Oct. 2% Renovasc. 30, 1962. 2. KAL’FMAN. J. J. Aortogrnms III the upright _ _ position. Is nephroptosis a factor in the development of rennf arterv fibromuscular hvwrolaria? UroI. Corres. CL&, Aug. 17, 1962. .‘I ' 3. KAWMAN, J. J. Experiences in diagnosing renal stenosis associated with hypcrtcnsion. artery UroI. Corres. Club. Dee. IO. 1a6z. 4. WINTER, C. C. Upright remi\ a&riography, renal ptosis and hypertension. Inverted radioisotope ienography. giol. Corres. Club, Feb. 25, 1963. _ C. C. RadioisotoDe RenoernDhv. Balti/4. WINTER. more, 1963. LVilliams & WiIkins Company. 6. WINTER, C. C. CorrectabIe Rena1 Hypcrtcnsion Philadefphia, 1964. Lea & Febiger.
SUMMARY
Aortography with the patient in an upright position is a new technic for visuaIizing the renaI arteries straightened to fuII Iength, and in our hands is confirmed as a usefu1 addition to standard arteriography. A cIinica1 case in which the transIumbar approach was used is
”
821
I
.,
o KNOWLEDGE,the use of the upright T position of the patient for abdomina1 OUR
aortography and concomitant renaI arteriography is a recent innovation. Our experience with it persuades us to consider it worthy of emphasis, and we are presenting a cIinica1 case in some detai1 because it so we11iIIustrates the value of the new technic. Kaufman [I] reported his experiences with the method among hypertensive patients at the CIeveIand meeting in October 1962 of the Cooperative Study of RenovascuIar Hypertension (NationaI Institutes of HeaIth). He aIso commented on apphcations of the procedure in two Ietters of the UroIogists’ Correspondence CIub [2,3] in 1962. According to his account, a catheter was threaded percutaneousIy into the aorta, either by the femora1 arteria1 route or by the axiIIary artery. The patient stood upright before a rapid cassette changer and a series of flms was exposed. An automatic injector was used. The advantages of ahowing gravitationa force to straighten the renaI artery and its branches are seIf-evident, since occasionaIIy narrow Iesions may be hidden by a coi1 in the renaI artery and overlap of its branches. It seems especiahy suitabIe in female patients in whom there is a high incidence of ptosis of the right kidney [a]. This articIe describes the effective use of an upright renaI arteriogram performed in a hypertensive patient immediateIy fohowing a routine transmmbar aortogram. The transIumbar needIe was retained in pIace for the upright x-ray exposure, which was the onIy roentgenogram made fohowing manua1 injection of the contrast materia1.
and
Columbus, Ohio
CASE REPORT
M. E., a white woman, fifty-four years oId, was referred for further study because of a constant ache in her right flank of one year’s duration. She worked as a clerk in a department store, remaining on her feet for many hours severa days a week. She noted that by the end of a working day her pain increased to the point where she obtained reIief onIy by Iying down upon reaching her home. Concomitant with this complaint, her family physician noted that she had mild systoIic and diastoIic hypertension. An excretory urogram reveaIed ptosis of both kidneys, but of significant degree onIy on the right side. She also had a moderate right hydronephrosis which appeared to be secondary to a stricture at the ureteropelvic junction. The ureter had a high origin from the renaI peIvis. There was delayed drainage from the right kidney, whiIe the left pyeIogram appeared normaI.
FIG. I. Fifteen minutes foIIowing aortography, the excretory urogram shows a normal pattern for the Ieft kidney but a moderate hydronephrosis is present on the right. The right ureter appears to be joined to the renaI petvis at a high point and to be obstructed at this junction.
Upright
Rena1 Arteriography
I
I~___~ i
I _-i-FIG. 2. The Icft rcnogram and bIood cIearance curve are normal. The right kidney has a norma functional scgmcnt, but n marked obstructive pattern is seen in the terminal phase in the upright position.
(Fig. I.) The initia1 urinaIysis showed pyuria for lvhich she received chemotherapy; the urinary sediment returned to normal. InitiaI uroIogic examination reveaIed the patient to have palpable right and Ieft kidneys upon assuming the upright position. There were no other abnormal findings referabIe to the back or abdomen. The results of pelvic and recta1 examinations wcrc nor remarkabIe. The patient did not admit to increased flank pain upon drinking copious amounts of fIuids or using diuretic agents. Initial bIoot1 pressures taken in the upright position 15616o/q8-102 mm. Hg. \vere Radioisotope renograms [j] showed an abnormality compatible with the excretory urogram. The initia1 Ieft renogram performed with the patient upright proved to bc normal but the drainage pattern was markcdly delayed on the right side, aIthough here the \-ascular and functional segments were normal (Fig. 2.) The test was rcpcated with the patient in the prone position. A dl-amatic change then appeared in the right renogram in that the drainage pattern reverted toward normal whiIc the Ieft renogram and the remainder of the right rrnogram wcrc unchanged. (Fig. 3.) It was aIso noted that
FIG. 3. With the patient prone, the Ieft renogram remains normal whiIe the right shows an improvement in the drainage pattern over that in Figure 2.
the supine position led to a lower blood pressure which subsequently returned to normal in the hospital, where she was admitted January 4, 1963, for further investigation. The resuIts of another series of rcnograms simuIated the original findings. TransIumbar aortography was performed with the use of local anesthesia and sedation with secobarbito1 and morphine. A preliminary fiIm after injection of 5 ml. of 50 per cent sodium diatrizoatc (IIypaquc”) showed the necdIc inferior to the renal arteries to bc in good position, and the main stem artcrics to each kidney were outlined in an adequate fashion. KO lesions were noted. The principal test series was conducted uith IO ml. of 50 per cent sodium diatrizoate administered by an automatic pressurr injector (3.5 kg. per cm.2 = 48 Ib. per in.2). Nine films wcrc cxposcd at a rate of three per second, and two additional roentgenograms were made during the seventh and tenth seconds to depict the nephrogram phase. SeIected Mms from this aortogram series arc shown in Figures 4, 5 and 6. Examination showed no artery crossing the region of the urctcropelvic junction, although there did appear to be an accessory artery to the superior pole of the right kidney. The examiner considered the possibiIity that this vessel, because of its Iocation and size, might be suppIying an adrena tumor. such as a pheochromocytoma.
Winter
FIG. 4. In the first second of the (prone) aortogram series, the main renaI artery trunks appear normaI and an accessory artcry is seen on the right (arrow). It couId either suppIy the upper pole of the right kidney or Iead to an adrena tumor.
FIG. 5. In the second second of the aortogram, the intrarenal branches of the renaI arteries are shown. The area suppEed by the accessory artery (right, upper arrow) is stiII uncertain. Note the Iower branch ofthe right renal artery (lower arrow) does not cross the ureteropelvic junction in the patient’s prone position. FIG. 6. The nephrogram
phase of the aortogram
is usefu1 for comparative
renaI measurements
and densities.
FIG. 7. The upright aortogram cIearIy shows the accessory artery (I) to suppIy the upper poIe of the right kidney and not a tumor of the adrena gIand. The right renaI artery is uncoiIed and its inferior branch (2) now appears to cross the ureteropeIvic junction, which couId account for the hydronephrosis, hypertension and decreased drainage on the upright renogram. Having knowIedge of Kaufman’s report on upright renaI arteriography, the aortographist judged the patient to be an appropriate candidate for such a maneuver. Since the tabIe over the cassette changer was not rotational, the patient was transferred by cart to an adjacent room, where a tabIe containing a cassette would tilt into an upright position. The transIumbar needle was Ieft in pIace during this transportation period. An upright roentgenogram of the renaI areas was then obtained, foIIowing manuaI injection of 8 mI. of 50 per cent sodium diatrizoate. (Fig. 7.) The patient withstood the entire two stage aorto-
graphic procedure without any discomfort or complications and had no sequeIae. SeveraI new facts were discIosed by the appIication of this nove1 technic to the aortographic examination of the patient. The right accessory artery was found definiteIy to supply the superior poIe of the right kidney, rather than to lead to an adrena tumor. The marked ptosis of the right kidney was again noted. The inferior branch of the right renaI artery was shown to cross the ureteropeIvic junction and thus couId account for obstruction of the right ureter onIy when the patient was in an upright position. 818
Upright RI,.SUJ.TS
TABLE I OF INDIVIDUAL RENAL
Tests
Right Kidney
Patient upright Urine volume (ml./min.).’ 1.4 Creatinine (mg. Per cent). 10.0 Sodium (mg./L.). / 30.0 Osmolality (mOsmj.. 98.0 Pntieot supine Urine volume. 1.; Crcntinine. 13.4 Sodium.. . 48.0 Osmolalltyv. 141 .o Indigo carmine Appearance time. . 7 min. ID set Initial concentration ~ trace Late concentration, . 2 plus
FUNCTION
-
Renal Arteriography
TESTS
Left Kidney
I 6 1I.O 30.0 98.0 I.4 34.3 99 5 330.0
Blndder
0.1
0.2
min. 45 sec. 4 plus 4 PIUS
Because of these observations, individua1 renaI function tests were thought to be indicated and were performed under IocaI anesthesia. One hundred mg. of intramuscuIar meperidine and 300 mg. of oral sodium secobarbito1 were given for sedation. She was then given 500 ml. of water oraIIy for hydration and maintained in an upright position. LocaI urethral anesthesia was initiated by instiIIing I per cent Xylocaine@ jelly. An intravenous infusion of 300 ml. of 3 per cent sodium chloride was administered during a thirty minute period. The patient was pIaced in the Iithotomy position and cystoscopy accompIished immediateIy with a No. z I Fr. Brown-Buerger instrument. The bladder and uretera orifices appeared normaI. Both ureters were intubated with No. 5 Fr. whistIetipped nyIon catheters. Urine, coIIected from each renaI pelvis, represented the effect of the water diuresis in the upright position. The patient was then aIlowed to remain supine for thirty minutes and continue water imbibition. CoIIection of urine from each kidney was repeated. The rates of urine excretion and urine concentrations of creatinine, sodium and osmoIaIities, and indigo carmine resuits with the patient in two positions are presented in TabIe 1. The patient was kept supine for severa hospita1 days with compIete reIief of her flank discomfort, and bIood pressure measurements were normaI. On the sixth hospita1 day, biIatera1 renaI expIoration was carried out through an upper abdomina1 midTine incision. BIood from the right renaI vein was coIIected, frozen and stored for subsequent assay for renin and angiotensin. The right renal arteries and branches were identified and found to conform to the aortographic findings. The inferior branch of the right renaI artery couId be we11 separated from the ureteropelvic junction. Thr right renal p&is was fiIIed with normal saIine soIution which entered into the ureter through a combination of peristaIsis and manipuIation after
FIG. 8. The right upright renogram is returning normal on the sixth postoperative day.
toward
the ureteropeIvic junction was dissected cIeanIy from surrounding tissue. It was elected, therefore, not to open the ureter or renaI pelvis. Both kidneys were pIaced in their norma anatomic positions and nephropexies accompIished by means of catgut sutures through their inferior capsuIes to the psoas muscles. The patient continued supine for five days postoperativeIy and was then aIIowed gradua1 ambuIation. The renogram on the sixth postoperative day showed drainage returning toward norma for the first time whiIe the patient was in the upright position. (Fig. 8.) The upright renogram on the ninth postoperative day indicated that renaI function and drainage were compIeteIy normaI. (Fig. 9.) BIood pressures continued to be norma and the patient was discharged on the sixteenth hospita1 day. The excretory urogram was almost norma by the fourth postoperative week. (Fig. IO.) COMMENT
Upright
aortography
is an additiona way especiaIIy if renaI The renaI arteries and
to evaIuate renaI vascuIature, ptosis
is
present.
Winter
FIG. IO. The upright excretory urogram is norma months postoperativcIy. Compare with Figure 7.
FIG. g. The right upright renogram norma on the ninth postoperative pressure is normat aIs0.
two
Erect aortography is not aIways indicated or feasibIe and patients shouId be seIected for this variation in technic. Those with renaI ptosis or in whom standard aortograms are unsatisfactory because of coiIed or overIapping renaI arteries wouId fuIfiI1 the prime requirements for the erect position. Since the cooperation of the patient seems essential, IocaI anesthesia is advocated and the pediatric age group wouId therefore be eIiminated from seIection. FinaIIy, a patient with vasomotor instabiIity, as reffected by a history of vertigo, syncope, orthostatic hypotension or excessive apprehension, should not undergo upright aortography. Kaufman used the transfemora1 and transaxiIIary catheter technics, which seem more suitabIe for this method than the transIumbar route, aIthough experience with the Iatter in the case herein reported was quite satisfactory. The resuIts of individua1 renaI function tests in this patient deserve brief comment. Their vaIues were unexpected, unusua1 and diffIcuIt to interpret. It was postuIated prior to their performance that in the upright position a pattern of right renaI ischemia wouId be obtained, that is, a Iower sodium concentration and a sIower rate of urine excretion. However, the vaIues for a11 of the tests were equa1 on the two sides, but quite Iow. When the tests were repeated with the patient in the supine position and unobstructed right renal drainage, the resuIts were again unexpected. The Ieft renaI
has returned to day. The bIood
branches are straightened by gravitationa factors and can be visuaIized in their entirety more readiIy. Narrow constrictures or those hidden by overIapping vesseIs are exposed. The reIationship of arteries to the ureters and renaI peIves in the erect position is eIucidated. The vaIue of such information, especiaIIy in renaI hypertension [dJ, was demonstrated in this patient. Some pathoIogists beIieve that mura1 hyperpIasia begins as a seque1 to trauma to the intima of the renaI artery. The “accordionpIeating” of such renaI arteries has been viewed by Kaufman [I] as possibIe evidence that renaI ptosis has produced such vascuIar insuIt because of the accordion-Iike action of an eIongated renaI artery. AIthough ptosis and mura1 hyperplasia are frequentIy associated and more common in young women and on the right side, they have been observed in maIes and on the Ieft side. a20
Upright:
Renal
Arteric-jgraphy described. Upright aortographyis chpccially adaptabIe to the examination of t.hr hj,pcrtensive patient or one who has renal ptc& with ureteropelvic junction obstruction. Certain contraindications are to be observed.
tests were normal but the right renaI functions, ;ncluding the sodium concentration, remained depressed. The rate of urine excretion from both sides continued equal. The tests were not in conformity with an ischemic Iesion of the right kidney. Rather, they were compatibIe with depressed right kidney function secondary to chronic obstruction. The espIanation for hypertension of renaI origin is diffIcuIt to make from the resuIts of the divided renaI tests. However, obstructive uropnthy and, rareIy, ptosis are known to be causes of renal hypertension.
REFERENCES
I. LI~I;K~Y, J. J. Upright angiogram. Coop. Study of Hyperten., CleveIand, Ohio, Oct. 2% Renovasc. 30, 1962. 2. KAL’FMAN. J. J. Aortogrnms III the upright _ _ position. Is nephroptosis a factor in the development of rennf arterv fibromuscular hvwrolaria? UroI. Corres. CL&, Aug. 17, 1962. .‘I ' 3. KAWMAN, J. J. Experiences in diagnosing renal stenosis associated with hypcrtcnsion. artery UroI. Corres. Club. Dee. IO. 1a6z. 4. WINTER, C. C. Upright remi\ a&riography, renal ptosis and hypertension. Inverted radioisotope ienography. giol. Corres. Club, Feb. 25, 1963. _ C. C. RadioisotoDe RenoernDhv. Balti/4. WINTER. more, 1963. LVilliams & WiIkins Company. 6. WINTER, C. C. CorrectabIe Rena1 Hypcrtcnsion Philadefphia, 1964. Lea & Febiger.
SUMMARY
Aortography with the patient in an upright position is a new technic for visuaIizing the renaI arteries straightened to fuII Iength, and in our hands is confirmed as a usefu1 addition to standard arteriography. A cIinica1 case in which the transIumbar approach was used is
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