Arteriography in Renal and Abdominal Conditions1

ARTERIOGRAPHY IN

RENAL AND ABDOMINAL CONDITIONS' 0. A. ~ELSON

Arteriography is nearly m; old as roentgenography. In 1896, within a few weeks after Roentgen discovered the rays that bear his name, Haschek and Lindenthal produced arteriograms by injecting a radiopaque medium into an amputated arm. From that date, considerable experimental work was done on lmYer animals and cadavers. But the lack of a suitable contrast medium prevented its application to patients. Cameron's aimouncement in 1918 that the iodide molecule iR opaque to the roentgen rays opened the way to clinical arteriography. The names that appear in connection with early work are tho::,e of Sicard and Forestier in 1923, in France; Berberich and Hirsch in 1923, in Germany; and Brooks in 1924, in America. JVIore recently various types of arteriography have been performed on the various portions of the body; on the extremities by Allen and Camp, Edwards, Brooks, Singleton, Greig and Knapp; considerable arteriography of the head has been done by Monizc, Pinto and Lima, Saito and Kamikawa, Lohr and Greig; and some good ,vork has been done on outlining the cardiac chambers and aortic arch, by Robb and Steinberg, Castellanos and Pereiras, Nuvoli, and others. However, to Santos and his co-work ers must be given the credit for pioneering arteriography of the abdominal organs by aortic injection. They published their first report in 1929 after about 2 years' ,vork. Jn order to make myself as clear as possible, I shall first describe the technique and discuss what might seem to be hazards, before demonstrating some of the diagnostic value of the procedure. TECHNIQUE

As the current in the abdominal arteries cannot well be stopped, the exposure of these films must be made ·while the opaque medium is moving swiftly. Also, dilution of the substance injected is rapid. Therefore the radiopaque substance must be concentrated, must be injected rapidly, and above all, injection and exposure of the films must be well-coordinated. Delay, or faulty timing even for one second, may result in failure to obtain a satisfactory gram. In the main, we have followed the technique devised by Santos and his co1rorkers. EQUIPMENT

The 1:1pecial equipment con1:1ists of a pressure apparatus for injecting the solution (fig. 1), and an 18 gauge needle 12 cm. long. The x-ray machine must have a potential power to deliver 500 milliampers of current; and the Bucky diaphragm must be so constructed as to allow exposure within 1/4 of one second without leaving grid marks. 1

Reau at annual meeting, American Urological Association, St. Louis, :Vlo., June 22,

1945.

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Sodium iodide solution 80 per cent, makes a good contrast medium. Under the heading of equipment should be mentioned the operator's training and anatomical knowledge. It is very important that he spend considerable time in the dissecting room before doing aortic puncture on the patient.

·~ - - - -- ---c~FIG. 1. Pressure apparatus PREPARATION OF THE PATIEN'l'

On the afternoon before the examination, the patient is given 2 ounces of castor oil in 3 or 4 ounces of root beer. Then he is allowed only liquid nourishment until after the examination. Before proceeding with the examination, all the equipment must be ready. Solution, needle, and part of the pressure apparatus must be sterilized. After

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the solution has been placed in the glass tube, the pressure is brought up to 1½ atmospheres. Before the aortic puncture is made, a scout film should be made of the patient in supine position. If the technique is found satisfactory, the patient is anesthetized. We prefer pentothal sodium. AORTIC PUNCTURE AND INJECTION OF THE OPAQUE MEDIUM: EXPOSURE OF THE FILM

After the anesthesia has progressed so that the patient's reflexes are abolished, the skin over the left side of the back and lower chest is prepared with tincture of iodine, and draped with sterile towels. The skin is punctured by the needle just below the twelfth rib and about 3 or 4 fingers' breadth to the left of the spinous processes. The point of the needle is directed inward and downward toward the body of the twelfth vertebra. As soon as the bone is encountered, the point of the needle is deviated laterally so as to glide over the vertebra. When that is accomplished, the stilet is removed, and the needle slowly advanced a few centimeters to enter the aorta (which lies along the anterior left margin of the vertebral column). Entrance into the aorta is signalized by blood coming through the needle; the needle is again advanced about½ centimeter, in order to make certain that it is well within the aorta. After the needle has been adjusted, the pressure apparatus is attached to it. Now, being certain that the x-ray technician is ready to make the exposure, the operator opens the outlet valve on the pressure apparatus, and allows 6 or 8 cc of the contrast solution to run into the aorta. The exposure must be made just as injection is completed. Then the pressure apparatus is disconnected from the needle, a few cubic centimeters of blood allowed to run out, and the needle withdrawn. Doctor Blake, at the Swedish Hospital, has devised a lead shield over the Bucky diaphragm, so that two films can be exposed at a 2 or 3 second interval. Such an arrangement gives us two chances to get a good film. There are three hazards which seemingly might cause untoward reaction from this procedure: First, acute iodism; second, extra-aortic injection of the opaque medium; and third, extravasation of blood through the needle wound in the aortic wall. Acute iodism. In our early work iodism occurred 4 times; but in none of the patients was the reaction severe. During the last 5 years the patients have been given 1,000 cc of 5 per cent glucose in normal saline solution, with 200 units of vitainin C. Since instituting the use of the mildly hypertonic solution immediately after the patient has been returned to bed, we have seen no evidence of iodism. Patients who have had untoward reaction from secretory pyelography have not been subjected to arteriography. Irritation to the arterial wall by the iodide solution has not been seen, either grossly or microscopically, in arteries of kidneys removed immediately or some

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days after arteriography. We have had no chance to study the intima of the aorta after these injections. Extra-aortic injection of the contrast medium. Following injection of the iodide solution in the peri-aortic area, the patient will usually have some pain, but not always. According to Santos, such an accident is of no serious consequence, as the hypertonic solution will be absorbed within a short time. No attempt should be made to drain, if extra-aortic injection occurs. Extravasation through needle puncture. Learning of aortic puncture for the first time, one is likely to believe that leakage through the needle wound might occur. The fear of that complication no doubt arises from seeing an arm vein rupture when injected. However, histologic comparison has shown that the aortic wall is many times thicker than that of the arm vein, in the same subject. In all the inadvertent aortic punctures that have been made during attempts to produce splanchnic anesthesia, we have found no record of such a perforation giving rise to complications. Furthermore, there are cases on record showing that bullets have perforated the aortic wall without sequential hematoma or extravasation. Kornblith mentions three such cases; one occurred in his practice. Brown had a patient who was shot through the chest. The 0.32 bullet entered the aorta and drifted into the left femoral artery, from which it was removed. No trouble occurred from the bullet wound in the aorta. Therefore, owing to the ruggedness of the aortic wall, it seems practically certain that perforation by an 18 gauge needle will not be followed by leg,kage. Santos contends, and we agree, that the only hazard from the procedure is the untoward reaction from the opaque medium, also that a person can tolerate more iodide if it be injected into the aorta and the capillary bed, than when injected into a vein. Although our experience is limited to 106 aortic punctures for arteriography, 22 for medication of the blood stream and one for obtaining blood for transfusion, we, at present, believe that an aortic puncture properly performed, carries no more hazard than a spinal puncture or a cystoscopy. RENOGRAMS AND PYELOGRAMS BY AORTIC INJECTION

In search of an opaque medium that would be less likely to produce untoward reaction than sodium iodide, we tried to use skiodan, and also diodrast 70 per cent. However, the iodide content in these substances is too low to produce clear delineation of the smaller arteries. Nevertheless, they brought out two interesting types of films. One of these was produced by rapidly injecting diodrast 70 per cent into the aorta for about 10 seconds before exposing the film. Such a procedure at times produced quite dense shadows of the renal parenchyma. This we have called a "renogram" (fig. 2). Whether such a film will be of diagnostic value remains to be seen. The second type of film is a secretory pyelogram, which has also been produced by Santos. By injecting about 40 cc of diodrast, 70 per cent into the aorta, satisfactory excretory pyelograms (fig. 3) can be obtained in patients whose renal function is too deficient to produce satisfactory grams after intravenous injection,

ARTERIOGRAPHY

N RENAL AND ABDOMINAL CONDITIONS

Frn. 2. Renogram produced by injecting 70 per cent diodrast into the aorta. aneurysm of the abdominal aorta.

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Note the

Frn. :3. Showing secretory pyelogram produced by injecting 70 per cent Dioclrast in Lo the aorta.

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or whose ureters cannot be catheterized. (If the renal function be extremely low, such films are of course not satisfactory.) For such a procedure the solution may be injected into the aorta with a hand syringe, and the films exposed at intervals, as though one were making secretory pyelograms. So much for the sidelights encountered in this work. We shall now return to the roentgenographic delineation of the arteries and discuss four conditions: 1) location of organs; 2) arterial obstruction; 3) aneurysm; 4) renal neoplasm that evades detection by pyelography. Aside from those mentioned above there are, of course, other conditions that arteriography will depict, but time and space do not permit their discussion here. In the films to be presented, we are quite certain about the interpretation. However, many times we have been in a quandary as to certain findings. Much

Frn. 4. Left kidney displaced by a retroperitoneal tumor

study and experience will be required before the diagnostician can make the most of these grams. The following case record shows displacement of kidney (fig. 4). Miss J. R., a Dutch refugee, age 28 years, had a mass filling the left side of the abdomen. About 4 months before coming for the examination, she had noticed enlargement of the abdomen which had increased so that she could no longer wear her usual clothes. Except for the abdominal mass, general examination revealed no particular abnormality. Urine and blood were normal to laboratory examination. Secretory pyelograms showed the right kidney and ureter to be normal. There was a left renal rotation so that the superior pole of the kidney pointed toward the midline. The calyces pointed toward the diaphragm. There ,vas pyelectasis and calyectasis. In trying to establish the diagnosis, we performed arteriography. It can be seen that the mass is not connected with either the kidney or

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the spleen. A diagnosis of a retroperitoneal mass was made. Operation re, vealed a retroperitoneal multilocular neoplasm. Although several pathologists

Fm, 5, Mrs. M. F. Shows blockage of the main left renal artery, wiLb budding of Bmall arteries from the stump.

Fm. 6, Mrs. ,KM. Aneurysm of the abdominal aorta

examined the specimen, they failed to agree on the diagnosis. The majority of them believed that the tumor ,yas of ovarian origin. The following case record shows obstruction of arteries within the kidney (fig.

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5). Mrs. M. F., aged 44, was referred for arteriography. A suprarenal tumor had be'en suspected because of intermittent hypertension of 15 years' duration. A shadow of a soft tissue mass was found above the left kidney in the roentgenogram made elsewhere. The family physician had, on several occasions, found her systolic blood pressure to be over 300 mm. of mercury. At times the pressure had been normal. Cystoscopy, ureteral catheterization, renal function as indicated by indigo carmine and pyelography showed no abnormality except for a constriction of the infundibulum of the middle calyx of the left kidney and a

FIG. 7. (Left), normal appearing pyelogram. (Right), arteriogram of same patient showing pooling of sodium iodide in right kidney~hypernephroma.

smaller kidney shadmv on the left than on the right. The arteriogram shows blockage of the main renal artery with budding of the small arteries from the stump. N ephrectomy was done; tissue sections showed marked arteriosclerosis of the kidney. Although the patient was, for a time, symptomatically improved, the hypertension persisted. Eighteen months after the operation she died from cerebral hemorrhage. It is questionable whether this condition can be classified as a Goldblatt's kidney. The following case record shows an aneurysm (fig. 6). Mrs. E. M. was aged 59. No information was obtained from the family or personal history that

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seemed to have any bearing on her chief complaint. Two months before entering the hospital, she was seized suddenly with severe pain in the right side of the abdomen. The pain was continuous and large doses of morphine were required to relieve her. Examination revealed tenderness in the mid portion of the abdomen. On pressure in that region, the pain was referred to the right groin, right genitalia and back. Urine and blood, including Wasserman test, were normal to laboratory examination. Pelvic examination, roentgenologic study

FIG. 8. Mr. P. W. (Left), the pyelogram shows no definite abnormality except filling defect produced by the blood clots in the right kidney, pelvis and ureter. (Right), arteriogram of same patient showing extensive pooling of the sodium iodide in ho.th, ,ienal areas-bilateral hypernephroma.

of the gastro-intestinal tract and excretory pyelograms revealed no findings to explain her symptoms. Believing that the lesion might be of the spinal cord and that arteriography would be of no aid in the diagnosis, we advised a neurologic consultation. However, the referring physician insisted that arteriography be done. The film showed an aneurysm of the aorta in juxtaposition to the second lumbar vertebra. The two next case records show the presence of renal neoplasm with normal-

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appearing pyelograms. Mr. C.R. P. was aged 64. Because of his intermittent hematuria, he had undergone 4 retrograde renal studies between .July, 1942, and March, 1944. At each examination the blood was found to be coming from the right ureter. Blood was the only abnormal finding in the urine. None of the pyeloureterograms showed evidence of tumor or other abnormality. On March 31, 1944, arteriography revealed pooling of the opaque medium in the parenchyma of the right kidney. (See figure 7.) )Jephrectomy was done April 4, 1944. The perirenal fat was adherent to the capsule and was removed with the kidney. The tissue section showed that "there is a tumor mass 5 cm. in diameter, ,vhich haR grown through the cortex of the kidney, but not through the capsule." Microscopic examination revealed it to be a hypernephroma. Mr. P. W., aged 53, gave a history of urinary frequency and dysuria of 3 months' duration Intermittent gross hematuria had been present 1 week. He had lost 8 pounds of weight within 4 weeks. A voided specimen of urine appeared to be all blood. Cystoscopic examination revealed considerable enlargement of the prostate, a non-infiltrating papillary tumor on the left lateral wall of the bladder and gross hematuria with clots from the right ureter. The urine from the left kidney was clear and showed no abnormalities to laboratory examination. Theindogo carmine returned from the left side was within normal limits. The pyelogram showed the presence of blood clots in the right kidney pelvis and ureter and a questionable deformity of the right superior calyx. The arteriogram shows extem,ive bilateral hypernephroma. See figure 8. SUMMARY

On discussing arteriography of the upper abdomen, we have pointed out some of its advantages and disadvantages~neither of which are today fully known. Secretory pyelography and renography are briefly discussed. The technique of arteriography is described. Our experience with untoward reactions is related. Five arteriograms are presented, with our interpretations. REFERENCES BROWN, FRANCIS H.: Personal communication. CAMERON, D. F.: Aqueous solutions of potassium and sodium iodids as opaque mediums in roentgenography. J. A. M. A., 70: 754, 1918. HASCHEK, E., AND LINDEN'.l'HAL, 0. T.: Ein Beitrag zur praktischen Verwerthung der Photographie nach Rontgen, Wien klin. Wchnschr., 9: 63-64, 1896. KoRNBLITH, B. A.: Gunshot wound through the abdominal aorta. Ann. Surg., 113: 637640, 1941. NELSON, 0. A.: Arteriography of abdominal organs by aortic injection. Surg., Gynec. & Obst., 74: 3, 1942. SANTOS, R. Dos, LAMAS, C., AND PEREIRA CALDAS, J.: L'Arteriographie des membres, de l'aorte et de ses branches abdominales. Med. contemp. (Lisbon), 47: 93-96, 1929.