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Selective phlebography of transplanted kidneys
Clin. Radio]4(!970)21, 144-149 SELECTIVE
PHLEBOGRAPHY
OF TRANSPLANTED
KIDNEYS
E. W. L. FLETCHER*, J. W. L E C K Y and H. C. G O N I C K
From U.C.L.A. School of Medicine, Los Angeles, California, 90024, U.S.A.
Renal transplantation may be followed by impaired function of the transplanted organ. Radiology is an important method of investigation. This paper discusses the value of retrograde selective phlebography of the transplanted kidney. Eight patients were examined by this technique. The phlebogram demonstrated diminished renal perfusion due to transplant rejection in two patients. Three patients had evidence of thrombosis in or near the renal vein. Three patients demonstrated a normal phlebogram indicating good renal perfusion and no local thrombotic lesion. It is considered that the method of selective renal phlebography described is a safe procedure in experienced hands and provides useful information about the vascular anatomy and physiology of the transplanted kidney.
INTRODUCTION Tim increasing number of renal transplants being performed has resulted in increasing demand for radiological investigations of some of the complications of this procedure. One of these complications is venous thrombosis, either of the vein of the transplanted kidney or of the vein of the recipient to which it is anastomosed. It is the purpose of this paper to describe the techniques we have employed for selective studies of the renal veins of transplanted kidneys and to discuss our findings. MATERIAL Eight patients had 9 selective phlebograms of their transplanted kidneys performed during the past year. Three of the patients had kidneys transplanted from close blood relatives and the other 5 patients had kidneys transplanted from cadavers. Three of the patients were male and 5 female with ages ranging from 20 to 27 years. The vein of the transplanted kidney was anastomosed to the right external iliae vein in 5 patients, to the left external iliac vein in 1 patient and to the left common iliac vein in 2 patients. METHOD The operative notes are reviewed to find the exact site of the anastomosis before commencing the radiological investigation. The common femoral vein on the side of the transplant is punctured by a Seldinger needle (Seldinger, 1953), and a Number 5
French brachio-vertebral polyethylene'~]" end and side hole catheter introduced. Contrast medium is injected by hand under television monitoring and the iliac veins and inferior vena cava observed for irregular outline or obstruction to flow, both of which may indicate thrombosis. If an abnormality is seen, 20 ml. of contrast medium is injected and a single film of the iliac veins and the lower inferior vena cava is taken. The presence of a large amount of thrombus is a contra-indication for further catheterisation and if there is complete obstruction of the ipsilateral iliac veins, pertrochanteric phlebography may be necessary (Smellie, Vinik, Freed, and Hume, 1968). If there is little thrombus distal to the site of the renal vein anastomosis and no thrombus to b e seen proximally, selective catheterisation is performed either from the contra-lateral common femoral vein or from the jugular vein (Lecky, 1968) using the Muller~ guided system. If there is no evidence of thrombosis, the catheter is advanced and an attempt is made to catheterise the (transplanted) renal vein. The brachio-vertebral catheter is slightly curved which makes it easier to find the renal vein. Normally the renal vein is anastomosed to the anterior surface of the external iliac vein, but it is sometimes difficult to see the catheter flip into the origin of the renal vein as the tip of the catheter moves towards the observer. When viewed on the television screen, the site of anastomosis is at the level of the lower part of the sacro-iliac joint and this is a useful reference point
~t PPX. 045H, Becton-Dickinson, Rutherford, New Jersey. * Present address and address for reprints: Radiology t U.S. Catheter and Instrument Corp., Glen Falls, New Department, Radcliffe Infirmary, Oxford. York. 144
SELECTIVE
PHLEBOGRAPHY
when attempting selective catheterisation. Sometimes the catheter slips posteriorly into the internal iliac vein, and injection of contrast into this vein may fill the gluteal veins producing an appearance which may be confused with filling of the renal veins. When the catheter is advanced, it sometimes sticks at the sharp angle of the renal vein, often found 1 centimetre beyond the anastomosis. The soft and very flexible brachiovertebral catheter usually slides round this angle fairly easily, but sometimes it is necessary to reinsert the guide wire and then advance the catheter over the guide wire. The tip of the catheter is positioned just proximal to the bifurcation of the renal vein, otherwise selective catheterisation of one of the renal vein tributaries results. Twenty ml. of Renografin 76 is then injected by hand while 10 films are taken on a serial changer at a speed of one and a half films per second, with the patient supine. If there is any significant overlapping of veins, a further series of films is taken with the patient in an oblique position. Occasionally thrombus is poorly demonstrated in one of the small renal veins and superselective catheterisation of a renal vein tributary may be necessary to show it to better advantage.
OF T R A N S P L A N T E D
KIDNEYS
145
FINDINGS Two patients had extremely good filling of the intra-renal veins when contrast was injected (Fig. 1). This finding suggests very poor renal arterial perfusion. Rejection was diagnosed on the grounds of the diminished renal blood flow, and this diagnosis was confirmed by renal artenography (Fig. 2 ) a n d renal biopsy. In one patient a small thrombus was shown at the site of the anastomosis, but the vein was still partially patent (Fig. 3). In another, a thrombus was present in the external iliac vein distal to the transplant venous anastomosis and this prevented selective catheterisation from the right femoral vein, but did not interfere with the function and drainage of the transplant (Figs. 4A and n). The fifth patient examined had suffered a thrombosis of the left common iliac vein but this, and the vein of the (left) transplanted kidney, had recanalised. The recanalised left common iliac vein in this patient was so narrow that a large collateral circulation had opened up through the presacral veins to the opposite internal iliac vein (Fig. 5A, B, C). In 3 patients we failed to fill the peripheral branches of the renal veins as the washout of contrast was extremely fast. This suggested that the blood flow was good (Fig. 6A and B), and as
Fro. 1 FIG. 2 FIG. 1--Selective phlebogram of a transplanted kidney which is rejecting. Note unusually good filling of the small renal veins indicating poor renal blood flow. Fro. 2 ~ R i g h t c o m m o n iliac arteriogram performed on the patient shown in Fig. 1. Contrast has already cleared from the external iliac artery but it is flowing very slowly through the sparse, irregular arteries of the rejecting transplanted kidney. The small artery to the upper pole is completely blocked.
146
CLINICAL RADIOLOGY
FIG. 3 Selective phlebogram of a transplanted kidney with some thrombus at the site of anastomosis of the renal vein to the left common iliac vein. The catheter was passed from the right external jugular vein.
FIO. 4 A--Phlebogram of the right leg showing thrombosis of the superficial femoral vein (<-). 3 - Phlebogram of the right i/iac veins showing thrombus in the external iliac vein ( ~ ) . Same patient as Fig. 4A. The transplanted kidney is concentrating contrast medium well.
SELECTIVE
PHLEBOGRAPHY
OF T R A N S P L A N T E D
KIDNEYS
FIG. 5 Kidney transplanted in the left side of the pelvis. A--Selective phlebogram of the main renal vein. Arrow points to thrombus. B--Phlebogram showing narrow recanalised common iliac vein with left ascending lumbar and presacral collateral veins. Washout from the vein of the transplanted kidney (<-). Inferior vena cava (-+). c--Selective phlebogram of the vein to the lower pole of the transplanted kidney. Presacral (~') and left ascending lumbar (<-) collateral veins.
147
148
CLINICAL
RADIOLOGY
FIG. 6 FIG_ 6A--Selective phlebogram of a normal transplanted kidney. The small peripheral veins were not filled. FIG. 6B--Film taken 1-4 seconds after (A). The contrast has washed out of the main renal veins.
there were no technical reasons for poor venous filling we regarded these phlebograms as normal. This rapid washout is the usual finding in retrograde renal phlebography of a normally situated kidney. DISCUSSION Renal transplant phlebography may be requested when a patient has marked proteinuria which is not accounted for by urinary obstruction or infection, or when there are signs and symptoms of acute rejection. Phlebography is then required to differentiate between chronic rejection and venous thrombosis. Thrombus is not difficult to detect in the main renal veins, but care must be taken to differentiate it from washout by blood flowing from veins not filled by contrast. Rapid washout of contrast injected into the renal veins shows that the renal blood flow is good (Alfridi, Meany, Buonocove and Nakamoto 1966; Vinik, Smellie, Freed, Hume and Weidner 1969). Although this frequently makes it impossible to fill the small peripheral veins (Fig. 6), such good renal blood flow implies absence of thrombosis. Venous filling can be improved by epinephrine (adrenalin) injection through a selective renal artery catheter (Olin and Reuter 1965; Sorby 1969), but we do not think this risk to the transplanted kidney is warranted, even though small doses of
epinephrine are not nephrotoxic in normal patients (Redman, Olin, Saldeen and Reuter 1966). Early and late rejection crises usually show few pathological changes on biopsy other than some interstitial cellular infiltrates and oedema (Hamburger, Crozier and Dormont 1965). Some patients examined during rejection show marked vascular changes. There is focal fibrinoid necrosis of the efferent arteries, arterioles and interlobular arteries, intimal deposits of platelets, interstitial elastic lamina reduplication and thrombosis of the small arteries and veins (Porter, Marchioro and Starzl 1965). This results in reduced renal blood flow (Kountz, Laub and Cohn 1965) which allows abnormally good opacification of the renal veins during retrograde phlebography (Alfridi et al. 1966). Filling defects of the small veins were seen in our 2 cases of rejection (Fig. 1) and we think that these represent small thromboses (Silverman 1967). Similar defects have been reported in the small veins of rejecting canine renal allographs (Knudsen, Davidson, Kountz and Cohn 1967). Three kidneys which had been transplanted into the left pelvis were examined by phlebography and 2 of these were shown to have renal vein thrombosis, whereas only 1 of the 5 kidneys transplanted into the right side of the pelvis was affected. Previous workers (Cockett and Lea Thomas 1965; Cockett, Lea Thomas and Negus 1967; Negus, Fletcher,
SELECTIVE PHLEBOGRAPHY OF TRANSPLANTED KIDNEYS
149
HAMBURGER,J., CROZrER,J. & DORMONT,J. (1965). Experience with 45 Renal Homotransplantationsin Man. Lancet, 1, 985-987. KNUDSEN, D. F., DAVIDSON,A. J., KOUNTZ, S. L. &COHN, R. (1967). Serial Angiography in Canine Renal Allographs. Transplantation, 5, 256-266. KOONTZ, S. L., LAtin, D. R. &COHN, R. (1965). Detecting and Treating Early Renal Homotransplant Rejection. Journal of the American Medical Association, 191, 9971001. LECKY, J. W. (1968). Pereutaneous Transjugular Approach to Adrenal Venography. American Journal of Roentgenology, Radium Therapy & Nuclear Medicine, 104, 380-385. NEGUS, D., FLETCHER, E. W. L., COCKETT, F. B. & LEA THOMAS, M. (1968). Compression and Band Formation at the Mouth of the Left Common Iliac Vein. British Journal of Surgery, 55, 369-374. OLIN, T. B. & REUTER, S. R. (1965). A Pharmacoangiographic Method for Improving Nephrophlebography. Radiology, 85, 1036-1042. PORTER, K. A., MARCI-~ORO,T. L. & STARZL,T. E. (1965). Pathological Changes in 37 Human Renal Homotransplants Treated with Immunosuppressive Drugs. British Journal of Urology, 37, 250-273. REDMAN, G. G., OLIN, T. B., SALEEN,T. & REUTER, S. R. (1966). Nephrotoxicity of Some Vasoactive Drugs followAeknowledgements.--We wish to thank Dr. J. W. Pierce ing Intra-arterial Injection. Investigative Radiology, 1, for his advice, Mr. Paul Stout for preparing the illustrations, 458-464. and Mrs. J. Lovely for typing the manuscript. SELDINGER,S. I. (1953). Catheter Replacement of the Needle in Percutaneous Arteriography. A New Technique. Acta Radiologica, 39, 368-376. SILVERMAN,F. N. (1967). Radiologic Contribution to Organ REFERENCES Transplantation. Journal of the Kentucky Medical AssociaALFRIDI,R. J., MEANY,T. F., BUONOCOVE,E. & NAKAMOTO, tion, 65, 1188-1191. S. (1966). Evaluation of Renal Homotransplants by SMELLIE,W. A. B., VINIK,M., FREED,T. A. & HUME,D. M. Selective Angiography. Radiology, 87-6, 1099-1104. (1968). Pertrochanterie Venography in the Study of Human COCKETr, F. B. & LEA THOMAS, M. (1965). The Iliae Renal Transplants. Surgery, GynaecoIogy & Obstetrics, Compression Syndrome. British Journal of Surgery, 52, 126, 777-778. 816-820. SORBY, W. A. (1969). Renal Phlebography. Clinical COCKETT,F. B., LEA THOMAS,M. & NEGUS,D. (1967). Iliac Radiology, 20, 166-172. Vein Compression- Its Relation to Iliofemoral Throm- VINIK, M., SMELLIE,W. A. B., FREED,T. A., HtrME, D. M. & bosis and the Post-Thrombotic Syndrome. British Medical WEIONER, W. A. (1969). Angiographie Evaluation of the Journal, 2, 14-16 Human Homotransplant Kidney. Radiology, 92, 873-879. Cockett and Lea T h o m a s 1968) have s h o w n left iliac vein thrombosis to be c o m m o n e r t h a n right iliac vein thrombosis due to the flattening of the left c o m m o n iliac vein where it is crossed b y the right c o m m o n iliac artery. This predisposition to thrombosis of the left c o m m o n iliac vein could be the reason for 2 of the 3 renal vein thromboses demonstrated, being i n the patients with a n a s t o m o sis of the transplanted renal vein to the left c o m m o n iliac vein. Selective catheterisation of the veins of transplanted kidneys did n o t prove technically difficult, although metal clips at the site of anastomosis would have m a d e location of the renal vein easier. I n no case was t h r o m b u s dislodged a n d there was n o clinical evidence o f additional thrombosis after selective catheterisation. It is therefore concluded that retrograde renal t r a n s p l a n t p h l e b o g r a p h y is a safe procedure in experienced hands, a n d plays a useful part i n the assessment of a m a l f u n c t i o n i n g t r a n s p l a n t e d kidney.
NOTICE SIX SMITH & NEPHEW FELLOWSHIPS FOR 1971
SMITH • NEPHEW Associated Companies of London are again offering six international Fellowships in medicine to doctors from British Commonwealth and emerging countries. The Fellowships are each worth £1,500, pins return air fare, and are tenable for one year (1971) in the United Kingdom only. As in previous years, the award is open to doctors, either men or women, who hold a professional qualification registrable in the United Kingdom and who have had at least two years' general clinical experience since registration.
Since the scheme began in 1962 more than 50 doctors and surgeons have come to Britain for postgraduate research and study under leading medical authorities in the specialist field of their choice. The Smith & Nephew group of companies is internationally known for its medical and surgical products, which include Elastoplast, Tensoplast, Gypsona and drugs for the treatment of tuberculosis. Application forms, to be completed and returned to England by May 31, 1970, can be obtained from the Fellowships Administrator, at 2 Temple Place, Victoria Embankment, London(W.C.2.
PHLEBOGRAPHY
OF TRANSPLANTED
KIDNEYS
E. W. L. FLETCHER*, J. W. L E C K Y and H. C. G O N I C K
From U.C.L.A. School of Medicine, Los Angeles, California, 90024, U.S.A.
Renal transplantation may be followed by impaired function of the transplanted organ. Radiology is an important method of investigation. This paper discusses the value of retrograde selective phlebography of the transplanted kidney. Eight patients were examined by this technique. The phlebogram demonstrated diminished renal perfusion due to transplant rejection in two patients. Three patients had evidence of thrombosis in or near the renal vein. Three patients demonstrated a normal phlebogram indicating good renal perfusion and no local thrombotic lesion. It is considered that the method of selective renal phlebography described is a safe procedure in experienced hands and provides useful information about the vascular anatomy and physiology of the transplanted kidney.
INTRODUCTION Tim increasing number of renal transplants being performed has resulted in increasing demand for radiological investigations of some of the complications of this procedure. One of these complications is venous thrombosis, either of the vein of the transplanted kidney or of the vein of the recipient to which it is anastomosed. It is the purpose of this paper to describe the techniques we have employed for selective studies of the renal veins of transplanted kidneys and to discuss our findings. MATERIAL Eight patients had 9 selective phlebograms of their transplanted kidneys performed during the past year. Three of the patients had kidneys transplanted from close blood relatives and the other 5 patients had kidneys transplanted from cadavers. Three of the patients were male and 5 female with ages ranging from 20 to 27 years. The vein of the transplanted kidney was anastomosed to the right external iliae vein in 5 patients, to the left external iliac vein in 1 patient and to the left common iliac vein in 2 patients. METHOD The operative notes are reviewed to find the exact site of the anastomosis before commencing the radiological investigation. The common femoral vein on the side of the transplant is punctured by a Seldinger needle (Seldinger, 1953), and a Number 5
French brachio-vertebral polyethylene'~]" end and side hole catheter introduced. Contrast medium is injected by hand under television monitoring and the iliac veins and inferior vena cava observed for irregular outline or obstruction to flow, both of which may indicate thrombosis. If an abnormality is seen, 20 ml. of contrast medium is injected and a single film of the iliac veins and the lower inferior vena cava is taken. The presence of a large amount of thrombus is a contra-indication for further catheterisation and if there is complete obstruction of the ipsilateral iliac veins, pertrochanteric phlebography may be necessary (Smellie, Vinik, Freed, and Hume, 1968). If there is little thrombus distal to the site of the renal vein anastomosis and no thrombus to b e seen proximally, selective catheterisation is performed either from the contra-lateral common femoral vein or from the jugular vein (Lecky, 1968) using the Muller~ guided system. If there is no evidence of thrombosis, the catheter is advanced and an attempt is made to catheterise the (transplanted) renal vein. The brachio-vertebral catheter is slightly curved which makes it easier to find the renal vein. Normally the renal vein is anastomosed to the anterior surface of the external iliac vein, but it is sometimes difficult to see the catheter flip into the origin of the renal vein as the tip of the catheter moves towards the observer. When viewed on the television screen, the site of anastomosis is at the level of the lower part of the sacro-iliac joint and this is a useful reference point
~t PPX. 045H, Becton-Dickinson, Rutherford, New Jersey. * Present address and address for reprints: Radiology t U.S. Catheter and Instrument Corp., Glen Falls, New Department, Radcliffe Infirmary, Oxford. York. 144
SELECTIVE
PHLEBOGRAPHY
when attempting selective catheterisation. Sometimes the catheter slips posteriorly into the internal iliac vein, and injection of contrast into this vein may fill the gluteal veins producing an appearance which may be confused with filling of the renal veins. When the catheter is advanced, it sometimes sticks at the sharp angle of the renal vein, often found 1 centimetre beyond the anastomosis. The soft and very flexible brachiovertebral catheter usually slides round this angle fairly easily, but sometimes it is necessary to reinsert the guide wire and then advance the catheter over the guide wire. The tip of the catheter is positioned just proximal to the bifurcation of the renal vein, otherwise selective catheterisation of one of the renal vein tributaries results. Twenty ml. of Renografin 76 is then injected by hand while 10 films are taken on a serial changer at a speed of one and a half films per second, with the patient supine. If there is any significant overlapping of veins, a further series of films is taken with the patient in an oblique position. Occasionally thrombus is poorly demonstrated in one of the small renal veins and superselective catheterisation of a renal vein tributary may be necessary to show it to better advantage.
OF T R A N S P L A N T E D
KIDNEYS
145
FINDINGS Two patients had extremely good filling of the intra-renal veins when contrast was injected (Fig. 1). This finding suggests very poor renal arterial perfusion. Rejection was diagnosed on the grounds of the diminished renal blood flow, and this diagnosis was confirmed by renal artenography (Fig. 2 ) a n d renal biopsy. In one patient a small thrombus was shown at the site of the anastomosis, but the vein was still partially patent (Fig. 3). In another, a thrombus was present in the external iliac vein distal to the transplant venous anastomosis and this prevented selective catheterisation from the right femoral vein, but did not interfere with the function and drainage of the transplant (Figs. 4A and n). The fifth patient examined had suffered a thrombosis of the left common iliac vein but this, and the vein of the (left) transplanted kidney, had recanalised. The recanalised left common iliac vein in this patient was so narrow that a large collateral circulation had opened up through the presacral veins to the opposite internal iliac vein (Fig. 5A, B, C). In 3 patients we failed to fill the peripheral branches of the renal veins as the washout of contrast was extremely fast. This suggested that the blood flow was good (Fig. 6A and B), and as
Fro. 1 FIG. 2 FIG. 1--Selective phlebogram of a transplanted kidney which is rejecting. Note unusually good filling of the small renal veins indicating poor renal blood flow. Fro. 2 ~ R i g h t c o m m o n iliac arteriogram performed on the patient shown in Fig. 1. Contrast has already cleared from the external iliac artery but it is flowing very slowly through the sparse, irregular arteries of the rejecting transplanted kidney. The small artery to the upper pole is completely blocked.
146
CLINICAL RADIOLOGY
FIG. 3 Selective phlebogram of a transplanted kidney with some thrombus at the site of anastomosis of the renal vein to the left common iliac vein. The catheter was passed from the right external jugular vein.
FIO. 4 A--Phlebogram of the right leg showing thrombosis of the superficial femoral vein (<-). 3 - Phlebogram of the right i/iac veins showing thrombus in the external iliac vein ( ~ ) . Same patient as Fig. 4A. The transplanted kidney is concentrating contrast medium well.
SELECTIVE
PHLEBOGRAPHY
OF T R A N S P L A N T E D
KIDNEYS
FIG. 5 Kidney transplanted in the left side of the pelvis. A--Selective phlebogram of the main renal vein. Arrow points to thrombus. B--Phlebogram showing narrow recanalised common iliac vein with left ascending lumbar and presacral collateral veins. Washout from the vein of the transplanted kidney (<-). Inferior vena cava (-+). c--Selective phlebogram of the vein to the lower pole of the transplanted kidney. Presacral (~') and left ascending lumbar (<-) collateral veins.
147
148
CLINICAL
RADIOLOGY
FIG. 6 FIG_ 6A--Selective phlebogram of a normal transplanted kidney. The small peripheral veins were not filled. FIG. 6B--Film taken 1-4 seconds after (A). The contrast has washed out of the main renal veins.
there were no technical reasons for poor venous filling we regarded these phlebograms as normal. This rapid washout is the usual finding in retrograde renal phlebography of a normally situated kidney. DISCUSSION Renal transplant phlebography may be requested when a patient has marked proteinuria which is not accounted for by urinary obstruction or infection, or when there are signs and symptoms of acute rejection. Phlebography is then required to differentiate between chronic rejection and venous thrombosis. Thrombus is not difficult to detect in the main renal veins, but care must be taken to differentiate it from washout by blood flowing from veins not filled by contrast. Rapid washout of contrast injected into the renal veins shows that the renal blood flow is good (Alfridi, Meany, Buonocove and Nakamoto 1966; Vinik, Smellie, Freed, Hume and Weidner 1969). Although this frequently makes it impossible to fill the small peripheral veins (Fig. 6), such good renal blood flow implies absence of thrombosis. Venous filling can be improved by epinephrine (adrenalin) injection through a selective renal artery catheter (Olin and Reuter 1965; Sorby 1969), but we do not think this risk to the transplanted kidney is warranted, even though small doses of
epinephrine are not nephrotoxic in normal patients (Redman, Olin, Saldeen and Reuter 1966). Early and late rejection crises usually show few pathological changes on biopsy other than some interstitial cellular infiltrates and oedema (Hamburger, Crozier and Dormont 1965). Some patients examined during rejection show marked vascular changes. There is focal fibrinoid necrosis of the efferent arteries, arterioles and interlobular arteries, intimal deposits of platelets, interstitial elastic lamina reduplication and thrombosis of the small arteries and veins (Porter, Marchioro and Starzl 1965). This results in reduced renal blood flow (Kountz, Laub and Cohn 1965) which allows abnormally good opacification of the renal veins during retrograde phlebography (Alfridi et al. 1966). Filling defects of the small veins were seen in our 2 cases of rejection (Fig. 1) and we think that these represent small thromboses (Silverman 1967). Similar defects have been reported in the small veins of rejecting canine renal allographs (Knudsen, Davidson, Kountz and Cohn 1967). Three kidneys which had been transplanted into the left pelvis were examined by phlebography and 2 of these were shown to have renal vein thrombosis, whereas only 1 of the 5 kidneys transplanted into the right side of the pelvis was affected. Previous workers (Cockett and Lea Thomas 1965; Cockett, Lea Thomas and Negus 1967; Negus, Fletcher,
SELECTIVE PHLEBOGRAPHY OF TRANSPLANTED KIDNEYS
149
HAMBURGER,J., CROZrER,J. & DORMONT,J. (1965). Experience with 45 Renal Homotransplantationsin Man. Lancet, 1, 985-987. KNUDSEN, D. F., DAVIDSON,A. J., KOUNTZ, S. L. &COHN, R. (1967). Serial Angiography in Canine Renal Allographs. Transplantation, 5, 256-266. KOONTZ, S. L., LAtin, D. R. &COHN, R. (1965). Detecting and Treating Early Renal Homotransplant Rejection. Journal of the American Medical Association, 191, 9971001. LECKY, J. W. (1968). Pereutaneous Transjugular Approach to Adrenal Venography. American Journal of Roentgenology, Radium Therapy & Nuclear Medicine, 104, 380-385. NEGUS, D., FLETCHER, E. W. L., COCKETT, F. B. & LEA THOMAS, M. (1968). Compression and Band Formation at the Mouth of the Left Common Iliac Vein. British Journal of Surgery, 55, 369-374. OLIN, T. B. & REUTER, S. R. (1965). A Pharmacoangiographic Method for Improving Nephrophlebography. Radiology, 85, 1036-1042. PORTER, K. A., MARCI-~ORO,T. L. & STARZL,T. E. (1965). Pathological Changes in 37 Human Renal Homotransplants Treated with Immunosuppressive Drugs. British Journal of Urology, 37, 250-273. REDMAN, G. G., OLIN, T. B., SALEEN,T. & REUTER, S. R. (1966). Nephrotoxicity of Some Vasoactive Drugs followAeknowledgements.--We wish to thank Dr. J. W. Pierce ing Intra-arterial Injection. Investigative Radiology, 1, for his advice, Mr. Paul Stout for preparing the illustrations, 458-464. and Mrs. J. Lovely for typing the manuscript. SELDINGER,S. I. (1953). Catheter Replacement of the Needle in Percutaneous Arteriography. A New Technique. Acta Radiologica, 39, 368-376. SILVERMAN,F. N. (1967). Radiologic Contribution to Organ REFERENCES Transplantation. Journal of the Kentucky Medical AssociaALFRIDI,R. J., MEANY,T. F., BUONOCOVE,E. & NAKAMOTO, tion, 65, 1188-1191. S. (1966). Evaluation of Renal Homotransplants by SMELLIE,W. A. B., VINIK,M., FREED,T. A. & HUME,D. M. Selective Angiography. Radiology, 87-6, 1099-1104. (1968). Pertrochanterie Venography in the Study of Human COCKETr, F. B. & LEA THOMAS, M. (1965). The Iliae Renal Transplants. Surgery, GynaecoIogy & Obstetrics, Compression Syndrome. British Journal of Surgery, 52, 126, 777-778. 816-820. SORBY, W. A. (1969). Renal Phlebography. Clinical COCKETT,F. B., LEA THOMAS,M. & NEGUS,D. (1967). Iliac Radiology, 20, 166-172. Vein Compression- Its Relation to Iliofemoral Throm- VINIK, M., SMELLIE,W. A. B., FREED,T. A., HtrME, D. M. & bosis and the Post-Thrombotic Syndrome. British Medical WEIONER, W. A. (1969). Angiographie Evaluation of the Journal, 2, 14-16 Human Homotransplant Kidney. Radiology, 92, 873-879. Cockett and Lea T h o m a s 1968) have s h o w n left iliac vein thrombosis to be c o m m o n e r t h a n right iliac vein thrombosis due to the flattening of the left c o m m o n iliac vein where it is crossed b y the right c o m m o n iliac artery. This predisposition to thrombosis of the left c o m m o n iliac vein could be the reason for 2 of the 3 renal vein thromboses demonstrated, being i n the patients with a n a s t o m o sis of the transplanted renal vein to the left c o m m o n iliac vein. Selective catheterisation of the veins of transplanted kidneys did n o t prove technically difficult, although metal clips at the site of anastomosis would have m a d e location of the renal vein easier. I n no case was t h r o m b u s dislodged a n d there was n o clinical evidence o f additional thrombosis after selective catheterisation. It is therefore concluded that retrograde renal t r a n s p l a n t p h l e b o g r a p h y is a safe procedure in experienced hands, a n d plays a useful part i n the assessment of a m a l f u n c t i o n i n g t r a n s p l a n t e d kidney.
NOTICE SIX SMITH & NEPHEW FELLOWSHIPS FOR 1971
SMITH • NEPHEW Associated Companies of London are again offering six international Fellowships in medicine to doctors from British Commonwealth and emerging countries. The Fellowships are each worth £1,500, pins return air fare, and are tenable for one year (1971) in the United Kingdom only. As in previous years, the award is open to doctors, either men or women, who hold a professional qualification registrable in the United Kingdom and who have had at least two years' general clinical experience since registration.
Since the scheme began in 1962 more than 50 doctors and surgeons have come to Britain for postgraduate research and study under leading medical authorities in the specialist field of their choice. The Smith & Nephew group of companies is internationally known for its medical and surgical products, which include Elastoplast, Tensoplast, Gypsona and drugs for the treatment of tuberculosis. Application forms, to be completed and returned to England by May 31, 1970, can be obtained from the Fellowships Administrator, at 2 Temple Place, Victoria Embankment, London(W.C.2.