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The visualization of the abdominal aorta and its branches
VISUALIZATION
OF
THE
ABDOMINAL
T H E VISUALIZATION OF T H E A B D O M I N A L A N D ITS B R A N C H E S *
AORTA
231
AORTA
BY ALAN S. JOHNSTONE, M.D., F.R.C.S.E., F.F.R. PROFESSOR OF DIAGNOSTIC RADIOLOGY, UNIVERSITY OF LEEDS
T~E material of this paper is drawn from an analysis of serial films taken during abdominal aortography with the Ormerod automatic cassette changer: This machine was loaded with eight 12 X IO in. cassettes and these were automatically exposed and changed at a speed of 1.25 seconds each, so that the complete series took an overall time of IO seconds. A new model, which is shown
Fig.
225.--Ormerod
cassette changer.
in Fig. 225, changes twelve 15 X i2 in. cassettes at half-second intervals. It is also possible to vary the speed and preselect a n u m b e r of cassettes to be taken at half seconds, and one and two seconds, if desired. Alternatively, all the films may be taken at one or other of the slower speeds. From a study of serial films it is clear that the aorta remains outlined for three to four seconds, which corresponds to the time taken for the injection. One film usually stands out from the rest in the density of its aortic shadow. It does not follow, however, that at the same time all the main branches are equally well defined. Some may show most clearly in the film preceding or succeeding *
Being a paper read at the Annual Meeting of the Faculty of Radiologists in Edinburgh, July 20, I95I.
232
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
the optimum filling of the aorta. Such observations demonstrate the importance of serial films, and it is obviously unwise to draw any conclusions without them. We have also confirmed that the subsequent distribution of the medium depends on the level of the injection, the direction of the flow, and the anatomical variations of the arteries. These points were strongly emphasized by Farinas when he described the use of a retrograde catheter to control fluoroscopically the level of injection. My collab6rator, H. D. Moore, has already shown how each of the main branches may be flushed with the medium, and it is my purpose to follow its subsequent disposal. After injection the medium became concentrated in viscera with large capillary beds, especially those of excretory function, increasing their density and thus making them more clearly defined in the radiograph. The speed of such Fig. 2 2 6 . - - T h e eighth film of a series in which both renal changes differed according to the concentration arteries appear to be of normal size but the right took a greater flush at the injection. T h e right kidney density appeared more and directional flow of the medium, so that rapidly and became greater than the left kidney. many variations were observed in the time between the arterial filling and the maximum density of the viscus. This is clearly evident in the last film of a series, in which the right renal artery bore the brunt of the injection although both arteries
YP~ME$ 0
1
2
b
4
5
6
7
DENSITY +++
I
/
++
,574.t!NI¢
+
f
//'~At VEIN 1"25
2-5
FARP&ND.
5,75
5,0
6"2g
7.$
5 "75
1~j~£rm~tl ~o,ccs
lO
7o~
Fig. 2 2 7 . - - G r a p h , which illustrates the densities of the vessels and viscera. A, Aorta ; S, Splenic artery ; R, Renal artery.
appeared well outlined. The different densities are shown in Fig. 226. A graph has been made based on assumptions of density and a fairly constant relationship between aortic and renal shadows is presented (Fig. 227).
VISUALIZATION
OF
THE
ABDOMINAL
AORTA
233
I n order to eliminate the variations just mentioned, serial films taken during angiocardiography were examined, and it was evident that filling of the renal arteries and the first changes in density of the kidney were in many cases to be found on the same film. T h e latter reached the maximum intensity towards the end of the examination at least six seconds later. Changes in D e n s i t y . - - T h e increased density of the organ provides a clear picture of its size, outline, and its uniformity of structure. T h e word ' n e p h r o g r a m ' or ' renogram ' has been applied to the kidney shadow, ' s p l e n o g r a m ' or ' lienogram' to the splenic shadow, ' p l a c e n t o g r a m ' to the placental shadow, and no doubt before long we shall have such concoctions as ' h e p a t o g r a m ' , ' adrenogram ', and ' intestinogram '. I n the nephrogram with adequate concentration the cortical and medullary segments can be defined and much information obtained about the functioning tissue which may b e of great value ~ig. 228.--Frame 5 in seriestaken of a patientwith bilateral cystickidneys. Some of the cysts c a n be identified in planning the surgery of simple tumours (Fig. congenital against the contrast of the functioning renal tissue. 226). Fig. 228 shows the extent of the functioning tissue in the case of congenital cystic kidney which you have already seen. T h e excretion of the diodone from the kidney takes place very rapidly, b u t we have not been able to show a pyelogram within i o seconds. On two occasions faint outlines of the pelves were thought to be present. Other viscera also become visible after injection--for example, the spleen, the liver, and the intestines. Fig. 229 is the eighth of a series in which the kidneys are clearly defined, and it is interesting
F*g. 2 2 9 . - - T h e eighth cf a series in which there is a nonrotation of the left kidney. Below this kidney shadow the walls of the small intestine are clearly defined,
Fig. 2 3 o . - - T h e fourth of a series in a case of cirrhosis of the liver. T h e right suprarenal gland is clearly identified, and it is interesting to note the gap between it and the upper pole of the kidney.
to note the density of the small intestine especially in the transverse section. T h e suprarenal glands can be detected by virtue of their arterial distribution, although the arterial filling is not always
234
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
complete. Fig. 230 illustrates an unusual feature in that the gland has become partially outlined by an increase in the density of its tissues. It is sufficiently striking to make one speculate on the possibilities of aortography in the investigation of suprarenal tumours.
A
B
C Fig. 23 I . - - A woman with a right renal carcinoma.
A, Frame 2. Shows a flushing of the splenic artery w h i l e the aorta is relatively faintly outlined. T h e spleen is becoming dense. T h e changes in the right kidney have been already referred to. B, Frame 5 (3"5 sec. later than Frame 2). Shows a fading splenic artery and dense spleen. T h e splenic vein is becoming dense C, Frame 7 (2'5 sec. later than Frame 5) T h e splenic :¢ein is clearly outlined. T h e arterial filling has gone. Tracing the splenic vein across the second lumbar vertebra the portal vein can be identified and its radicles in the liver are evident.
Venous R e t u r n . - - I t seems obvious that after a sudden flooding of the arterial system and capillaries much of the m e d i u m must find its way into the veins. It did not occur to us that the density would be suffÉcient for venography until we obtained a series of films from a patient with a right renal tumour. T h e second film showed a poor outline of the aorta b u t a dense filling of the splenic artery (Fig. 231 A). T h e fifth film (Fig. 23I B) showed a better aortic filling, a fading splenic
VISUALIZATION
OF
THE
ABDOMINAL
AORTA
235
artery, and below it a curled shadow which crossed the midline at the second lumbar vertebra. The spleen was dense. The seventh film (Fig. 23i C) showed this curled shadow to be the splenic vein, and it could be traced across the midline, where it became the portal vein. The distribution of the portal radicles in the liver Was clearly shown. T o confirm this interpretation a post-mortem specimen was injected and the resulting radiograph showed an identical pattern of the portal radicles. The result of this demonstration made us review earlier cases, and we found another one showing the portal vein. In this case, however, the splenic vein could not be defined. These venograms tempted us to see whether we could get any information about the venous return in portal hypertension. Two cases were tried and proved unsuccessful. The faults were probably technical, for in one the injection rate was too slow although the needle was correctly placed.
A
B
.Fig. 232.--A, T h e second aortogram with the needle entering at the upper border of the eleventh thoracic Vertebra. Frame I shows a dense aortic filling With hepatic, splenic, and renal arteries moderately filled. B, Frame 8 of the series (8"75 sec. after Frame I). T h e splenic vein, the left renal vein, and the portal vein can be identified and are marked with arrows.
A third patient was known to have a small cirrhotic liver although she did not present any signs of portal hypertension. In the first aortogram the injection was made lower than expected and the needle entered the aorta opposite the first lumbar vertebra ; 3 ° c.c. of 7 ° per cent diodone were injected and the bulk of the medium entered the right renal and superior mesenteric vessels, with the subsequent opacification of the right kidney and intestines. No venous return was observed (Fig. 23o ). The examination was repeated and the needle entered opposite the eleventh thoracic vertebra. This time the hepatic, splenic, and renal vessels were displayed (Fig. 232 A). In Frame 4 (3'75 sec. later) a Curly shadow appeared which was considered to be the splenic vein, and below- it another shadow which was thought to be the renal vein. In Frame 8 (5 sec. later) (Fig. 232 B) the portal vein was clearly recognized. T h e hepatic radicles were not defined, but this was not unexpected for the liver was small and extremely cirrhotic. I t is therefore evident that the splenic, the portal, and the left renal veins have been identified radiologically. In other cases the right renal and the inferior mesenteric veins were faintly Outlined. It is obvious from these examples that this method of abdominal venography is still in its preliminary stages and it may be that from this technique more accurate methods will be found. Vascular C o n d i t i o n s . - - A p a r t from renal conditions abdominal aortography has real value in the investigation of arterial disease affecting particularly the lower limbs. In the classical Leriche's syndrome with thrombosis at the origin of the common iliac arteries one may obtain a clear picture
236
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
of the circulation. A man of 42 complained of intermittent claudication, severe in the right calf, and occasionally in the right thigh and left calf. His left femoral pulse was just palpable ; no other
A
C Fig. 233.--A, Franae 2, showing the termination of the abdominal aorta.
B
D
Complete block of the right common iliac. A partial block of the left common iliac. T h e left external iliae and femoral are clearly outlined, b u t appear smaller than normal. A n unidentified vessel looping across L.5 and upper part of sacrum is noted. B, Frame 3. More branches of the lilacs and femoral are filled. T h e looped vessel is fading, but another artery parallel to the aorta and r u n n i n g towards the right side of the pelvis has appeared (1"25 see. later). C, Frame 4 (1"25 sec. later than Frame 3). T h e arterial filling has almost cleared. T h e looped vessel remains clearly outlined in the right side of the pelvis and collateral vessels to the right leg are filling. D, Frame 5 (1"25 sec. later than Frame 4). T h e looped vessel has cleared. T h e medium is still seen in the collateral vessels which are supplying the right leg.
VISUALIZATION
OF
THE
ABDOMINAL
AORTA
237
pulsation was found in either lower limb. Frame z (Fig. 233 A) showed the filling of the abdominal aorta and a complete block at the right common iliac artery. T h e left common iliac artery appeared irregular in outline. The left femoral artery appeared smooth but a little small. No medium was seen entering the right leg. A long vessel, with no branches, looping across t h e spine was clearly demonstrated. Frame 3 (Fig. z33 B) showed better filling of the left femoral and its branches. No medium was observed on the right side. The looped vessel began to fade and another vessel of similar size appeared nearer the midline and ran towards the right iliac region. In Frame 4 (Fig. e33 C) the aorta and right femoral artery had emptied, but a few branches remain visible. The large vessel appeared to be anastomosing in the right side of the pelvis and various branches converged on
FgAX ES 0
1
2
I)E~T~ITY
3
4
5
5
7
8
F
+.+.+
+-F
t
/ 1-25
2-5
3-75
5.0
6-25
F~MOP-~LVE]N6 7-5
6.75
10
• BUCKTROUT.
Fig. z34. the right femoral triangle. Frame 5 (Fig. 233 D) showed the left side clear, but demonstrated the collateral circulation into the right leg. No venous return was apparent. In the case of a young woman, suspected of having arterial disease affecting the lower limbs, a graph (Fig. a34 ) has been made from the radiographs obtained with aortography. It is evident that in Frame z the arteries showed their maximum opacity. T h e y were only visible on two frames (or 2"5 sec.). The size and outlines appeared normal. At the sixth frame the faint outlines of the iliac veins were seen, and these shadows increased throughout the remainder of the examination. The circulation time was clearly recorded and was taken as normal, The patient, however, had intermittent claudication in the calves, cold feet, discoloured skin, and reduced oscillations. Bilateral sympathectomy was performed, with immediate improvement in circulation. The aortography has not yet been repeated so that one cannot decide whether or not the first radiographs showed an abnormality which we did not recognize. For comparison another case is described in which the circulation time in the lower limbs was inadvertently studied. The position of this patient was faulty and the upper pole of the kidney was cut off the film. Some compensation, however, was obtained in the demonstration of the vessels of the lower limbs. Frame i (Fig. 235 A) showed the abdominal aorta and common iliacs well filled. Frame a (Fig. 235 B) showed the aorta emptying and the femoral well outlined. In Frame 4 (Fig. z35 C) the lower arteries had almost emptied. Some
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A
B
C
D
Fig. z35,--A, F r a m e I (1"25 sec.). M e d i u m f i l l i n g aorta, superior mesenteric and right renal arteries, iliac arteries and entering femoral arteries. B, F r a m e 2 (1"25 sec. later than F r a m e I). I m p r o v e d filling of femoral arteries and branches. K i d n e y density increasing. C, F r a m e 4 (2"5 sec. later than F r a m e 2). Aorta and iliac arteries empty. Femoral arteries fading. Corpus eavernosa filled. K i d n e y very dense. D, F r a m e 7 (3"75 sec. later than F r a m e 4). Femoral and internal iliac veins can be defined. Corpus cavernosa and kidney still dense.
ROENTGENTHERAPY
OF
CARCINOMA
OF
LARYNX
239
m e d i u m was observed in the corpus cavernosum. F r a m e 7 (Fig. 235 D) showed femoral and iliac veins faintly outlined. T h e total time between the femoral artery filling and the venogram was 6"25 sec.
CONCLUSION Serial rad.iographs are essential to abdominal aortography if t h e fullest information i s to be obtained. Apart from the improved demonstration of the arterial field and the clearer definition of many viscera, some of the main veins may be outlined. While their definition at present is not satisfactory there is reason to believe that with improvements in the m e d i u m serial studies may provide a method of examining the venous circulation of some abdominal viscera. Studies of circulatory disorders affecting the lower limbs have been made. Serial examinations should assist in assessing the circulation time, and the method m a y also permit a better study and understanding of the collateral vessels. Note.--For references see subsequent paper, by H. D. Moore.
ROENTGENTHERAPY
OF CARCINOMA
OF THE LARYNX
BY F. BACLESSE FONDATION CURIE--INSTITUT DU RADIUM DE LJUNIVERSITt~DE PARIS
FIRST results of combined treatment of carcinoma of tire larynx by surgery and roentgentherapy have been reported in a previous paper.* Our statistics dealt with patients mostly treated during the war. Fifty-four observations had been collected, but several patients had been untraced and therefore those cases had been accounted as failures of the treatment ; moreover some cases had not been reviewed. A new inquiry leads to the following results : from i 9 4 i to I946 , 59 patients were treated at the Fondation Curie by total laryngectomy systematically followed by roentgentherapy; 3 I remained clinically cured after three years or more. Table I V in the previous paper may now be amended as follows : Table I V . - - F I F T Y - N I N E CASES OF CANCERS OF THE LARYNX TREATED FROM 194~ TO 1946 BY T O T A L LARYNGECTOMY ( D R . LEROUX-ROBERT, FONDATION CURIE) SYSTEMATICALLY FOLLOWED BY ROENTGENTHERAPY AT HIGH DOSES
(Three out of these cases were recurrences after hemilaryngectomy) LOCATION
TREATED
Vestibulum
HEALED
43
23
[
II
7
Laryngeal cancers extended to the pharynx I
5
I
59
31
Subglottis and fixed glottis
Total
PERCENTAGE
52
These statistics would deserve additional statements, which will be developed in a further paper. * BACLESSE, F. ( I 9 5 I ) , "
Roentgentherapy of Carcinoma of the Larynx ", .7. Fac. Radiologists, 3, 3. 17
OF
THE
ABDOMINAL
T H E VISUALIZATION OF T H E A B D O M I N A L A N D ITS B R A N C H E S *
AORTA
231
AORTA
BY ALAN S. JOHNSTONE, M.D., F.R.C.S.E., F.F.R. PROFESSOR OF DIAGNOSTIC RADIOLOGY, UNIVERSITY OF LEEDS
T~E material of this paper is drawn from an analysis of serial films taken during abdominal aortography with the Ormerod automatic cassette changer: This machine was loaded with eight 12 X IO in. cassettes and these were automatically exposed and changed at a speed of 1.25 seconds each, so that the complete series took an overall time of IO seconds. A new model, which is shown
Fig.
225.--Ormerod
cassette changer.
in Fig. 225, changes twelve 15 X i2 in. cassettes at half-second intervals. It is also possible to vary the speed and preselect a n u m b e r of cassettes to be taken at half seconds, and one and two seconds, if desired. Alternatively, all the films may be taken at one or other of the slower speeds. From a study of serial films it is clear that the aorta remains outlined for three to four seconds, which corresponds to the time taken for the injection. One film usually stands out from the rest in the density of its aortic shadow. It does not follow, however, that at the same time all the main branches are equally well defined. Some may show most clearly in the film preceding or succeeding *
Being a paper read at the Annual Meeting of the Faculty of Radiologists in Edinburgh, July 20, I95I.
232
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
the optimum filling of the aorta. Such observations demonstrate the importance of serial films, and it is obviously unwise to draw any conclusions without them. We have also confirmed that the subsequent distribution of the medium depends on the level of the injection, the direction of the flow, and the anatomical variations of the arteries. These points were strongly emphasized by Farinas when he described the use of a retrograde catheter to control fluoroscopically the level of injection. My collab6rator, H. D. Moore, has already shown how each of the main branches may be flushed with the medium, and it is my purpose to follow its subsequent disposal. After injection the medium became concentrated in viscera with large capillary beds, especially those of excretory function, increasing their density and thus making them more clearly defined in the radiograph. The speed of such Fig. 2 2 6 . - - T h e eighth film of a series in which both renal changes differed according to the concentration arteries appear to be of normal size but the right took a greater flush at the injection. T h e right kidney density appeared more and directional flow of the medium, so that rapidly and became greater than the left kidney. many variations were observed in the time between the arterial filling and the maximum density of the viscus. This is clearly evident in the last film of a series, in which the right renal artery bore the brunt of the injection although both arteries
YP~ME$ 0
1
2
b
4
5
6
7
DENSITY +++
I
/
++
,574.t!NI¢
+
f
//'~At VEIN 1"25
2-5
FARP&ND.
5,75
5,0
6"2g
7.$
5 "75
1~j~£rm~tl ~o,ccs
lO
7o~
Fig. 2 2 7 . - - G r a p h , which illustrates the densities of the vessels and viscera. A, Aorta ; S, Splenic artery ; R, Renal artery.
appeared well outlined. The different densities are shown in Fig. 226. A graph has been made based on assumptions of density and a fairly constant relationship between aortic and renal shadows is presented (Fig. 227).
VISUALIZATION
OF
THE
ABDOMINAL
AORTA
233
I n order to eliminate the variations just mentioned, serial films taken during angiocardiography were examined, and it was evident that filling of the renal arteries and the first changes in density of the kidney were in many cases to be found on the same film. T h e latter reached the maximum intensity towards the end of the examination at least six seconds later. Changes in D e n s i t y . - - T h e increased density of the organ provides a clear picture of its size, outline, and its uniformity of structure. T h e word ' n e p h r o g r a m ' or ' renogram ' has been applied to the kidney shadow, ' s p l e n o g r a m ' or ' lienogram' to the splenic shadow, ' p l a c e n t o g r a m ' to the placental shadow, and no doubt before long we shall have such concoctions as ' h e p a t o g r a m ' , ' adrenogram ', and ' intestinogram '. I n the nephrogram with adequate concentration the cortical and medullary segments can be defined and much information obtained about the functioning tissue which may b e of great value ~ig. 228.--Frame 5 in seriestaken of a patientwith bilateral cystickidneys. Some of the cysts c a n be identified in planning the surgery of simple tumours (Fig. congenital against the contrast of the functioning renal tissue. 226). Fig. 228 shows the extent of the functioning tissue in the case of congenital cystic kidney which you have already seen. T h e excretion of the diodone from the kidney takes place very rapidly, b u t we have not been able to show a pyelogram within i o seconds. On two occasions faint outlines of the pelves were thought to be present. Other viscera also become visible after injection--for example, the spleen, the liver, and the intestines. Fig. 229 is the eighth of a series in which the kidneys are clearly defined, and it is interesting
F*g. 2 2 9 . - - T h e eighth cf a series in which there is a nonrotation of the left kidney. Below this kidney shadow the walls of the small intestine are clearly defined,
Fig. 2 3 o . - - T h e fourth of a series in a case of cirrhosis of the liver. T h e right suprarenal gland is clearly identified, and it is interesting to note the gap between it and the upper pole of the kidney.
to note the density of the small intestine especially in the transverse section. T h e suprarenal glands can be detected by virtue of their arterial distribution, although the arterial filling is not always
234
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
complete. Fig. 230 illustrates an unusual feature in that the gland has become partially outlined by an increase in the density of its tissues. It is sufficiently striking to make one speculate on the possibilities of aortography in the investigation of suprarenal tumours.
A
B
C Fig. 23 I . - - A woman with a right renal carcinoma.
A, Frame 2. Shows a flushing of the splenic artery w h i l e the aorta is relatively faintly outlined. T h e spleen is becoming dense. T h e changes in the right kidney have been already referred to. B, Frame 5 (3"5 sec. later than Frame 2). Shows a fading splenic artery and dense spleen. T h e splenic vein is becoming dense C, Frame 7 (2'5 sec. later than Frame 5) T h e splenic :¢ein is clearly outlined. T h e arterial filling has gone. Tracing the splenic vein across the second lumbar vertebra the portal vein can be identified and its radicles in the liver are evident.
Venous R e t u r n . - - I t seems obvious that after a sudden flooding of the arterial system and capillaries much of the m e d i u m must find its way into the veins. It did not occur to us that the density would be suffÉcient for venography until we obtained a series of films from a patient with a right renal tumour. T h e second film showed a poor outline of the aorta b u t a dense filling of the splenic artery (Fig. 231 A). T h e fifth film (Fig. 23I B) showed a better aortic filling, a fading splenic
VISUALIZATION
OF
THE
ABDOMINAL
AORTA
235
artery, and below it a curled shadow which crossed the midline at the second lumbar vertebra. The spleen was dense. The seventh film (Fig. 23i C) showed this curled shadow to be the splenic vein, and it could be traced across the midline, where it became the portal vein. The distribution of the portal radicles in the liver Was clearly shown. T o confirm this interpretation a post-mortem specimen was injected and the resulting radiograph showed an identical pattern of the portal radicles. The result of this demonstration made us review earlier cases, and we found another one showing the portal vein. In this case, however, the splenic vein could not be defined. These venograms tempted us to see whether we could get any information about the venous return in portal hypertension. Two cases were tried and proved unsuccessful. The faults were probably technical, for in one the injection rate was too slow although the needle was correctly placed.
A
B
.Fig. 232.--A, T h e second aortogram with the needle entering at the upper border of the eleventh thoracic Vertebra. Frame I shows a dense aortic filling With hepatic, splenic, and renal arteries moderately filled. B, Frame 8 of the series (8"75 sec. after Frame I). T h e splenic vein, the left renal vein, and the portal vein can be identified and are marked with arrows.
A third patient was known to have a small cirrhotic liver although she did not present any signs of portal hypertension. In the first aortogram the injection was made lower than expected and the needle entered the aorta opposite the first lumbar vertebra ; 3 ° c.c. of 7 ° per cent diodone were injected and the bulk of the medium entered the right renal and superior mesenteric vessels, with the subsequent opacification of the right kidney and intestines. No venous return was observed (Fig. 23o ). The examination was repeated and the needle entered opposite the eleventh thoracic vertebra. This time the hepatic, splenic, and renal vessels were displayed (Fig. 232 A). In Frame 4 (3'75 sec. later) a Curly shadow appeared which was considered to be the splenic vein, and below- it another shadow which was thought to be the renal vein. In Frame 8 (5 sec. later) (Fig. 232 B) the portal vein was clearly recognized. T h e hepatic radicles were not defined, but this was not unexpected for the liver was small and extremely cirrhotic. I t is therefore evident that the splenic, the portal, and the left renal veins have been identified radiologically. In other cases the right renal and the inferior mesenteric veins were faintly Outlined. It is obvious from these examples that this method of abdominal venography is still in its preliminary stages and it may be that from this technique more accurate methods will be found. Vascular C o n d i t i o n s . - - A p a r t from renal conditions abdominal aortography has real value in the investigation of arterial disease affecting particularly the lower limbs. In the classical Leriche's syndrome with thrombosis at the origin of the common iliac arteries one may obtain a clear picture
236
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
of the circulation. A man of 42 complained of intermittent claudication, severe in the right calf, and occasionally in the right thigh and left calf. His left femoral pulse was just palpable ; no other
A
C Fig. 233.--A, Franae 2, showing the termination of the abdominal aorta.
B
D
Complete block of the right common iliac. A partial block of the left common iliac. T h e left external iliae and femoral are clearly outlined, b u t appear smaller than normal. A n unidentified vessel looping across L.5 and upper part of sacrum is noted. B, Frame 3. More branches of the lilacs and femoral are filled. T h e looped vessel is fading, but another artery parallel to the aorta and r u n n i n g towards the right side of the pelvis has appeared (1"25 see. later). C, Frame 4 (1"25 sec. later than Frame 3). T h e arterial filling has almost cleared. T h e looped vessel remains clearly outlined in the right side of the pelvis and collateral vessels to the right leg are filling. D, Frame 5 (1"25 sec. later than Frame 4). T h e looped vessel has cleared. T h e medium is still seen in the collateral vessels which are supplying the right leg.
VISUALIZATION
OF
THE
ABDOMINAL
AORTA
237
pulsation was found in either lower limb. Frame z (Fig. 233 A) showed the filling of the abdominal aorta and a complete block at the right common iliac artery. T h e left common iliac artery appeared irregular in outline. The left femoral artery appeared smooth but a little small. No medium was seen entering the right leg. A long vessel, with no branches, looping across t h e spine was clearly demonstrated. Frame 3 (Fig. z33 B) showed better filling of the left femoral and its branches. No medium was observed on the right side. The looped vessel began to fade and another vessel of similar size appeared nearer the midline and ran towards the right iliac region. In Frame 4 (Fig. e33 C) the aorta and right femoral artery had emptied, but a few branches remain visible. The large vessel appeared to be anastomosing in the right side of the pelvis and various branches converged on
FgAX ES 0
1
2
I)E~T~ITY
3
4
5
5
7
8
F
+.+.+
+-F
t
/ 1-25
2-5
3-75
5.0
6-25
F~MOP-~LVE]N6 7-5
6.75
10
• BUCKTROUT.
Fig. z34. the right femoral triangle. Frame 5 (Fig. 233 D) showed the left side clear, but demonstrated the collateral circulation into the right leg. No venous return was apparent. In the case of a young woman, suspected of having arterial disease affecting the lower limbs, a graph (Fig. a34 ) has been made from the radiographs obtained with aortography. It is evident that in Frame z the arteries showed their maximum opacity. T h e y were only visible on two frames (or 2"5 sec.). The size and outlines appeared normal. At the sixth frame the faint outlines of the iliac veins were seen, and these shadows increased throughout the remainder of the examination. The circulation time was clearly recorded and was taken as normal, The patient, however, had intermittent claudication in the calves, cold feet, discoloured skin, and reduced oscillations. Bilateral sympathectomy was performed, with immediate improvement in circulation. The aortography has not yet been repeated so that one cannot decide whether or not the first radiographs showed an abnormality which we did not recognize. For comparison another case is described in which the circulation time in the lower limbs was inadvertently studied. The position of this patient was faulty and the upper pole of the kidney was cut off the film. Some compensation, however, was obtained in the demonstration of the vessels of the lower limbs. Frame i (Fig. 235 A) showed the abdominal aorta and common iliacs well filled. Frame a (Fig. 235 B) showed the aorta emptying and the femoral well outlined. In Frame 4 (Fig. z35 C) the lower arteries had almost emptied. Some
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FACULTY
OF
RADIOLOGISTS
A
B
C
D
Fig. z35,--A, F r a m e I (1"25 sec.). M e d i u m f i l l i n g aorta, superior mesenteric and right renal arteries, iliac arteries and entering femoral arteries. B, F r a m e 2 (1"25 sec. later than F r a m e I). I m p r o v e d filling of femoral arteries and branches. K i d n e y density increasing. C, F r a m e 4 (2"5 sec. later than F r a m e 2). Aorta and iliac arteries empty. Femoral arteries fading. Corpus eavernosa filled. K i d n e y very dense. D, F r a m e 7 (3"75 sec. later than F r a m e 4). Femoral and internal iliac veins can be defined. Corpus cavernosa and kidney still dense.
ROENTGENTHERAPY
OF
CARCINOMA
OF
LARYNX
239
m e d i u m was observed in the corpus cavernosum. F r a m e 7 (Fig. 235 D) showed femoral and iliac veins faintly outlined. T h e total time between the femoral artery filling and the venogram was 6"25 sec.
CONCLUSION Serial rad.iographs are essential to abdominal aortography if t h e fullest information i s to be obtained. Apart from the improved demonstration of the arterial field and the clearer definition of many viscera, some of the main veins may be outlined. While their definition at present is not satisfactory there is reason to believe that with improvements in the m e d i u m serial studies may provide a method of examining the venous circulation of some abdominal viscera. Studies of circulatory disorders affecting the lower limbs have been made. Serial examinations should assist in assessing the circulation time, and the method m a y also permit a better study and understanding of the collateral vessels. Note.--For references see subsequent paper, by H. D. Moore.
ROENTGENTHERAPY
OF CARCINOMA
OF THE LARYNX
BY F. BACLESSE FONDATION CURIE--INSTITUT DU RADIUM DE LJUNIVERSITt~DE PARIS
FIRST results of combined treatment of carcinoma of tire larynx by surgery and roentgentherapy have been reported in a previous paper.* Our statistics dealt with patients mostly treated during the war. Fifty-four observations had been collected, but several patients had been untraced and therefore those cases had been accounted as failures of the treatment ; moreover some cases had not been reviewed. A new inquiry leads to the following results : from i 9 4 i to I946 , 59 patients were treated at the Fondation Curie by total laryngectomy systematically followed by roentgentherapy; 3 I remained clinically cured after three years or more. Table I V in the previous paper may now be amended as follows : Table I V . - - F I F T Y - N I N E CASES OF CANCERS OF THE LARYNX TREATED FROM 194~ TO 1946 BY T O T A L LARYNGECTOMY ( D R . LEROUX-ROBERT, FONDATION CURIE) SYSTEMATICALLY FOLLOWED BY ROENTGENTHERAPY AT HIGH DOSES
(Three out of these cases were recurrences after hemilaryngectomy) LOCATION
TREATED
Vestibulum
HEALED
43
23
[
II
7
Laryngeal cancers extended to the pharynx I
5
I
59
31
Subglottis and fixed glottis
Total
PERCENTAGE
52
These statistics would deserve additional statements, which will be developed in a further paper. * BACLESSE, F. ( I 9 5 I ) , "
Roentgentherapy of Carcinoma of the Larynx ", .7. Fac. Radiologists, 3, 3. 17