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The visualization of the abdominal aorta and its branches
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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
BY H. D. MOORE, M.C., M.B., B.S. (SYDNEY), F.R.C.S., F.R.C.S.E. SURGICAL TUTOR I N THE DEPARTMENT OF SURGERY~ UNIVERSITY OF LEEDS
EXAMINATION of the abdominal aorta and its branches by injection of a radio-opaque substance into them is still in its early stages, b u t we have had enough experience to know most of the difficulties which can arise, and to be able to demonstrate cases showing its value. W e have also some original observations to make which may point to useful lines of research. It is almost a quarter century since dos Santos, Lamas, and Caldas (i929) first wrote about aortography ; they were followed by Osorio in i933. In i 9 4 i Farinas and in i942 Doss and his co-workers and Nelson wrote of this procedure in the U.S.A., and since that time there has been a fairly regular series of publications by various American authors, so that by I948 Melick a n d Vitt were able to quote 3000 recorded aortographies. T h e procedure had not, however, been used, or at any rate written about, in this country until an article by Griffiths appeared at the end of i95o. Three methods of injecting the radio-opaque substance have been described : - L By direct puncture of the aorta through the back. 2. By catheterization of the aorta via the femoral artery (Farinas, ~94i). 3. By forceful retrograde injection via the femoral artery after t e m p o r a r y occlusion of the artery distal to the needle (Farinas, i945). W e have not used the latter two methods. T h e first method, which has been often and well described, consists of inserting the needle in the .back four finger-breadths to the left of the midline and directing it upwards and inwards first'to strike the vertebral body as a landmark and then to pass just in front of it to enter the aorta at the desired l e v e l - - t h e level being at the u p p e r border of D . I 2 for the cmliac axis, superior mesenteric artery, a n d the renal vessels,.and at L.2 for the inferior mesenteric, iliac, and femoral arteries. T h e whole success of the procedure depends on a rapid i n j e c t i o n - - a i m i n g at 20 c.c. in 2 seconds. To achieve this speed some mechanical method for the injection is probably helpful, and several have been described, but we have relied so far on a simple syringe and manual injection, using a 27 or I6 B.W.G. needle (i.e., the diameter of the needle is 1.45-i.65 mm.) using 20 c.c. of 7 ° per cent diodone to outline the arteries and 3 ° or 40 e.c. if venous filling is sought as well. Local anaesthesia has been used except in children, so that one has the co-operation of the patient, who holds his breath during the examination. T h e injection of the diodone causes no more than a feeling of heat, but some patients are intolerant of the needle as it enters the back and a minimal dose of pentothal may be desirable in some cases. W h a t are t h e risks of this procedure ? Melick and Vitt quote 3000 collected cases without fatality, and since their paper many more cases, including some 7 ° in pregnant women, have been added to this figure (Hartnett, i948 ). T h e risks can be considered under three headings : - i. Possible damage to abdominal organs while inserting the needle. 2. Damage to the aorta itself. 3. Danger from the substances injected. T h e needle i n i t s passage to the aorta traverses the paravertebral muscle mass and therefore strikes no abdominal organ, as can be readily shown in the cadaver and has been repeatedly demonstrated in lumbar sympathetic block, which is, of course, exactly the same approach. T h e puncture Being a paper read at the Annual Meeting of the Faculty of Radiologists in Edinburgh, July 2o, i95i.
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of the aorta causes no ill effects--we have seen several of our cases at operation within a day or two of the puncture and the aorta looks normal without extravasation round it ; Smith, Rush, and Evans (1951) show photographs and slides of aortae punctured shortly before death which demonstrate that little damage is done. T h e opaque substances used are sodium iodide 80 per cent, thorotrast, and diodone. Sodium Iodide is stated by its users to be harmless, but it is painful to use, it does produce iodism from time to time, and one case of thrombosis of the superior mesenteric artery has been described following direct injection into that ~vessel (Wagner and Price, 195o ). Thorotrast is quite safe in its immediate effects, but it is radio-active and therefore to be avoided even in small doses. Diodone appears to be quite safe. M a n y hundreds of thousands of injections have been given for pyelograms, venograms, and arteriograms, and the number of fatalities which could be definitely attributed to the diodone is negligible. If it is injected outside the vessel it is quickly absorbed without ill effects, and it has been directly, or almost directly, injected into a renal or mesenteric artery by us and other workers without ill effects. It is suggested, however, that i c.c. should be given intravenously to test for sensitivity in those patients who have not already had an .intravenous pyelogram.
D I F F I C U L T I E S A R I S I N G D U R I N G T H E INJECTIONS W e have found it quite impossible to estimate the vertebral level except by taking a preliminary film with small lead markers on the back. If there are apparently six lumbar vertebrae, and filling of the cceliac axis is aimed at, a full spinal count is necessary to determine if the extra vertebra is the I2th dorsal or i s t l u m b a r - - a n d it is to be noted that this anomaly is very frequent. T h e actual puncture of the aorta has so far caused no trouble when the needle has been long enough. For a child or thin woman, I I cm. (41 in.) is sumcient, but for a thick-set man a needle of 12. 5 cm. (5 in.) is necessary. Difficulty in entering the aorta is almost always due to too short a needle, for with an inclination up and in, it is most deceptive how far the needle must go. It is easy to enter a vein and to mistake it for the aorta, and we once made a venogram of an ascending lumbar venous trunk, but this does not happen if it is remembered that bright-red blood runs out in a constant strong rivulet when the aorta is entered. I f a vein is entered, clotting will quickly occur in the needle ; therefore it must be withdrawn and washed thoroughly before proceeding. It is as well, also, to make sure that the needle is clear by injecting a little procaine just before the actual puncture of the aorta is made. Injection of part or all of the m e d i u m outside the aorta occurs from time to time (see Fig. 24i), but this should not happen if the needle is advanced a millimetre 6r two after puncture and if the needle is carefully watched during the injection. I n the effort to inject rapidly, the needle can be pushed in or pulled out, particularly if a protective lead screen blocks the view, and it is remarkable how little force is required to inject fluid into the lax periaortic tissues. This accident, however, leads to no ill effects other than a good deal of pain for some hours.
R E S U L T S TO B E E X P E C T E D In the normal patient (Figs. 236 , 237) the level of the main arteries is : - Coeliac axis Superior mesenteric artery Renal vessels Inferior mesenteric artery Aorta branches at
------
U p p e r border of i 2 t h thoracic vertebra Centre of I2th thoracic vertebra Centre of ISt l u m b a r vertebra U p p e r border of 3rd lumbar vertebra ~th lumbar vertebra
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The direction of the hepatic, splenic, and renal arteries is at right angles to the aorta, while the superior mesenteric is usually in line with or just to the left of the aorta, and therefore difficult to see, but it occasionally sweeps well to the right. The splenic artery is never straight and is often tortuous ; the hepatic and gastroduodenal branch of the hepatic fill well, but the left gastric has not, so far, been seen. T h e renal arteries are about the same size as the hepatic and splenic, and can be seen arborizing in the kidneys. The ~filling 9 f the mesenteric vessels has varied, sometimes all branches showing, sometimes only the main ones. Venous filling has been :observed and is discussed by Professor Johnstone in his paper. In the later films of the series the dense outline of various organs are seen, particularly the kidneys and spleen, but also liver, suprarenals, and gut, as their capillary beds fill with diodone. The value of the density of the kidney shadow as an index of its function is discussed later. Vascular abnormalities, as would be expected, are very well seen. Aneurysms are shown in detail (F@ 238): arterial thromboses and collateral vessels, which are discussed by Professor Johnstone, are Fig. 236.--Post-mortem injection in a patient who died outlined (Fig. 233, in Professor Johnstone's paper); from a cerebral tumour. Note the direction and size of the 'main vessels, the at:borizations in the kidneys, and that and aberrant vessels (Figs. 241 , 242 A) or other the main part of the superior mesenteric artery is hidden by the aorta. vascular changes in an organ are shown in Figs. 240 ,
A
B
Fig. 237.--A, Aortogram and intravenous pyelogram of a normal patient done at the same time. Note the size, position, and direction of the vessels, and that there are apparently six lumbar vertebrm--~the sixth in this case is an unfused first sacral. Note also that the kidneys are just beginning to become dense. (Frame 2 in the Series.) B, Frame 5 (6"25 seconds after start of injection) showing dense kidneys and spleen (' renogram ' and ' splenogram ') in a normal patient.
243 B, 244A ). The patient with the aneurysm shown in Fig. 239 had clinically quite a large femoral aneurysm, but it can be seen from the aortogram that its lumen is reasonably regular and
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that any surgical attack would involve ligation of the femoral and profunda femoris arteries, so that conservative treatment was decided upon. T h e examination of the kidney is particularly useful and can be considered under the headings of congenital anomalies, hydronephrosis, tumours, and sclerosis of the vessels. In congenital lesions it can settle the diagnosis--for example, as to whether there are two kidneys or one, or whether an anomaly in the intravenous pyelogram represents a horseshoe or non-rotated kidney. It can help in the treatment-for instance, to show if the blood-supply to the kidney with a double pelvis is such that part of the kidney can be removed (Fig. 239 ) . In hydronephrosis an aortogram can help in two ways : First it may show the cause, such, for example, as an aberrant vessel (Figs. 24 I, 242 A) : secondly it can g i v e valuable evidence of the functional state of the kidney by the size of the vessels supplying it (Figs. 242 A, 243 B) and by the density of the ' renogram' (Figs. 242 B, 243 B). In considering the ' renogram ', however, a word of warning must be given ; first, if the injection is made at about the level of the renal vessels most of the diodone may go to one or other kidney, with a subsequent much more dense kidney outline Fig. 2 3 8 . - - A patient with, clinically, a femoral aneurysm about 3 in. in diameter. T h e aortogram shows that the lumen of the artery is not grossly altered and that the aneurysm involves the profunda femoris.
A
B
Fig. 239.--A, Intravenous pyelogram, and B, aortogram of a patient with a double pelvis and recurrent pyelitis, showing
that the upper part of the kidney has a separate blood-supply. Note also that the injection is almost directly into the right renal artery, giving a more dense right renogram than l e f t - - a factor to be carefully watched when using renograms to assess the function of the kidneys.
on that side, so that the ' renogram' must be viewed with the density of the filling of the renal artery in mind (Fig. 239 B) ; second, any functioning kidney tissue will become opaque, so that
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a poorly functioning sclerotic kidney may appear dense (Fig. 245 B), but its shrivelled Small state is also evident. The comparative density of the kidney shadow, therefore, is chiefly of value where the kidney substance has become stretched and atrophied over a hydronephrotic sac.
Fig. 2 4 o . - - A patient w i t h polycystic disease of the kidneys s h o w i n g displacement of t h e vessels b y the cysts, with the avaseular areas w h e r e the cysts lie.
Fig. 2 4 I . - - A o r t o g r a m o f a girl w i t h a m i l d hydronephrosis and an aberrant vessel to the l o w e r pole o f the left kidney. T h e r e a r e t w o m a i n renal arteries o n t h e right side and a visible splenic artery. S o m e o f the d i o d o n e has been' injected outside the aorta, but at operation the n e x t d a y there was n o t h i n g abnormal to be seen. T h e renal vessels on t h e left side are marked w i t h arrows.
A
B
Fig. 2 4 2 . - - A o r t o g r a m s (Frames I and 7 in t h e series) of a girl w i t h s-considerable hydronephrosis o n the left side.
A, T h e first frame shows an aberrant vessel to the u p p e r pole of the right kidney and to b o t h poles o f the left kidney (confirmed at operation) and, o n the left, that the vessels are displaced by the h y d r o n e p h r o t i c sac and are m u c h smaller than on t h e right. B, T h e seventh frame shows very well that the density of the kidney is less on t h e left than the right, but that it is still good.
Hypernephroma of the kidney presents as a distortion of the vessels with a variable area of normal kidney shadow and with an area where diodone has collected, but. not diffusely and evenly, in what has been described as 'puddling' (Fig. 244 ). Avascular tumours of the kidney--for example, cysts--give an entirely different appearance ; in these, the distortions of the vessels is the primary object, together with an area or areas where there is no diodone (Fig. 24o ).
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Sclerosis of the kidney (Fig. 245 ) is of considerable interest as it may be the cause of hypertension. In the case shown the aortogram provided the only evidence of the cause of recurrent loin pain, rigors, etc., i n a patient in whom an intravenous and retrograde pyelogram were normal. Aortography has been used in the diagnosis of other conditions, such as obscure abdominal swellings and placenta prmvia, but we have not, as yet, had occasion to use it in such cases, nor have
A
B
Fig. 243.--A, Intravenous pyelogram, and B, aortogram of a patient with severe hydronephrosis (bilateral). T h e intravenous pyelogram on the right side shows only a very small area where there has been some e:~cretion, and the aortogram shows very thin vessels on that side, but normal-sized arteries on the left. On the right there are left only three small areas of kidney substance which become dense, whereas on the left, although the kidney does not become as dense as normal, it is of normal outline and reasonably opaque.
Fig. 244.--Patient with a hypernephroma of the right kidney. A, Shows the displacement of the branches of the renal artery, the beginning of the ' p u d d l i n g ' A in the t u m o u r area, and the start of the outline of the remaining kidney substance. T h e full ' p u d d l i n g ' and opacity of the remaining kidney substance is seen in F~g. 231 B, in Professor Johnstone's paper, where he discusses the splenic filling. B~ T h e specimen split and opened out showing the small amount of normal kidney substance to the medial side of the turnout mass.
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we yet had a suprarenal tumour to examine, although it looks as if aortography would be of the greatest value in this difficult diagnostic problem.
A
B
C
Fig. z45.--A, Retrograde pyelogram, S, aortogram (Frame 3 in series), and C, photograph of kidney of a man with recurrent attacks of pain in right loin and rigors. T h e retrograde pyelogram shows a normal outline, b u t the aortogram shows the renal artery running into a very small kidney with an uneven outline, and the specimen shows clearly the infarcted area. T h e question of the density of the kidney is discussed in the text.
The value of the procedure in venography, especially of the portal system, is discussed by Professor Johnstone and will not b e considered further here, but this, too, appears to be a useful field for further study.
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SUMMARY
The history and technique of aortography are briefly described and the risks and difficulties discussed. The results and value of the procedure are considered in the normal, in arterial lesions, and in renal anomalies u n d e r the headings of congenital abnormalities, hydronephrosis, tumours, and sclerosis. T h e other uses, Which have been described, are mentioned. T h e possible value of aortograms in suprarenal tumours and in the study of veins, particularly the portal vein, is referred to. BIBLIOGRAPHY DOS SANTOS,R., LAMAS,A. C., and CALDAS,J. PEREIRA(1929), Med. Contemp., 47, 93. (1931), Arteriographie des Mernbres et de L'Aorte abdominale. Paris : Masson et Cie. Doss, A. K. (I947), J. Urol. 57, 521. - - - - THOMAS,H. C., and BOND, T. B. (1942)i Texas St.J. Med., 38, 277. FAmNAS,P. L. (1941), Amer. J. Roentgenol., 46, 641. - - - - (I945), Surgery, 18, 244. GRIFEITHS, I. H. (195o), Brit. J. Urol. 22, 281. HARTNETT, L. J. (1948), Amer. J. Obstet. Gynec., 55, 94°. MELICK, W. F., and VITT, A. E. (I948), J. Urol., 60, 3~I. NELSON, O. A. (1942), Surg. Gynee. Obstet., 74, 655. - - - - (1945), J. Urol., 53, 521. Osomo, P. A. (I933),J. Amer. reed. Ass., IOO, I555. SMITH, P, G., RUSH,T. W., and EVANS,H. T. (I951),J. Urol., 65, 911. WAGNER, F. B., jun. (1946), Ibid., 56, 625. - - - - and PRICE, A. H. (i95o), Surgery, 27, 621. and SWENSON,P. C. (I947), Amer. J. Roentgenol., 58, 591.
THE
SKINNER
LECTURE
T h e 1952 Skinner Lecture will be given before the Faculty of Radiologists at the Royal College of Surgeons, Lincoln's I n n Fields, London, W.C.2, by Dr. H. R. Sear of Sydney on Friday, May 16, at 4 p.m. His subject will be " Congenital Bone Dystrophies and their Correlation "
Since the above was printed the
time of
the lecture has been altered to 3.3 ° p.m.
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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
BY H. D. MOORE, M.C., M.B., B.S. (SYDNEY), F.R.C.S., F.R.C.S.E. SURGICAL TUTOR I N THE DEPARTMENT OF SURGERY~ UNIVERSITY OF LEEDS
EXAMINATION of the abdominal aorta and its branches by injection of a radio-opaque substance into them is still in its early stages, b u t we have had enough experience to know most of the difficulties which can arise, and to be able to demonstrate cases showing its value. W e have also some original observations to make which may point to useful lines of research. It is almost a quarter century since dos Santos, Lamas, and Caldas (i929) first wrote about aortography ; they were followed by Osorio in i933. In i 9 4 i Farinas and in i942 Doss and his co-workers and Nelson wrote of this procedure in the U.S.A., and since that time there has been a fairly regular series of publications by various American authors, so that by I948 Melick a n d Vitt were able to quote 3000 recorded aortographies. T h e procedure had not, however, been used, or at any rate written about, in this country until an article by Griffiths appeared at the end of i95o. Three methods of injecting the radio-opaque substance have been described : - L By direct puncture of the aorta through the back. 2. By catheterization of the aorta via the femoral artery (Farinas, ~94i). 3. By forceful retrograde injection via the femoral artery after t e m p o r a r y occlusion of the artery distal to the needle (Farinas, i945). W e have not used the latter two methods. T h e first method, which has been often and well described, consists of inserting the needle in the .back four finger-breadths to the left of the midline and directing it upwards and inwards first'to strike the vertebral body as a landmark and then to pass just in front of it to enter the aorta at the desired l e v e l - - t h e level being at the u p p e r border of D . I 2 for the cmliac axis, superior mesenteric artery, a n d the renal vessels,.and at L.2 for the inferior mesenteric, iliac, and femoral arteries. T h e whole success of the procedure depends on a rapid i n j e c t i o n - - a i m i n g at 20 c.c. in 2 seconds. To achieve this speed some mechanical method for the injection is probably helpful, and several have been described, but we have relied so far on a simple syringe and manual injection, using a 27 or I6 B.W.G. needle (i.e., the diameter of the needle is 1.45-i.65 mm.) using 20 c.c. of 7 ° per cent diodone to outline the arteries and 3 ° or 40 e.c. if venous filling is sought as well. Local anaesthesia has been used except in children, so that one has the co-operation of the patient, who holds his breath during the examination. T h e injection of the diodone causes no more than a feeling of heat, but some patients are intolerant of the needle as it enters the back and a minimal dose of pentothal may be desirable in some cases. W h a t are t h e risks of this procedure ? Melick and Vitt quote 3000 collected cases without fatality, and since their paper many more cases, including some 7 ° in pregnant women, have been added to this figure (Hartnett, i948 ). T h e risks can be considered under three headings : - i. Possible damage to abdominal organs while inserting the needle. 2. Damage to the aorta itself. 3. Danger from the substances injected. T h e needle i n i t s passage to the aorta traverses the paravertebral muscle mass and therefore strikes no abdominal organ, as can be readily shown in the cadaver and has been repeatedly demonstrated in lumbar sympathetic block, which is, of course, exactly the same approach. T h e puncture Being a paper read at the Annual Meeting of the Faculty of Radiologists in Edinburgh, July 2o, i95i.
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of the aorta causes no ill effects--we have seen several of our cases at operation within a day or two of the puncture and the aorta looks normal without extravasation round it ; Smith, Rush, and Evans (1951) show photographs and slides of aortae punctured shortly before death which demonstrate that little damage is done. T h e opaque substances used are sodium iodide 80 per cent, thorotrast, and diodone. Sodium Iodide is stated by its users to be harmless, but it is painful to use, it does produce iodism from time to time, and one case of thrombosis of the superior mesenteric artery has been described following direct injection into that ~vessel (Wagner and Price, 195o ). Thorotrast is quite safe in its immediate effects, but it is radio-active and therefore to be avoided even in small doses. Diodone appears to be quite safe. M a n y hundreds of thousands of injections have been given for pyelograms, venograms, and arteriograms, and the number of fatalities which could be definitely attributed to the diodone is negligible. If it is injected outside the vessel it is quickly absorbed without ill effects, and it has been directly, or almost directly, injected into a renal or mesenteric artery by us and other workers without ill effects. It is suggested, however, that i c.c. should be given intravenously to test for sensitivity in those patients who have not already had an .intravenous pyelogram.
D I F F I C U L T I E S A R I S I N G D U R I N G T H E INJECTIONS W e have found it quite impossible to estimate the vertebral level except by taking a preliminary film with small lead markers on the back. If there are apparently six lumbar vertebrae, and filling of the cceliac axis is aimed at, a full spinal count is necessary to determine if the extra vertebra is the I2th dorsal or i s t l u m b a r - - a n d it is to be noted that this anomaly is very frequent. T h e actual puncture of the aorta has so far caused no trouble when the needle has been long enough. For a child or thin woman, I I cm. (41 in.) is sumcient, but for a thick-set man a needle of 12. 5 cm. (5 in.) is necessary. Difficulty in entering the aorta is almost always due to too short a needle, for with an inclination up and in, it is most deceptive how far the needle must go. It is easy to enter a vein and to mistake it for the aorta, and we once made a venogram of an ascending lumbar venous trunk, but this does not happen if it is remembered that bright-red blood runs out in a constant strong rivulet when the aorta is entered. I f a vein is entered, clotting will quickly occur in the needle ; therefore it must be withdrawn and washed thoroughly before proceeding. It is as well, also, to make sure that the needle is clear by injecting a little procaine just before the actual puncture of the aorta is made. Injection of part or all of the m e d i u m outside the aorta occurs from time to time (see Fig. 24i), but this should not happen if the needle is advanced a millimetre 6r two after puncture and if the needle is carefully watched during the injection. I n the effort to inject rapidly, the needle can be pushed in or pulled out, particularly if a protective lead screen blocks the view, and it is remarkable how little force is required to inject fluid into the lax periaortic tissues. This accident, however, leads to no ill effects other than a good deal of pain for some hours.
R E S U L T S TO B E E X P E C T E D In the normal patient (Figs. 236 , 237) the level of the main arteries is : - Coeliac axis Superior mesenteric artery Renal vessels Inferior mesenteric artery Aorta branches at
------
U p p e r border of i 2 t h thoracic vertebra Centre of I2th thoracic vertebra Centre of ISt l u m b a r vertebra U p p e r border of 3rd lumbar vertebra ~th lumbar vertebra
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The direction of the hepatic, splenic, and renal arteries is at right angles to the aorta, while the superior mesenteric is usually in line with or just to the left of the aorta, and therefore difficult to see, but it occasionally sweeps well to the right. The splenic artery is never straight and is often tortuous ; the hepatic and gastroduodenal branch of the hepatic fill well, but the left gastric has not, so far, been seen. T h e renal arteries are about the same size as the hepatic and splenic, and can be seen arborizing in the kidneys. The ~filling 9 f the mesenteric vessels has varied, sometimes all branches showing, sometimes only the main ones. Venous filling has been :observed and is discussed by Professor Johnstone in his paper. In the later films of the series the dense outline of various organs are seen, particularly the kidneys and spleen, but also liver, suprarenals, and gut, as their capillary beds fill with diodone. The value of the density of the kidney shadow as an index of its function is discussed later. Vascular abnormalities, as would be expected, are very well seen. Aneurysms are shown in detail (F@ 238): arterial thromboses and collateral vessels, which are discussed by Professor Johnstone, are Fig. 236.--Post-mortem injection in a patient who died outlined (Fig. 233, in Professor Johnstone's paper); from a cerebral tumour. Note the direction and size of the 'main vessels, the at:borizations in the kidneys, and that and aberrant vessels (Figs. 241 , 242 A) or other the main part of the superior mesenteric artery is hidden by the aorta. vascular changes in an organ are shown in Figs. 240 ,
A
B
Fig. 237.--A, Aortogram and intravenous pyelogram of a normal patient done at the same time. Note the size, position, and direction of the vessels, and that there are apparently six lumbar vertebrm--~the sixth in this case is an unfused first sacral. Note also that the kidneys are just beginning to become dense. (Frame 2 in the Series.) B, Frame 5 (6"25 seconds after start of injection) showing dense kidneys and spleen (' renogram ' and ' splenogram ') in a normal patient.
243 B, 244A ). The patient with the aneurysm shown in Fig. 239 had clinically quite a large femoral aneurysm, but it can be seen from the aortogram that its lumen is reasonably regular and
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that any surgical attack would involve ligation of the femoral and profunda femoris arteries, so that conservative treatment was decided upon. T h e examination of the kidney is particularly useful and can be considered under the headings of congenital anomalies, hydronephrosis, tumours, and sclerosis of the vessels. In congenital lesions it can settle the diagnosis--for example, as to whether there are two kidneys or one, or whether an anomaly in the intravenous pyelogram represents a horseshoe or non-rotated kidney. It can help in the treatment-for instance, to show if the blood-supply to the kidney with a double pelvis is such that part of the kidney can be removed (Fig. 239 ) . In hydronephrosis an aortogram can help in two ways : First it may show the cause, such, for example, as an aberrant vessel (Figs. 24 I, 242 A) : secondly it can g i v e valuable evidence of the functional state of the kidney by the size of the vessels supplying it (Figs. 242 A, 243 B) and by the density of the ' renogram' (Figs. 242 B, 243 B). In considering the ' renogram ', however, a word of warning must be given ; first, if the injection is made at about the level of the renal vessels most of the diodone may go to one or other kidney, with a subsequent much more dense kidney outline Fig. 2 3 8 . - - A patient with, clinically, a femoral aneurysm about 3 in. in diameter. T h e aortogram shows that the lumen of the artery is not grossly altered and that the aneurysm involves the profunda femoris.
A
B
Fig. 239.--A, Intravenous pyelogram, and B, aortogram of a patient with a double pelvis and recurrent pyelitis, showing
that the upper part of the kidney has a separate blood-supply. Note also that the injection is almost directly into the right renal artery, giving a more dense right renogram than l e f t - - a factor to be carefully watched when using renograms to assess the function of the kidneys.
on that side, so that the ' renogram' must be viewed with the density of the filling of the renal artery in mind (Fig. 239 B) ; second, any functioning kidney tissue will become opaque, so that
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a poorly functioning sclerotic kidney may appear dense (Fig. 245 B), but its shrivelled Small state is also evident. The comparative density of the kidney shadow, therefore, is chiefly of value where the kidney substance has become stretched and atrophied over a hydronephrotic sac.
Fig. 2 4 o . - - A patient w i t h polycystic disease of the kidneys s h o w i n g displacement of t h e vessels b y the cysts, with the avaseular areas w h e r e the cysts lie.
Fig. 2 4 I . - - A o r t o g r a m o f a girl w i t h a m i l d hydronephrosis and an aberrant vessel to the l o w e r pole o f the left kidney. T h e r e a r e t w o m a i n renal arteries o n t h e right side and a visible splenic artery. S o m e o f the d i o d o n e has been' injected outside the aorta, but at operation the n e x t d a y there was n o t h i n g abnormal to be seen. T h e renal vessels on t h e left side are marked w i t h arrows.
A
B
Fig. 2 4 2 . - - A o r t o g r a m s (Frames I and 7 in t h e series) of a girl w i t h s-considerable hydronephrosis o n the left side.
A, T h e first frame shows an aberrant vessel to the u p p e r pole of the right kidney and to b o t h poles o f the left kidney (confirmed at operation) and, o n the left, that the vessels are displaced by the h y d r o n e p h r o t i c sac and are m u c h smaller than on t h e right. B, T h e seventh frame shows very well that the density of the kidney is less on t h e left than the right, but that it is still good.
Hypernephroma of the kidney presents as a distortion of the vessels with a variable area of normal kidney shadow and with an area where diodone has collected, but. not diffusely and evenly, in what has been described as 'puddling' (Fig. 244 ). Avascular tumours of the kidney--for example, cysts--give an entirely different appearance ; in these, the distortions of the vessels is the primary object, together with an area or areas where there is no diodone (Fig. 24o ).
VISUALIZATION
QF
THE
ABDOMINAL
AORTA
245
Sclerosis of the kidney (Fig. 245 ) is of considerable interest as it may be the cause of hypertension. In the case shown the aortogram provided the only evidence of the cause of recurrent loin pain, rigors, etc., i n a patient in whom an intravenous and retrograde pyelogram were normal. Aortography has been used in the diagnosis of other conditions, such as obscure abdominal swellings and placenta prmvia, but we have not, as yet, had occasion to use it in such cases, nor have
A
B
Fig. 243.--A, Intravenous pyelogram, and B, aortogram of a patient with severe hydronephrosis (bilateral). T h e intravenous pyelogram on the right side shows only a very small area where there has been some e:~cretion, and the aortogram shows very thin vessels on that side, but normal-sized arteries on the left. On the right there are left only three small areas of kidney substance which become dense, whereas on the left, although the kidney does not become as dense as normal, it is of normal outline and reasonably opaque.
Fig. 244.--Patient with a hypernephroma of the right kidney. A, Shows the displacement of the branches of the renal artery, the beginning of the ' p u d d l i n g ' A in the t u m o u r area, and the start of the outline of the remaining kidney substance. T h e full ' p u d d l i n g ' and opacity of the remaining kidney substance is seen in F~g. 231 B, in Professor Johnstone's paper, where he discusses the splenic filling. B~ T h e specimen split and opened out showing the small amount of normal kidney substance to the medial side of the turnout mass.
Z46
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
we yet had a suprarenal tumour to examine, although it looks as if aortography would be of the greatest value in this difficult diagnostic problem.
A
B
C
Fig. z45.--A, Retrograde pyelogram, S, aortogram (Frame 3 in series), and C, photograph of kidney of a man with recurrent attacks of pain in right loin and rigors. T h e retrograde pyelogram shows a normal outline, b u t the aortogram shows the renal artery running into a very small kidney with an uneven outline, and the specimen shows clearly the infarcted area. T h e question of the density of the kidney is discussed in the text.
The value of the procedure in venography, especially of the portal system, is discussed by Professor Johnstone and will not b e considered further here, but this, too, appears to be a useful field for further study.
VISUALIZATION
OF
THE
ABDOMINAL
AORTA
247
SUMMARY
The history and technique of aortography are briefly described and the risks and difficulties discussed. The results and value of the procedure are considered in the normal, in arterial lesions, and in renal anomalies u n d e r the headings of congenital abnormalities, hydronephrosis, tumours, and sclerosis. T h e other uses, Which have been described, are mentioned. T h e possible value of aortograms in suprarenal tumours and in the study of veins, particularly the portal vein, is referred to. BIBLIOGRAPHY DOS SANTOS,R., LAMAS,A. C., and CALDAS,J. PEREIRA(1929), Med. Contemp., 47, 93. (1931), Arteriographie des Mernbres et de L'Aorte abdominale. Paris : Masson et Cie. Doss, A. K. (I947), J. Urol. 57, 521. - - - - THOMAS,H. C., and BOND, T. B. (1942)i Texas St.J. Med., 38, 277. FAmNAS,P. L. (1941), Amer. J. Roentgenol., 46, 641. - - - - (I945), Surgery, 18, 244. GRIFEITHS, I. H. (195o), Brit. J. Urol. 22, 281. HARTNETT, L. J. (1948), Amer. J. Obstet. Gynec., 55, 94°. MELICK, W. F., and VITT, A. E. (I948), J. Urol., 60, 3~I. NELSON, O. A. (1942), Surg. Gynee. Obstet., 74, 655. - - - - (1945), J. Urol., 53, 521. Osomo, P. A. (I933),J. Amer. reed. Ass., IOO, I555. SMITH, P, G., RUSH,T. W., and EVANS,H. T. (I951),J. Urol., 65, 911. WAGNER, F. B., jun. (1946), Ibid., 56, 625. - - - - and PRICE, A. H. (i95o), Surgery, 27, 621. and SWENSON,P. C. (I947), Amer. J. Roentgenol., 58, 591.
THE
SKINNER
LECTURE
T h e 1952 Skinner Lecture will be given before the Faculty of Radiologists at the Royal College of Surgeons, Lincoln's I n n Fields, London, W.C.2, by Dr. H. R. Sear of Sydney on Friday, May 16, at 4 p.m. His subject will be " Congenital Bone Dystrophies and their Correlation "
Since the above was printed the
time of
the lecture has been altered to 3.3 ° p.m.