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AORTOGRAPHY by I Postgrad Med J: first published as 10.1136/pgmj.35.409.620 on 1 November 1959. Downloaded from 620 AORTOGRAPHY By I. H. GRIFFITHS, F.R.C.S. Genito-Uri;lary Surgeon, Mt. Vernon Hospital, Northwood; Chief Assistant, Urology D3partment, Middlesex Hospital Abdcmiral aortography is an investigation was first described by Pierce (195 ) and consists of which consists of rendering opaque the blood flow percutaneous puncture of the femoral artery and through the aorta and its larger branches to permit introduction of polythene tube via the cannula into a radiological study of the vascular pattern in the the external and common iliac arteries and up to organs of the abdomen. The renal artery, unlike the aorta to the level of the renal vessels. The vessels to the abdominal viscera, divides regularly lumbar route is easier to master, quicker to per- with mincr variations and arborizes into a fine form and more suitable for routine use in an delicate but typical pattern in the renal otherwise busy radiological department. parenchyma. Rcynaldo Des Santos and his colleagues Lamas Technique and Caldas (I929) workirg at the Santa Maria Equipment Hospital, Lisbon, first introduced translumbar The equipment for trans lumbar injection is for the aortic puncture purpose of aortography, now provided a3 a set-Middlesex HospitalProtected by copyright. and in their publication of 300 cases were con- Pattern, produced by Warner Bros. It ha3 three vinced of its importance in renal investigation. needles of different length and calibre, the largest It encourtered much criticism because of the being 15 cm. i6 S.W.G. for adults, 12 cm. i8 serious reaction which occurred from the injection S.W.G. for small adults and 9 cm. 20 S.W.G. for of Ioo per cent. solution of sodium iodide. use in children. It also contains a 30 ml. syringe Henline and Moore (I936) using the same con- with a metal case to envelop it for protection trast medium for aortography in experimental against bursting during manual injection, and a dogs, reported a high mortality which further length of reinforced pressure tubing with adaptor prejudiced the use of this procedure in human to connect the needle to the syringe. beings. Nelson and Doss (1942) and other American Contrast Medium investigators working independently, re-intro- Sodium iodide is the most radiologically dense duced aortography as a safe and valuable procedure of all intravascular contrast mediums but toxicity and series involving many thousands of is its Since it has been published great disadvantage. 1950 http://pmj.bmj.com/ cases without there being a fatality. replaced by an organic iodide solution-70 per The slow acceptance of aortography in this cent. diodone-which has the merit of causing country as an adjunct to other more familiar fewer and less severe reactions with small sacrifice diagnostic procedures was due to the misappre- of contrast and definition. An iodide sensitivity hension that the technique was difficult and test must always be carried out if an I.V.P. has dangerous, and that the indications for its use not already been obtained. were not precise. Anaesthesia The increasing demand in recent years for on September 25, 2021 by guest. arteriography in the field of renal as well as vascular The procedure can be performed under general surgery has inspired ingenious devices for the or local anaesthesia but, unless one has had much rapid automatic change of film cassettes and the experience with the technique, the advantages of injection of contrast medium with great speed by having a conscious patient to co-operate in holding a mechanically-driven syringe. A simple technique the breath during the performance are far out- such as described below gives adequate informa- weighed by having the patient relaxed under tion and has fewer complications. general anaesthesia. Under the latter circum- stances there is less tension at both ends of the Routes needle. The contrast medium-30 ml. of 70 per cent. The patient lies in a prone position on a wooden diodone-is introduced into the vascular system tunnel through which cassettes can be passed. by trans lumbar aortic puncture or by retrograde A metal marker is applied at the level of the body femoral artery catheterization. The latter route of the twelfth dorsal vertebra-the level at which Postgrad Med J: first published as 10.1136/pgmj.35.409.620 on 1 November 1959. Downloaded from Nov.tnber 1959 GRIFFITHS: Aortography 621 the aortic puncture is proposed. A trial film will verify this, as well as confirm the accuracy of siting and exposure. A syringe of saline is con- nected up to the needle by the pressure tubing and the system filled with saline. The skin is punctured below the last rib on the left, four- finger breadths away from the spinous processes- two-finger breadths in children-and the needle is advanced to the side of the body of the last dorsal vertebra. Having found this landmark, the needle is then directed more vertically, slipping past the vertebral body to penetrate the aorta with a sensation of puncturing the theca. Pulsating puffs of blood gently pushing the syringe plunger back will indicate a successful puncture. A trial film whilst injecting 5 ml. of diodone is always advisable to confirm the position of the needle. The 30 ml. syringe is now charged with 70 per cent. diodone and connected to the system. The FIG. i.-Translucent area in middle third of nephro- injection is then made and completed in four to gram of R. kidney produced by a solitary cyst. five seconds, sending a column of diodone up- It is well defined, avascular and show3 no pooling. wards into the thoracic aorta. During this time the respirations are stopped by the anaesthetist Ectopic kidney. On the other hand a nephro- Protected by copyright. and four loaded cassettes are passed through the gram may prove the kidney, absent from its normal tunnel beneath the patient and exposed at two- position, to be an ectopic or a crossed ectopic one, second intervals. Co-ordination is essential and and in the arterial phase the aberrant vascular a preliminary practice by the team is worthwhile. supply to the kidney may be clearly seen. This information is of considerable value if for any Interpretation of the Normal Arteriogram reason surgical exploration is proposed. Using this simple technique a series of four Hypoplastic or atrophic kidney. In the arterio- films is obtained. The first taken half way gram the renal artery is of slender calibre and the through the injection shows a column of diodone nephrogram shows a faint shadow of a very small in the thoracic aorta; the second represents the kidney. arterial phase when the column of contrast Horse-shoe kidney. The disposition of the material descends to the abdominal aorta and fills aberrant vascular supply can be demonstrated its main branches. In this phase the coeliac axis prior to sectioning the isthmus should this be con- and its divisions are usually well filled and may templated. Engel and Poutasse (I955) record an http://pmj.bmj.com/ obscure some branches of the renal arteries. It is autopsy finding of a single renal artery supplying possible to obtain stereoscopic pictures by a an entire horse shoe kidney. second injection of diodone when the origin and Polycystic kidney. This condition is more course of the vessels can then be traced easily. usually demonstrated and proved by intravenous Experience has taught that such a refinement is or retrograde pyelography but there are occasions rarely indicated. The third film may demon- when neither of these investigations can be of any strate a transient venous phase when the renal assistance. Aortography may then demonstrate a on September 25, 2021 by guest. veins may be seen coincident with the small arterial typical picture of long narrow kidneys with a poor branches. The fourth film of the series is the blood supply. The long slender vessels are nephrogram phase when the kidneys are sil- deviated around the cysts and the nephrogram, houetted by increased density. which is not as dense as in the normal, is blotchy Indications giving a cotton wool effect. Congenital abnormalities Swellings of the Kidney Absent kidney. An aortogram carried out after It is in the differential diagnosis between cysts an I.V.P. has indicated an apparently non- and solid tumours of the kidney that aortography functioning kidney occasionally discloses a com- finds its greatest application for by this means a plete absence of kidney. In such a case the renal cyst accurately diagnosed can prevent an un- artery is completely absent and a nephrogram does necessary surgical undertaking, and a parenchymal not appear. tumour can be unequivocably demonstrated. Postgrad Med J: first published as 10.1136/pgmj.35.409.620 on 1 November 1959. Downloaded from 622 POSTGRADUATE MEDICAL JOURNAL November 1959 SpIenic A RKIDNEY. ooi~ng t9..< Contrast bRwz,.. Normai art of tidney FIG. 2a.-Line drawing of the aortogram showing area FIG. 2.-Arterial phase in an angiogram of an adeno- of pooling in upper pole of L. kidney. carcinoma of L. kidney with specimen on R. of film. The degree of renal function is the most im- portant pre-operative information in the condition In a solitary cyst the vessels are displaced by a of pelvi-ureteric obstruction for upon this rests the well defined rather translucent avascular soft tissue decision to retain or remove the kidney. shadow, and in the nephrogram it is usually well Cortical atrophy is associated with a reductionProtected by copyright. demonstrated by contrast with the dense paren- in vascular supply and is indicated in the aorto- chyma around it (Fig.
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