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 and through the 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 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 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. 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. i). Further confirmation gram by diminished calibre of the main artery and of presence of a cyst may be obtained by per- its branches. Many of these vessels are further cutaneous needling and aspiration of the contents attenuated by deviation over a voluminous renal for cytological examination. pelvis. The nephrogram is reduced in density A parenchymal tumour, on the other hand, is and if seen with a coincident the thick- demonstrated characteristically by a stippling or ness of functioning cortex is well delineated. mottling by contrast material pooling in the Hypertension. An important place for renal vascular spaces of the tumour (Figs. 2 and 2a). arteriography is in the investigation of unexplained Aortography serves no useful purpose in the hypertension and particularly if it is of recent investigation of tumours of the renal pelvis for they onset. Early recognition of hypertension due to show no typical picture. Their diagnosis rests renal artery or pyelonephritic changes is essential if entirely on clinical and pyelographic findings. improvement by nephrectomy is to be expected,

Nevertheless it is important for the surgeon to for delay in such treatment may allow irreversible http://pmj.bmj.com/ make a pre-operative distinction between a changes to take place in the normal kidney. An parenchymal adenoma and a tumour of the renal arteriogram in such patients may demonstrate: pelvis, for in the latter case the whole ureter as well (i) An aneurysm of the renal artery. as the kidney must be removed. (ii) An obstruction due to arterial thrombosis. (iii) A small contracted pyelonephritic kidney Assessment of Renal Function showing only a faint nephrogram and a Hydronephrosis. Aortography is particularly poor blood supply. helpful in cases of hydronephrosis in determining Aneurysms are rare but thromboses of the renal on September 25, 2021 by guest. the cause and in deciding the type of operation for artery are more commonly found. Obstruction its correction. In some cases it will reveal the may occur in a branch of the renal artery when it is presence of an aberrant artery to the lower pole of possible to recognize in the arteriogram an the kidney apparently obstructing the pelvi- avascular infarcted area in the renal cortex. ureteric junction. It is most debatable to place Chronic pyelonephritis causing hypertension the whole guilt of obstruction on this accessory may be a unilateral condition with improvement artery for, in reviewing a long series of aorto- following nephrectomy, or bilateral when the out- graphies, it is surprising how frequently trouble- look is hopeless and beyond surgical influence. free aberrant vessels are seen. However, a pre- This important detail can be determined by operative study of the calibre of the vessel and an aortography. estimate:of the amount of the lower pole supplied Haematuria ofunexplained origin. A renal cause by it is helpful if its ligature and section is of haematuria can in some cases escape detection proposed. by pyelography when aortography may demon- Postgrad Med J: first published as 10.1136/pgmj.35.409.620 on 1 November 1959. Downloaded from November 1959 GRIFFITHS: Aortography 623

APICAL

,,,ArR0ArwRrERY LOWER LOE Protected by copyright.

FIG. 3.-Diagram showing the distribution of the anterior and posterior divisions of the renal artery (after Graves, I954). strate an adenocarcinoma of the renal cortex which recovery is quick and complete unless some im- has not become large enough to disclose itself by pairment of renal function is already present. deviation of a calyx. For this reason it is inadvisable to perform aorto- Inconclusive pyelograms. Aortography can also graphy if the level of non-protein nitrogen of the help to confirm the presence or reassure one of the blood is raised unless the circumstances are absence of a tumour of the renal cortex when exceptional. Neither is it advisable to perform pyelographic investigation has raised a suspicion. any major surgery without an interval of some http://pmj.bmj.com/ Retroperitoneal tumours. Particularly in con- days following aortography in order to allow junction with retroperitoneal oxygen insufflation complete recovery of renal function. is aortography useful to distinguish renal tumours Iodine sensitivity naturally precludes aorto- from other retroperitoneal swellings. It does oc- graphy. casionally show the vessels to a suprarenal tumour quite clearly, but this is more by good fortune than Complications good technique and is not a reliable form of in- The complications associated with the per- vestigation in this condition. formance of aortography in this country are few on September 25, 2021 by guest. Partial Nephrectomy. A study of the arterial and rarely serious. No fatality has occurred in a phase of an aortogram carried out in the course of long series carried out by the writer in collabora- investigating a renal condition is of particular tion with Dr. C. G. Whiteside at the Middlesex value if partial nephrectomy is contemplated. Hospital since I950. In only one case has Graves (1954) has shown that the renal artery anuria occurred and may have been due to hyper- divides into branches which have been named and sensitivity from summation of effect following a though the pattern of division is irregular, their second injection of 30 ml. diodone. The patient number and distribution are constant (Fig. 3). made a satisfactory recovery. Contra Indications Intramural Injection Transient renal damage from rapid injection Intramural injection can be the most serious of of iodine contrast material undoubtedly occurs and accidents occurring in the performance of aorto- Postgrad Med J: first published as 10.1136/pgmj.35.409.620 on 1 November 1959. Downloaded from 624 POSTGRADUATE MEDICAL JOURNAL November I959

.., .... '.j::;.-:.::

*: ...' ..; ....

..:..... Protected by copyright.

FIG. 4.-Intramural injection showing a dense thoracic aorta. The nephrograms indicate that some of the contrast material entered the aortic lumen. graphy: 20 to 30 ml. of contrast medium may be Periaortic Injection of Diodone forcibly introduced into the media of the vessel This is a common incident particularly in obese causing a dissection of the wall. This process in patients but the contrast medium is quickly which the intima is raised may involve the orifice absorbed and usually causes only a short period http://pmj.bmj.com/ of a major branch or may extend into the branch to of lumbar backache. cause occlusion, ischaemia and thrombosis with necrosis of the organ it supplies. To avoid such an accident Whiteside (I959) emphasizes the im- Conclusion portance of directing the needle obliquely upwards In conclusion aortography is a safe procedure into the aorta at the level of Dorsal XII. Should when using a simple technique but requires the intramural injection occur dissection is more practised co-operation and co-ordination of a team likely to extend upwards and will involve only the for the best results to be attained. It should be on September 25, 2021 by guest. intercostal branches. used selectively and where the more familiar This accident occurred in one case of the methods of urological investigation have proved Middlesex Hospital series when the terminal few inadequate and inconclusive. ml. of contrast medium was introduced into the media in spite of a preliminary test to determine the Acknowledgments site of the needle. There were no sequelae I am indebted to Sir Eric Riches for the free (Fig. 4) use of his cases and for the X-rays reproduced in Extravasation of Blood this article, to Dr. C. G. Whiteside for his help Extravasation of blood following the withdrawal and advice, and to Miss Hewland and Mr. Turney of the needle or by transfixion of the aorta does of the art and photographic departments of the occur, particularly in hypersensitive cases, but it Middlesex Hospital. has never been a serious matter. Bibliography continued on page 639. Postgrad Med J: first published as 10.1136/pgmj.35.409.620 on 1 November 1959. Downloaded from November 1959 LLOYD-THOMAS: Diuretics 639 thiazide is in the range of o00-2oo mg. When natraemia with a normal or elevated serum potas- prolonged therapy is required, supplementation of sium and a raised blood urea with one exception. potassium intake will be required and the sup- All exhibited a great increase in urinary output plements are best given on non-diuretic days due to a predominant water diuresis with disap- (Poznanski and Cromie, I959). pearance of oedema following the addition of pred- Hydroflumethiazide (' Hydrenox ')-chemically nisolone, in a dose of 5 mg. t.d.s. for 24-48 hours 3 : 4 - dihydro - 7 - sulphamyl - 6 - trifluoro- followed by a maintenance dosage of 2.5 mg. twice methyl - : 2 4 - benzothiadiazine - i : I - or thrice daily, to existing therapy with digitalis dioxide, has been introduced more recently and and diuretics and the substitution of the low- is undergoing investigation (Hobolth et al., 1958; sodium intake by a normal diet. Sele, 1958; Kobinger and Lund, 1959). It has approximately the same potency as hydrochloro- BIBLIOGRAPHY DRESDALE, D. T., GREENE, M. A., and GUZMAN, S. V. thiazide and the dosage range is similar. (I958), Amer. Heart .., 55, 85I. its and in of much ex- FLEMING, P. R. ZILVA, J. F., BAYLISS, R. I. S., and PIRKIS Despite frequency spite J. (I959), Lncet, i, 1219. perimental study, the mechanisms responsible for GUTNER, L. B., MOSES, J. B., DANN, S., and KUPPERMAN, hyponatraemia in chronic cardiac failure are still H. S. (x957), Amer... med. Sd., 234, 28x. far from clear. There is no HEIDERN, G. H., and SCHEMM, F. R. (I955), Ibid., 229, 62. question, however, HOBOLTH, N., and THOMSEN, K., from HANSEN P. that some patients with intractable cardiac oedema HAGENSEN, N. R., and OPRESNIK, J. (z958), Ugeskr. Laeg. benefit from steroid et 120, 1585. therapy (Gutner al., 1957; HAVARD, C. W. H., and FENTON, J. C. B. (x959), Brit. med. J. Heidorn et al., 1955; Reimer, 1956; Dresdale i, rS60. et Mickerson and Swale have KERR, D. N. S., READ, A. E., and SHERLOCK, S. (I959), al., 1958). (I959) Lancet, 1, 1221. recently described a series of 13 patients who KOBINGER, W., and LUND, F. J. (z9S9), Acta pharmacol. (Kbh.),

showed the features in common: all had I5, 265. Protected by copyright. following MICKERSON, J. N., and SWALE, J. (1959), Brit. med. J., i, 876. obstinate cardiac failure and had become resistant NORDQUIST, P., CRAMER, G., and BJORNTORP, P. (I959) to treatment with digitalis, low-sodium diet and Lancet, i, 271. diuretics; they complained of excessive tiredness POZNANSKI, W. J., and CROMIE, B. W. (I959), Brit. med.g. and increased both of the skin and PLATIS M. M. (I959), Ibid., I565. pigmentation REIMER A. D. (956), B'.Iohns Hopk. Hosp., 35, 728. buccal mucosa was present; all showed hypo- SELE, V. (x958), Ugeskr. Laeg., 120, x592.

Bibliography continuedfrom page 624-I. H. Griffiths, F.R.C.S. BIBLIOGRAPHY HENLINE, R. B., and MOORE, S. W. (1936), Amer. J. Sug., DOS SANTOS, R., LAMAS, A. C., and CALDAS, J. (1929), 32, 222. Med. contemp., 47, 93. NELSON, O. A. (942), Surg. Gyc. Obstet., 74, 655. http://pmj.bmj.com/ DOSS, A. K., THOMAS, H. C., and BOND, T. B. (1942), Tex. St. g. Med., 38, 277. PIERCE, E. C. (i95g), Ibid., 93, 56. GRAVES, F. T. (1954), Brit. J. Surg., 42, 132. WHITESIDE, C. G. (x959), Personal Communication. on September 25, 2021 by guest. Bibliography continuedfrom page 630-F. M. Parsons, B.Sc., M.B., Ch.B. BIBLIOGRAPHY McCANCE, R. A., and WIDDOWSON, E. M. (x946), London, ABEL, J. J., ROWNTREE, L. G., and TURNER, B. B. (1913), Her Majesty's Stationery Office. Trans. Ass. Amer. Phys., 28, Si. MERRILL, J. P. (r955), 'The Treatment of Renal Failure,' ALWALL, N. (x947), Acta med. scand., 28, 317. Grune & Stratton, New York and London. BULL, G. M., JOEKES, A. M., and LOWE, K. G. (r949), MERRILL, J. P., and WELLER, J. M. (1952), Ann. Int. Md., Lancet, ii, 229. 37, x86. DANZIG, L. E. (i955), New Engl. 7. Med., 252 49. MURPHY, W. P., Jr. SWAN, R. C., WALTER, C. W., WELLER, DOOLAN P. D., WALSH, W. P., KYLE, L. H., and J. M., and MERRILL, J. P. (1952), J. Lab. din. Med., 4o 436. WISHiINSKY, H. (I95g), 7. . med. Ass., 146, xoS. PARSONS, F. M. (i959), Lancet, i, 148. GJO RUP, S., and THAYSEN, J. H. (I958), Lancet, ii, 886. PARSONS, F. M., and McCRACKEN, B. H. (i958), Brit. J. KOLFF, W. J., and BERK, H. Th. J. ('944), Acta med. scand., Urol., 30, 463. 117, 121. PARSONS, F. M., and McCRACKEN, B. H. (g959), Brit. med. ., KOLFF, W. J., and WATSCHINGER, B. (1956), . Lab. cdn. i, 740. Med., 47, 969. SKEGGS, L. T., Jnr., and LEONARDS, J. R. (x948), Science, KYLE L. H JEGHERS, H., WALSH, W. P. DOOLAN P. D., 108, 212. WISHINSKY, H., and PALLOTTA, A. (I953), Y. cn. WOLF, A. V., REMP, D. G., KILEY, J. E., and CURRIE, G. D. Invest., 32, 364. (x95i), g. cin. Invest., 30o1,062.