Pancreatic Angiography

Pancreatic angiography

Angiography has become an important procedure in the diagnosis of pancreatic disease. Because of the difficulty in examining the pan- Thomas R. Havrilla, M.D creas by the traditional roentgenographic tech- Norbert E. Reich, D.O. niques such as gastrointestinal barium exami- John R. Haaga, M.D. nations, hypotonic duodenography, and endo- scopic retrograde pancreatography (ERCP), an- Department of Radiology giography serves as a complementary study. Avram M. Cooperman, Perhaps the chief attribute is its role in diagnos- M.D. ing pancreatic tumors. The angiogram can aid in showing the extent of a tumor, its resectabil- Department of General Surgery ity, and vascular variations which may compli- cate the surgical procedure. It is the procedure of choice for diagnosing and locating islet cell adenomas because they frequently are small and difficult to find on exploration. With accurate localization, only limited resection of the pancreas is needed and operative mortality and morbidity are reduced.1 Pancreatitis is more of a clinical diagnosis than an angiographic one. However, it must be differentiated from pancreatic carcinoma. Angiography is also an aid in the diagnosis of cystadenomas and cystadeno- carcinomas, other rare endocrine tumors, met- astatic disease, and lymphomas. Occasionally, it is an aid in the diagnosis of trauma and congenital vascular abnormalities. 157

Downloaded from www.ccjm.org on September 30, 2021. For personal use only. All other uses require permission. 158 Cleveland Clinic Quarterly Vol. 44, No. 3 ' Technique arterial blush, for example, in var- Since the first selective celiac and ious pancreatic lesions as well as col- superior mesenteric angiograms per- lateral circulation when vascular oc- formed by arteriotomy of the carotid clusions are present. Magnification or brachial arteries in 1951,2 angio- techniques are rarely used. Film sub- graphic technique has been perfected traction techniques are not of great to almost a fine art. Today, pan- benefit but can occasionally demon- creatic angiography is usually per- strate small areas of tumor blush or formed by a percutaneous femoral neovascularity. Therefore, subtrac- approach utilizing the Seldinger tion techniques are used only in se- technique, first performed in 1953.3 lected patients to enhance a question- If the femoral arteries cannot be uti- able abnormality. lized secondary to severe athero- Superselective injection of individ- sclerotic disease, axillary catheteriza- ual pancreatic arteries is done rou- tion is a good alternative.4'5 Usually tinely by many investigators if a le- celiac and superior mesenteric an- sion is suspected on the initial celiac giography should be performed or mesenteric arteriogram or if there either as a combined injection using is strong clinical evidence of pan- two catheters from each femoral ar- creatic abnormality.5'8'9 Superselec- tery or by sequential injections using tive studies are usually performed by one catheter only. Sequential injec- advancing a catheter into the gas- tions help separate many of the pan- troduodenal artery or into a pancreatic vessels from overlying celiac creatic branch of the splenic artery. and mesenteric artery branches on If a standard catheter cannot be ad- the combined injections. Combined vanced, a catheter shaped to conform injections can aid in gross pancreatic to the vascular anatomy is used; re- diagnoses, in showing the vascular motely controlled guide wires and anatomy, and possibly demonstrating catheters have also been developed.9 liver metastases. At present double Injections can be made by hand or catheter techniques are not widely by large bolus injections delivered used.6'7 with a pressure injector to visualize Selective superior mesenteric an- small capillaries, pancreatic paren- 10 giography usually is performed with chyma, and the venous system. 40- to 60-ml Renografin 76 delivered Injections into the gastroduodenal, with a pressure injector at a rate of 7 dorsal pancreatic and splenic arteries to 12 ml/sec for 7 seconds. Serial have four advantages.1 (1) The pan- filming is necessary at one to two creatic arteries are filled with higher exposures per second for 7 seconds concentration solution. (2) Overlying with a total filming time of 18 to 30 left gastric and jejunal artery branches seconds. A satisfactory program con- are not a problem. (3) Injection into sists of 7 ml/sec for 7 seconds with the gastroduodenal artery distends one exposure per second for 7 sec- the pancreatoduodenal arcade onds and then one exposure per 3 branches. Therefore, fixed, nondis- seconds for the next 21 seconds. Usu- tensible irregularities in the lumen ally this results in excellent visualiza- are more easily seen. (4) Excellent tion of both arterial and venous sys- filling of the splenic and portal veins tems and can demonstrate prolonged can be attained for visualization of

Downloaded from www.ccjm.org on September 30, 2021. For personal use only. All other uses require permission. Winter 1977 Pancreatic angiography 159 venous narrowing and occlusion. acteristically does not react to a vaso- Subtle changes in the pancreatoduo- constrictor.13-15 denal arcades are often the only clue Bradykinin is a potent arterial di- in the diagnosis of tumor. lator and gives earlier and better fill- The pancreatic arteries are usually ing of veins. Tolazoline (Priscoline) well demonstrated by injecting the can also enhance the venous phase in splenic and gastroduodenal arteries. dosages of approximately 25 mg. Se- The anastomosing branches of the cretin, trypsin, and histamine have pancreatic arcades of the dorsal pan- been used to improve the paren- creatic artery allow evaluation of the chymal phases of the pancreatic an- 16 head and body of the pancreas. In- giogram. Tolazoline and prosta- jection of the splenic artery will visu- glandin E have also been investi- 17, 18 alize the branches to the distal tail. gated. The splenic vein is also well visual- The complications of percutaneous ized. Injection of the dorsal pan- femoral angiography are few and di- creatic artery, because of wide anas- rectly related to the experience and tomoses throughout the pancreas, expertise of the angiographer. The will demonstrate the branches in the number of catheter changes, the total head and body. In superselective time of the procedure, and the pres- catheterization, the injection volume ence of arterial disease are also re- 11 should be kept to a minimum and lated factors. The incidence of mi- care should be taken to avoid wedg- nor complications is below 3%; major ing of the catheter. complications occur in less than 0.5% of patients. Complications which can Pharmacoangiography has also occur are bleeding and femoral arte- been adapted for evaluating pan- rial thrombosis at the site of catheter creatic abnormalities. Some pharma- introduction, hematoma, arterial ve- ceuticals enhance the visualization of nous fistula, and embolization sec- certain vessels in selective and super- ondary to formation of thrombi at selective angiography. Two basic cat- the puncture site. Complications egories are vasoconstrictive and va- rarely include thrombophlebitis of sodilating drugs.11 Vasoconstrictors the lower extremity, dissection of the consist of epinephrine, norepineph- aorta or its branches, vascular perfo- rine, vasopressin, and angiotensin.12 ration, and parenchymal infarction Small doses of epinephrine (5 to 10 secondary to wedging of the catheter. /xg) given intraarterially will constrict A rare complication is permanent pa- the entire splenic bed, but in differ- ralysis secondary to transverse myeli- ent degrees. Since pancreatic vessels tis. Breakage of catheters and guide react the least to epinephrine, shunt- wires intravascularly may also occur. ing occurs from the gastric, hepatic, Abdominal pain may occur at the and splenic beds into the pancreatic time of injection but usually lasts only vascular bed on the celiac angiogram. a few moments.19 Small tumor vessels in pancreatic carcinoma and abnormal vessels in pan- Normal vascular anatomy creatitis are often displayed to better The arterial supply to the pancreas advantage. This is secondary to the originates from the celiac and supe- relative increase in pancreatic flow rior mesenteric arteries. The arterial and also because neovascularity char- supply varies20 and selective angiog-

Downloaded from www.ccjm.org on September 30, 2021. For personal use only. All other uses require permission. 160 Cleveland Clinic Quarterly Vol. 44, No. 3 ' raphy is usually necessary for evalua- small pancreatic arteries also arise tion of the intrapancreatic arteries. from the splenic artery throughout With the aid of superselective gas- its course. Rich anastomotic branches troduodenal and splenic angiograms, extend to the anterior or posterior the entire pancreatic circulation can pancreatoduodenal arcade. be demonstrated. The celiac artery The gastroduodenal artery is the divides into three major branches first major branch of the hepatic ar- (Fig. 1) in approximately 60% of pa- tery and extends inferiorly behind tients: left gastric, splenic, and com- the first portion of the duodenum mon hepatic arteries.1 Occasionally (Fig. 2). Its first branch is the poste- the dorsal pancreatic artery arises rior superior pancreatoduodenal ar- from the celiac artery. The dorsal tery. This artery courses next to the pancreatic artery arises from the common duct and over the dorsal proximal aspect of the splenic artery aspect of the head of the pancreas. in about 40% of patients. This feeds It forms a portion of the posterior the dorsal surface of the pancreas arcade. The second branch of the and uncinate process. The transverse gastroduodenal artery is the anterior pancreatic artery arises from the dor- superior pancreatoduodenal artery. sal artery and supplies blood to the This artery passes along the anterior tail of the pancreas. The pancreatic aspect of the pancreatic head supply- magna artery extends from the distal ing the head and forming the ante- third of the splenic artery and sup- rior pancreatic arcade. plies the tail of the pancreas. Many The common hepatic artery arises from the celiac trunk in approximately 50% of patients. The right hepatic artery has its origin from the superior mesenteric artery in 8% to 14% of persons.1 The inferior pancreatoduodenal artery arises from the superior mesenteric artery proximally and aids in forming the inferior portion of the anterior and posterior arcades. Nor- mal pancreatic parenchyma has a patchy, lobulated pattern. The intrapancreatic veins have the same distri- bution as the arteries and drain into Fig. 1. Normal celiac trunk. The hepatic the portal, superior mesenteric, and (short small arrow), splenic (large arrow head) splenic veins. and left gastric (small arrow head) arteries are demonstrated originating from the celiac The anatomy of the venous system trunk. The gastroduodenal artery (small ar- varies, but knowledge of the venous row) is a branch of the common hepatic artery. system and drainage patterns is im- The right gastroepiploic artery (large arrow) portant for thorough angiographic supplies the greater curvature of the stomach. investigation. Veins of the gastroin- Increased subdiaphragmatic vascularity is secondary to an incidental echinococcal cyst in testinal tract drain into the portal the dome of the right lobe of the liver with system. The superior mesenteric vein calcifications. and splenic vein join to form the

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Fig. 2. Gastroduodenal artery. Celiac angiogram. The gastroduodenal artery (g) originates from the hepatic artery (h). The posterior superior pancreatoduodenal artery (arrow) arises 2 cm from the origin of the gastroduodenal artery. It anastomoses with the transverse pancreatic artery (t) which in turn arises from the dorsal pancreatic artery (d) originating from the celiac trunk (C). The anterior superior pancreatoduodenal artery (arrow heads) is one of the terminal branches of the gastroduodenal artery which anastomoses with the inferior pancreatoduodenal arteries and the superior mesenteric artery. The other terminal branch of the gastroduodenal artery is the right gastroepiploic artery (r). Overlying gas is present in the stomach.

portal vein. The portal vein then Angiographic evaluation of pan- enters the liver hilum and usually creatic disease divides into right and left branches which empty toward the periphery Goldstein et al21 in 1974 defined of the liver (Fig. 5). The portal veins the angiographic criteria needed for are therefore oriented toward the evaluating the pancreatic disease and liver hilum. The portal venous sys- providing an accurate diagnosis. The tem can have potential collateral criteria are as follows: (1) arterial en- anastomoses to the systemic venous casement as evidenced by irregular system.1 The veins of Retzius form a or smooth narrowing of a vessel (Fig. retroperitoneal plexus between the 4); (2) arterial occlusion; (3) tortuosity colic, splenic, duodenal, and pan- or sharp angulations of intrapancreatic veins and the inferior vena creatic arteries without narrowing; cava via the phrenic and azygous (4) beaded arteries suggesting local- veins. Collateral pathways also are ized dilatations along the course of present between the gastric and an artery; (5) displacement indicating splenic veins, left renal veins, and enlargement of the pancreas or a inferior phrenic veins. portion thereof (Fig. 5); (6) increased

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Fig. 3. Portal venous system. Venous phase, celiac angiogram. The splenic (small arrow) and portal veins (large arrow) are well demonstrated including the distal hepatic portal branches.

vascularity, decreased vascularity, neovascularity, or abnormal pancreatic stain; (7) compression, displacement, or occlusion of splenic, portal or superior mesenteric veins; (8) distention of the gallbladder; and (9) signs of hepatic metastases. These criteria are defined in the several specific disease entities. Pancreatic carcinoma According to some investigators, angiographic abnormalities can be identified in all symptomatic patients with pancreatic carcinoma.21 Pan- creatic adenocarcinoma is usually a scirrhous infiltrating tumor and is poorly vascularized. The main angio- Fig. 4. Selective hepatic arteriogram. Smooth graphic finding is encasement of the encasement of the distal right hepatic artery arteries about the pancreas (Fig. 6). and proximal intrahepatic branches (arrows) Reuter and Redman1 described two in a patient with invasive mucinous adenocarcinoma of the pancreas involving the liver and types of arterial encasement depend- porta hepatis. ing on the size of the vessel. In a

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genographic examination. Superse- lective angiography is also a great benefit. Another major sign of carcinoma is venous invasion (Fig. 7A and B). Carcinomas in the head of the pancreas will often distort or block the superior mesenteric vein or the splenic vein in the region of the tail of the pancreas. Also for better visualization of the superior mesenteric and splenic veins, a large injection of contrast medium is made into the splenic or superior mesenteric arteries. Less reliable signs of carcinoma are arterial displacement, parenchymal blush, and early venous drainage. Neovascularity can occur and some authors believe that small vessel changes are the most common abnormal findings in pancreatic carci- Fig. 5. Selective gastroduodenal arteriogram. noma.11 These small vessel changes Symmetrical displacement of several branches r \usuall y are of deformed abnormal (small arrows) of the gastroduodenal artery (large arrow) secondary to pancreatic carci- tortuous vessels which vary in caliber. noma in the head of the pancreas. The intense Often they are only seen in the pe- blush is within the duodenum and normal riphery of a tumor and may require variation. superselective techniques and mag- large vessel, for example, the splenic nification for visualization. The inci- or hepatic artery, the encased vessel dence of venous involvement ranges 22 23 will have a saw-tooth margin with a from 40% to 98%. - serrated appearance. Small vessels such as an intrapancreatic branch of- Differential diagnosis of pancreatic ten have abrupt angulations in the carcinoma course and caliber, termed serpigi- Differentiation between pancreati- nous encasement. Smooth encase- tis and carcinoma can be made in up ment of an artery, however, is a non- to 85% of cases.21 Arterial encase- specific sign and can be seen in ath- ment alone or venous abnormality erosclerotic disease. If smooth en- alone are often suggestive of pan- casement is present, other signs of creatitis, whereas encasement plus neoplasm must also be present on venous abnormalities more often im- angiograms for valid diagnosis. Reu- ply carcinoma. Neovascularity is a ter and Redman also state that tumor prominent feature of carcinoma. Ar- vessels can be seen in approximately terial tortuosity and angulations with- 60% of carcinomas of the pancreas. out narrowing are more characteris- They believe that the ability to dem- tic of pancreatitis. Arterial displace- onstrate these vessels is directly pro- ment with vascular or parenchymal portional to the quality of the roent- enhancement and early venous

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Fig. 6. Celiac arteriogram depicting encasement of the proximal splenic and common hepatic arteries (arrows). The encasement is of the serrated type. drainage are all signs of pancreatitis. The pancreatogram phase of carci- Hypervascularity and alternating dil- noma usually is decreased in compar- atations and stenoses in pancreatic ison with the increased phase in pan- arteries are also characteristic of pancreatitis. creatitis. Pancreatitis is usually more Peripancreatic malignant lympho- diffuse than carcinoma. mas can mimic the clinical features In an elderly population, athero- of primary pancreatic disease.24 Usu- sclerotic changes can be a problem. ally, these lymphomas appear as a Atherosclerotic disease usually con- large hypovascular mass with dis- sists of smooth, short stenoses of ma- placement of pancreatic and peripan- jor arteries with complete or partial creatic arteries and compression of occlusion. The stenoses usually are adjacent veins. Smooth arterial en- within the proximal 1 cm of the ma- casement can occur. Signs of mass jor take-off of the artery. The veins out of proportion to signs of invasion are always normal in atherosclerosis. mitigate against the diagnosis of car- If smooth encasement is present, tu- cinoma. mor vessels or venous invasion must Pancreatography25 or retrograde also be present before a diagnosis of pancreatic cholangiography26 are pancreatic carcinoma can be made.1 complementary procedures which Arterial and venous changes in dif- can aid in outlining the internal ar- ferent regions of the pancreas indi- chitecture of the pancreatic gland cate pancreatitis; localized stenoses and ductal system. Percutaneous an- and occlusions indicate carcinoma. tecubital transvenous cholangiogra-

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Endocrine tumors Adenomas of the islands of Lan- gerhans fall into several groups. The insulinoma is composed of beta cells and causes hyperinsulinism; the Zol- linger-Ellison adenoma is a nonbeta- cell tumor causing overproduction of gastrin.1 Another nonbeta-cell tumor can produce severe diarrhea and hy- pokalemia and an alpha-cell tumor can produce hypergluconism and di- abetes. Some islet cell adenomas are nonfunctioning.28 The overall suc- cess rate in finding these adenomas is approximately 60%;" surgical suc- cess in removing these tumors blindly is 50%.29 Most of these tumors have a homogeneous blush and a prolonged capillary stain. Insulinomas are usually found in the body and tail of the pancreas but may be multiple. Usually they are smaller than nonbeta islet cell tumors. Some irregular vessels may occasionally be seen within the tumor. Often, a benign and malignant adenoma cannot be differentiated by angiography. In small lesions, the main angiographic finding is a well-circum- scribed area of increased contrast in the capillary and venous phases. The number of tumor vessels is propor- tional to the size of the tumor. Be- cause of the subtleness in angiographic findings, superselective tech- Fig. 7. A, Celiac arteriogram. Smooth encase- niques may be necessary for assist- ment of the proximal splenic artery is depicted (arrow). Hepatomegaly is also present with ance in diagnosis. A false-positive straightening of intrahepatic arteries. B, On study can occur if a localized area of the venous phase, the splenic vein is not visu- increased vascularity near the junc- alized and completely occluded with visualization of the body and tail of the pan- tion of the portal vein (p) filling retrograde creas in normal patients is not recog- from splenic and mesenteric varices (arrows). Pathologic diagnosis: carcinoma, body and tail nized. This finding is most likely sec- of the pancreas. ondary to prominence of a pancreatic magna or dorsal pancreatic artery.1 phy27 and retrograde pancreatic ven- Malignancy should be suspected ography9 may also aid in diagnosis in when tumors are more than 5 cm in the future. diameter (Fig. 8A). Metastases are

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Fig. 8. A. Venous phase, celiac arteriogram. Intense, large venous blush is present (arrows) overlying the upper pole, right kidney. Diagnosis at laparotomy and pathologic diagnosis: islet cell carcinoma. B, Nonfunctioning benign islet cell tumor. Celiac arteriogram. Dense capillary staining is noted on the arterial phase of this very large pancreatic tumor. (Published with permission of Baghery S et al, Radiology 120: 57-59, 1976.

usually demonstrated in the liver and clinical findings.28 Mainly, nonfunc- are hypervascular. tioning islet cell tumors are large be- Nonfunctioning tumors usually do cause of the lack of clinical findings not have endocrine or other specific in the early stages of tumor growth.

Downloaded from www.ccjm.org on September 30, 2021. For personal use only. All other uses require permission. Winter 1977 Pancreatic angiography 167 Clinical diagnoses are usually made Pancreatitis after a palpable mass is noted or an adjacent organ is obstructed. All Pancreatitis is an important differ- cases of nonfunctioning islet cell tu- ential diagnosis in pancreatic carci- mors show severe hypervascularity noma. The angiographic abnormali- with dense capillary stains (Fig. 8B). ties are related to the chronicity of A pathologic condition of the vessels the disease,34 and the variable find- can occur with early venous fil- ings often depend on the stages of ling.28' 30 Vascular displacement is the disease. Acute or mild pancreati- common. tis does not have significant abnor- Insulinomas cause hyperinsulinism malities by angiography. Patients with bouts of hypoglycemic shock. with hemorrhagic pancreatitis and They are the most frequent type of pancreatic necrosis can have normal islet cell tumors (75%).31 Only 5% of angiograms. With acute pancreatitis, the tumors do not secrete hormones. there may be minor alterations in the Beta-cell tumors show signs of hyper- size and shape of the pancreas with insulinism with hypoglycemia, mi- mild widening or stretching of the graine, and psychosis, and can mimic pancreatic arcades. Associated hy- conditions found in alcoholism, brain pervascularity may be present. As the tumors, and hyperthyroidism. Gas- disease progresses, nonspecific, mild trin-producing tumors give rise to arterial irregularities of the intrapan- hyperacidity with recurrent ulcera- creatic branches can be seen. Hyper- tions. vascularity is again prominent and occasionally arterial venous shunting Cystadenoma occurs. With chronic pancreatitis, the Cystadenomas usually are lobu- arteries assume a beaded appear- lated pancreatic tumors, well-encap- ance. Smooth narrowing of the sulated with many cystic spaces; they splenic artery often occurs. The grow slowly. On angiography, they course of the arteries remains un- are usually highly vascular and large. changed. Abrupt angulations and Multiple fine tumor vessels are seen distortions of the arteries also may throughout the lesion on the arterial be present. In the capillary phases, phase with a prolonged capillary the pancreatic parenchyma is non- stain.32, 33 Multiple avascular cystic homogeneous. The splenic and mes- areas are present within the zones of enteric veins can be involved with hypervascularity. Arterial venous either irregular lumens or occlusion. shunting and tortuous veins can oc- Aneurysms of the intrapancreatic cur with displacement of adjacent vessels may occur. vessels because of the large size of Pancreatic pseudocysts are second- the tumor. With the malignant ary to chronic pancreatitis or pre- forms, irregular and truncated ves- vious trauma. The main angio- sels are seen. Differentiation between graphic finding is arterial stretching benign and malignant cystadenomas or displacement with sharp pan- cannot always be made by angiogra- creatic parenchymal margins (Fig. 9). phy. Malignancy can be suspected if Very large cysts occlude the splenic the lesions are large or if peripan- vein and even erode into arteries creatic invasion and hepatic metas- causing hemorrhage into the cyst. tases occur.1 Smaller pseudocysts resemble intra-

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Pancreatic vascular disease Congenital abnormalities of the pancreas are rare. Grannis et al37 reported a case of arteriovenous fistula of the pancreas and duodenum secondary to an arteriovenous malformation. In this rare lesion, angiography provided accurate deline- ation of the lesion allowing proper surgical treatment with pancreatoduodenal resection. Usually, arteriovenous malformations are managed by total or partial excision of the Fig. 9. Selective splenic arteriogram shows organs involved in order to control smooth displacement of the dorsal pancreatic the vascular malformation and asso- artery and its branches (arrows) in a patient ciated intestinal bleeding. with a history of chronic alcoholism and 38 chronic pancreatitis. Diagnosis at laparotomy Harris et al have described sev- and pathologic diagnosis: pseudocyst, tail of eral cases of aneurysms of the small the pancreas. pancreatic arteries causing upper abdominal pain and intestinal bleeding. pancreatic aneurysms. Usually, pan- A high mortality rate is associated creatic pseudocysts are easily diag- with rupture of these aneurysms nosed by angiography, although oc- which can occur in patients with pan- casionally a large cystadenoma mim- creatitis or pancreatic pseudocysts. ics a pseudocyst. Often the preoperative diagnosis can be made by selective arteriography. Trauma Another major factor in the for- Trauma is very rare with a fre- mation of aneurysms is athero- quency of 0.5% to 5.4%.35 Pancreatic sclerotic disease. These aneurysms injury is frequently associated with occur in long-standing celiac artery multiple, severe organ injuries and stenosis or stenosis of the superior laparotomy is usually performed mesenteric artery. Possibly, chronic- without angiography. Complications increased blood flow in the pancrea- that may occur from trauma are com- toduodenal arcade weakens the arte- plete transection, traumatic pseudo- rial walls and accounts for the acute cyst, hematoma, and pancreatitis. or chronic blood loss secondary to Angiographic findings may include vessel dilatation and tortuosity with arterial occlusion secondary to vascu- aneurysm formation. Rarely, aneu- lar laceration, displacement of adja- rysms are found associated with pan- cent arteries by hematoma and creatic carcinoma, retroperitoneal tu- edema, and portal vein obstruction. mor, penetrating duodenal ulcer, But even in complete pancreatic tran- surgery and trauma.

Downloaded from www.ccjm.org on September 30, 2021. For personal use only. All other uses require permission. Winter 1977 Pancreatic angiography 169 Discussion cinoma, angiography is highly accu- Although the technique of angio- rate depending upon the experience graphic diagnosis of pancreatic carci- of the angiographer and the radio- noma has been perfected, the prog- logic technique used. Resectability, nosis in carcinoma is still poor. Five- and the surgical and therapeutic ap- year survival is approximately 1% to proach to treatment can be deter- 2%. Frequently when a tumor is di- mined. Since endocrine tumors are agnosed by angiography, the lesion usually vascular, angiography is an is unresectable, that is, the tumor ideal method for localizing these le- has broken out of the confines of the sions, which can be detected in over pancreatic organ. Angiography can 50% of patients. aid in the management of pancreatic carcinoma and once the diagnosis is References established, it can alleviate the fur- 1. Reuter SR, Redman HC: Gastrointestinal ther need for clinical or surgical in- Angiography. Philadelphia, WB Saunders Co, 1972. vestigations. Also benign diseases can 2. Bierman HR, Miller ER, Byron RL Jr, et be differentiated. The normal vascu- al: Intra-arterial catheterization of viscera lar anatomic variants to the pancreas in man. Am J Roentgenol 66: 555-568, and liver can be detected prior to 1951. surgery and can be an invaluable aid 3. Seldinger SI: Catheter replacement of the to the surgeon. A prediction of re- needle in percutaneous arteriography; a 21 new technique. Acta Radiol 39: 368-376, sectability can be made. If one or 1953. two intrapancreatic arteries are in- 4. Beachley MC, Ranniger K: Abdominal vaded, a direct correlation with re- aortography from the axillary approach. sectability and survival in tumors of Am J Roentgenol 119: 508-511, 1973. the head of the pancreas can be made 5. Boijsen E: Selective visceral angiography 39, 40 using a percutaneous axillary technique. according to Suzuki et al. In Su- Br J Radiol 39: 414-421, 1966. zuki's series, 11 of 53 cases were con- 6. Bedacht R, Zimmermann H: Angiogra- sidered resectable. In Goldstein's se- phie zur präeoperativen Pankreasdiagnos- ries, nonresectability was predicted tik. Bruns Beitr Klin Chir 215: 257-274, in 25 of 29 lesions.21 1967. 7. Lunderquist A: Angiography in carcinoma Although initially it was hoped that of the pancreas. Acta Radiol (Suppl 235), angiography would diagnose pan- 1965. creatic carcinoma in an early stage, 8. Boijsen E, Samuelsson L: Angiographic this has not proved to be the case. diagnosis of tumors arising from the pancreatic islets. Acta Radiol (Diag) (Stockh) Accuracy of a prospective diagnosis 10: 161-176, 1970. of carcinoma by angiography in- 9. Rösch J, Grollman JH Jr: Superselective creases with superselective tech- arteriography in the diagnosis of abdomi- nique. The presence of two or more nal pathology; technical considerations. signs of malignancy improves diag- Radiology 92: 1008-1013, 1969. 11 10. Eisenberg H: Angiography of the pan- nostic accuracy. creas, in Small Vessel Angiography. Hilal In conclusion, pancreatic angiog- S, ed. St. Louis, CV Mosby Co, 1973. raphy has not affected the prognosis 11. Ranniger K, Beachley MC: Pancreatic an- of pancreatic carcinoma, although it giography, Curr Probl Radiol. Chicago, Year Book Medical Publishers Inc, July- has aided in earlier diagnosis in dif- August 1974. ferentiation among benign entities. 12. Kaplan JH, Bookstein JJ: Abdominal vis- In patients suspected of having car- ceral pharmacoangiography with angi-

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