Pancreatic angiography Angiography has become an important pro- cedure 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 accu- rate 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 pan- creatic 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 congen- ital 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 pan- creatic 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 car- cinoma 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