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AORTOGRAPHYBy 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 investigationwhich consists of rendering opaque the blood flowthrough the aorta and its larger branches to permita radiological study of the vascular pattern in theorgans of the abdomen. The renal artery, unlikevessels to the abdominal viscera, divides regularlywith mincr variations and arborizes into a finedelicate but typical pattern in the renalparenchyma.

Rcynaldo Des Santos and his colleagues Lamasand Caldas (I929) workirg at the Santa MariaHospital, Lisbon, first introduced translumbaraortic puncture for the purpose of aortography,and in their publication of 300 cases were con-vinced of its importance in renal investigation.It encourtered much criticism because of theserious reaction which occurred from the injectionof Ioo per cent. solution of sodium iodide.Henline and Moore (I936) using the same con-trast medium for aortography in experimentaldogs, reported a high mortality which furtherprejudiced the use of this procedure in humanbeings.

Nelson and Doss (1942) and other Americaninvestigators working independently, re-intro-duced aortography as a safe and valuable procedureand published series involving many thousands ofcases without there being a fatality.The slow acceptance of aortography in this

country as an adjunct to other more familiardiagnostic procedures was due to the misappre-hension that the technique was difficult anddangerous, and that the indications for its usewere not precise.The increasing demand in recent years for

arteriography in the field of renal as well as vascularsurgery has inspired ingenious devices for therapid automatic change of film cassettes and theinjection of contrast medium with great speed bya mechanically-driven syringe. A simple techniquesuch as described below gives adequate informa-tion and has fewer complications.RoutesThe contrast medium-30 ml. of 70 per cent.

diodone-is introduced into the vascular systemby trans lumbar aortic puncture or by retrogradefemoral artery catheterization. The latter route

was first described by Pierce (195 ) and consists ofpercutaneous puncture of the femoral artery andintroduction of polythene tube via the cannula intothe external and common iliac arteries and up tothe aorta to the level of the renal vessels. Thelumbar route is easier to master, quicker to per-form and more suitable for routine use in anotherwise busy radiological department.TechniqueEquipmentThe equipment for trans lumbar injection is

now provided a3 a set-Middlesex HospitalPattern, produced by Warner Bros. It ha3 threeneedles of different length and calibre, the largestbeing 15 cm. i6 S.W.G. for adults, 12 cm. i8S.W.G. for small adults and 9 cm. 20 S.W.G. foruse in children. It also contains a 30 ml. syringewith a metal case to envelop it for protectionagainst bursting during manual injection, and alength of reinforced pressure tubing with adaptorto connect the needle to the syringe.Contrast MediumSodium iodide is the most radiologically dense

of all intravascular contrast mediums but toxicityis its great disadvantage. Since 1950 it has beenreplaced by an organic iodide solution-70 percent. diodone-which has the merit of causingfewer and less severe reactions with small sacrificeof contrast and definition. An iodide sensitivitytest must always be carried out if an I.V.P. hasnot already been obtained.

AnaesthesiaThe procedure can be performed under general

or local anaesthesia but, unless one has had muchexperience with the technique, the advantages ofhaving a conscious patient to co-operate in holdingthe breath during the performance are far out-weighed by having the patient relaxed undergeneral anaesthesia. Under the latter circum-stances there is less tension at both ends of theneedle.The patient lies in a prone position on a wooden

tunnel through which cassettes can be passed.A metal marker is applied at the level of the bodyof the twelfth dorsal vertebra-the level at which

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Nov.tnber 1959 GRIFFITHS: Aortography 621

the aortic puncture is proposed. A trial film willverify this, as well as confirm the accuracy ofsiting and exposure. A syringe of saline is con-nected up to the needle by the pressure tubingand the system filled with saline. The skin ispunctured below the last rib on the left, four-finger breadths away from the spinous processes-two-finger breadths in children-and the needle isadvanced to the side of the body of the last dorsalvertebra. Having found this landmark, theneedle is then directed more vertically, slippingpast the vertebral body to penetrate the aorta witha sensation of puncturing the theca. Pulsatingpuffs of blood gently pushing the syringe plungerback will indicate a successful puncture.A trial film whilst injecting 5 ml. of diodone is

always advisable to confirm the position of theneedle.The 30 ml. syringe is now charged with 70 per

cent. diodone and connected to the system. Theinjection is then made and completed in four tofive seconds, sending a column of diodone up-wards into the thoracic aorta. During this timethe respirations are stopped by the anaesthetistand four loaded cassettes are passed through thetunnel beneath the patient and exposed at two-second intervals. Co-ordination is essential anda preliminary practice by the team is worthwhile.

Interpretation of the Normal ArteriogramUsing this simple technique a series of four

films is obtained. The first taken half waythrough the injection shows a column of diodonein the thoracic aorta; the second represents thearterial phase when the column of contrastmaterial descends to the abdominal aorta and fillsits main branches. In this phase the coeliac axisand its divisions are usually well filled and mayobscure some branches of the renal arteries. It ispossible to obtain stereoscopic pictures by asecond injection of diodone when the origin andcourse of the vessels can then be traced easily.Experience has taught that such a refinement israrely indicated. The third film may demon-strate a transient venous phase when the renalveins may be seen coincident with the small arterialbranches. The fourth film of the series is thenephrogram phase when the kidneys are sil-houetted by increased density.

IndicationsCongenital abnormalities

Absent kidney. An aortogram carried out afteran I.V.P. has indicated an apparently non-functioning kidney occasionally discloses a com-plete absence of kidney. In such a case the renalartery is completely absent and a nephrogram doesnot appear.

FIG. i.-Translucent area in middle third of nephro-gram of R. kidney produced by a solitary cyst.It is well defined, avascular and show3 no pooling.

Ectopic kidney. On the other hand a nephro-gram may prove the kidney, absent from its normalposition, to be an ectopic or a crossed ectopic one,and in the arterial phase the aberrant vascularsupply to the kidney may be clearly seen. Thisinformation is of considerable value if for anyreason surgical exploration is proposed.

Hypoplastic or atrophic kidney. In the arterio-gram the renal artery is of slender calibre and thenephrogram shows a faint shadow of a very smallkidney.

Horse-shoe kidney. The disposition of theaberrant vascular supply can be demonstratedprior to sectioning the isthmus should this be con-templated. Engel and Poutasse (I955) record anautopsy finding of a single renal artery supplyingan entire horse shoe kidney.

Polycystic kidney. This condition is moreusually demonstrated and proved by intravenousor retrograde pyelography but there are occasionswhen neither of these investigations can be of anyassistance. Aortography may then demonstrate atypical picture of long narrow kidneys with a poorblood supply. The long slender vessels aredeviated around the cysts and the nephrogram,which is not as dense as in the normal, is blotchygiving a cotton wool effect.Swellings of the Kidney

It is in the differential diagnosis between cystsand solid tumours of the kidney that aortographyfinds its greatest application for by this means acyst accurately diagnosed can prevent an un-necessary surgical undertaking, and a parenchymaltumour can be unequivocably demonstrated.

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622 POSTGRADUATE MEDICAL JOURNAL November 1959

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FIG. 2.-Arterial phase in an angiogram of an adeno-carcinoma of L. kidney with specimen on R. offilm.

In a solitary cyst the vessels are displaced by awell defined rather translucent avascular soft tissueshadow, and in the nephrogram it is usually welldemonstrated by contrast with the dense paren-chyma around it (Fig. i). Further confirmationof presence of a cyst may be obtained by per-cutaneous needling and aspiration of the contentsfor cytological examination.A parenchymal tumour, on the other hand, is

demonstrated characteristically by a stippling ormottling by contrast material pooling in thevascular spaces of the tumour (Figs. 2 and 2a).

Aortography serves no useful purpose in theinvestigation of tumours of the renal pelvis for theyshow no typical picture. Their diagnosis restsentirely on clinical and pyelographic findings.Nevertheless it is important for the surgeon tomake a pre-operative distinction between aparenchymal adenoma and a tumour of the renalpelvis, for in the latter case the whole ureter as wellas the kidney must be removed.

Assessment of Renal FunctionHydronephrosis. Aortography is particularly

helpful in cases of hydronephrosis in determiningthe cause and in deciding the type of operation forits correction. In some cases it will reveal thepresence of an aberrant artery to the lower pole ofthe kidney apparently obstructing the pelvi-ureteric junction. It is most debatable to placethe whole guilt of obstruction on this accessoryartery for, in reviewing a long series of aorto-graphies, it is surprising how frequently trouble-free aberrant vessels are seen. However, a pre-operative study of the calibre of the vessel and anestimate:of the amount of the lower pole suppliedby it is helpful if its ligature and section isproposed.

SpIenic At9RKIDNEY.

ooi~ng..< Contrast

Normaiart of tidney

FIG. 2a.-Line drawing of the aortogram showing areaof pooling in upper pole of L. kidney.

The degree of renal function is the most im-portant pre-operative information in the conditionof pelvi-ureteric obstruction for upon this rests thedecision to retain or remove the kidney.

Cortical atrophy is associated with a reductionin vascular supply and is indicated in the aorto-gram by diminished calibre of the main artery andits branches. Many of these vessels are furtherattenuated by deviation over a voluminous renalpelvis. The nephrogram is reduced in densityand if seen with a coincident pyelogram the thick-ness of functioning cortex is well delineated.

Hypertension. An important place for renalarteriography is in the investigation of unexplainedhypertension and particularly if it is of recentonset. Early recognition of hypertension due torenal artery or pyelonephritic changes is essential ifimprovement by nephrectomy is to be expected,for delay in such treatment may allow irreversiblechanges to take place in the normal kidney. Anarteriogram in such patients may demonstrate:

(i) An aneurysm of the renal artery.(ii) An obstruction due to arterial thrombosis.(iii) A small contracted pyelonephritic kidney

showing only a faint nephrogram and apoor blood supply.

Aneurysms are rare but thromboses of the renalartery are more commonly found. Obstructionmay occur in a branch of the renal artery when it ispossible to recognize in the arteriogram anavascular infarcted area in the renal cortex.

Chronic pyelonephritis causing hypertensionmay be a unilateral condition with improvementfollowing nephrectomy, or bilateral when the out-look is hopeless and beyond surgical influence.This important detail can be determined byaortography.Haematuria of unexplained origin. A renal cause

of haematuria can in some cases escape detectionby pyelography when aortography may demon-

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November 1959 GRIFFITHS: Aortography 623

APICAL

,,,ArR0ArwRrERYLOWERLOE

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 whichhas not become large enough to disclose itself bydeviation of a calyx.

Inconclusive pyelograms. Aortography can alsohelp to confirm the presence or reassure one of theabsence of a tumour of the renal cortex whenpyelographic investigation has raised a suspicion.

Retroperitoneal tumours. Particularly in con-junction with retroperitoneal oxygen insufflationis aortography useful to distinguish renal tumoursfrom other retroperitoneal swellings. It does oc-casionally show the vessels to a suprarenal tumourquite clearly, but this is more by good fortune thangood technique and is not a reliable form of in-vestigation in this condition.

Partial Nephrectomy. A study of the arterialphase of an aortogram carried out in the course ofinvestigating a renal condition is of particularvalue if partial nephrectomy is contemplated.Graves (1954) has shown that the renal arterydivides into branches which have been named andthough the pattern of division is irregular, theirnumber and distribution are constant (Fig. 3).

Contra IndicationsTransient renal damage from rapid injection

of iodine contrast material undoubtedly occurs and

recovery is quick and complete unless some im-pairment of renal function is already present.For this reason it is inadvisable to perform aorto-graphy if the level of non-protein nitrogen of theblood is raised unless the circumstances areexceptional. Neither is it advisable to performany major surgery without an interval of somedays following aortography in order to allowcomplete recovery of renal function.

Iodine sensitivity naturally precludes aorto-graphy.

ComplicationsThe complications associated with the per-

formance of aortography in this country are fewand rarely serious. No fatality has occurred in along series carried out by the writer in collabora-tion with Dr. C. G. Whiteside at the MiddlesexHospital since I950. In only one case hasanuria occurred and may have been due to hyper-sensitivity from summation of effect following asecond injection of 30 ml. diodone. The patientmade a satisfactory recovery.

Intramural InjectionIntramural injection can be the most serious of

accidents occurring in the performance of aorto-

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624 POSTGRADUATE MEDICAL JOURNAL November I959

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FIG. 4.-Intramural injection showing a dense thoracic aorta. The nephrograms indicate that some ofthe contrast material entered the aortic lumen.

graphy: 20 to 30 ml. of contrast medium may beforcibly introduced into the media of the vesselcausing a dissection of the wall. This process inwhich the intima is raised may involve the orificeof a major branch or may extend into the branch tocause occlusion, ischaemia and thrombosis withnecrosis of the organ it supplies. To avoid suchan accident Whiteside (I959) emphasizes the im-portance of directing the needle obliquely upwardsinto the aorta at the level of Dorsal XII. Shouldintramural injection occur dissection is morelikely to extend upwards and will involve only theintercostal branches.

This accident occurred in one case of theMiddlesex Hospital series when the terminal fewml. of contrast medium was introduced into themedia in spite of a preliminary test to determine thesite of the needle. There were no sequelae(Fig. 4)Extravasation of Blood

Extravasation of blood following the withdrawalof the needle or by transfixion of the aorta doesoccur, particularly in hypersensitive cases, but ithas never been a serious matter.

Periaortic Injection of DiodoneThis is a common incident particularly in obese

patients but the contrast medium is quicklyabsorbed and usually causes only a short periodof lumbar backache.

ConclusionIn conclusion aortography is a safe procedure

when using a simple technique but requires thepractised co-operation and co-ordination of a teamfor the best results to be attained. It should beused selectively and where the more familiarmethods of urological investigation have provedinadequate and inconclusive.

AcknowledgmentsI am indebted to Sir Eric Riches for the free

use of his cases and for the X-rays reproduced inthis article, to Dr. C. G. Whiteside for his helpand advice, and to Miss Hewland and Mr. Turneyof the art and photographic departments of theMiddlesex Hospital.Bibliography continued on page 639.

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November 1959 LLOYD-THOMAS: Diuretics 639

thiazide is in the range of o00-2oo mg. Whenprolonged therapy is required, supplementation ofpotassium intake will be required and the sup-plements are best given on non-diuretic days(Poznanski and Cromie, I959).

Hydroflumethiazide (' Hydrenox ')-chemically3 : 4 - dihydro - 7 - sulphamyl - 6 - trifluoro-methyl - : 2 4 - benzothiadiazine - i : I -

dioxide, has been introduced more recently andis undergoing investigation (Hobolth et al., 1958;Sele, 1958; Kobinger and Lund, 1959). It hasapproximately the same potency as hydrochloro-thiazide and the dosage range is similar.

Despite its frequency and in spite of much ex-perimental study, the mechanisms responsible forhyponatraemia in chronic cardiac failure are stillfar from clear. There is no question, however,that some patients with intractable cardiac oedemabenefit from steroid therapy (Gutner et al., 1957;Heidorn et al., 1955; Reimer, 1956; Dresdaleet al., 1958). Mickerson and Swale (I959) haverecently described a series of 13 patients whoshowed the following features in common: all hadobstinate cardiac failure and had become resistantto treatment with digitalis, low-sodium diet anddiuretics; they complained of excessive tirednessand increased pigmentation both of the skin andbuccal mucosa was present; all showed hypo-

natraemia with a normal or elevated serum potas-sium and a raised blood urea with one exception.All exhibited a great increase in urinary outputdue to a predominant water diuresis with disap-pearance of oedema following the addition of pred-nisolone, in a dose of 5 mg. t.d.s. for 24-48 hoursfollowed by a maintenance dosage of 2.5 mg. twiceor thrice daily, to existing therapy with digitalisand diuretics and the substitution of the low-sodium intake by a normal diet.

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H. S. (x957), Amer... med. Sd., 234, 28x.HEIDERN, G. H., and SCHEMM, F. R. (I955), Ibid., 229, 62.HOBOLTH, N., and THOMSEN, K., from HANSEN P.

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DOS SANTOS, R., LAMAS, A. C., and CALDAS, J. (1929),Med. contemp., 47, 93.DOSS, A. K., THOMAS, H. C., and BOND, T. B. (1942), Tex. St.

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ABEL, J. J., ROWNTREE, L. G., and TURNER, B. B. (1913),Trans. Ass. Amer. Phys., 28, Si.ALWALL, N. (x947), Acta med. scand., 28, 317.BULL, G. M., JOEKES, A. M., and LOWE, K. G. (r949),Lancet, ii, 229.DANZIG, L. E. (i955), New Engl. 7. Med., 252 49.DOOLAN P. D., WALSH, W. P., KYLE, L. H., andWISHiINSKY, H. (I95g), 7. . med. Ass., 146, xoS.GJO RUP, S., and THAYSEN, J. H. (I958), Lancet, ii, 886.KOLFF, W. J., and BERK, H. Th. J. ('944), Acta med. scand.,117, 121.KOLFF, W. J., and WATSCHINGER, B. (1956), . Lab. cdn.

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