Selective abdominal angiography · Ekman, and Olin, 1963; Acker, Galambos, and Weens, 1964; and...

Gut, 1965, 6, 477

Selective abdominal angiographyM. J. LAURIJSSENS1 AND JOHN T. GALAMBOS

From the Department of Medicine, Section of Gastroenterology,Emory University School of Medicine, and the Medical Service,

Grady Memorial Hospital, Atlanta, Georgia, U.S.A.

EDITORIAL SYNOPSIS This paper illustrates the value of carefully siting the tip of the intra-aorticcatheter adjacent to the artery supplying the organ about which more information is required. Cancersin the liver were consistently identified correctly, and useful information has been obtained con-tributing to the diagnosis of pancreatic tumours, chronic pancreatitis, cirrhosis of the liver, cancerof the colon, and visceral vascular disease.

Angiography of the abdominal viscera can givediagnostic information in selected patients and thevalue of percutaneous splenoportography has beenwell established (Steiner, Sherlock, and Turner,1957). The diagnostic usefulness of hepatic veno-graphy is currently being evaluated at this institution.This procedure has been shown to define diagnosticabnormalities in the presence of cirrhosis or tumourin the human liver (Schlant, Galambos, Shuford,Rawls, Winter, and Edwards, 1963). The hepaticartery has been visualized both by direct needlepuncture during laparotomy and also by retrogradecatheterization (Farinas, 1946). Odman (1958, 1959)has shown that selective catheterization of the coeliacartery allowed the visualization not only of thehepatic arterial system but also that of the spleen,stomach, and of the pancreas.

Selective abdominal angiography recently becamethe subject of studies in several institutions (Boijsen,Ekman, and Olin, 1963; Acker, Galambos, andWeens, 1964; and Glenn, Evans, Halpern, andThorbjarnarson, 1964). A preliminary report fromthis institution was based on 19 patients and itdescribed six types of cases in which selectivecoeliac arteriography was of diagnostic value(Acker et al., 1964). Selective abdominal angio-graphy in the study of vascular diseases of theabdominal viscera was recently reviewed (Galambos,1965). The present report describes the diagnosticvalue and the dangers of selective abdominalangiography in 44 studies, and 25 patients notpreviously described are reported.

TECHNIQUE

The patients were premedicated with hydroxyzihepamoate (Vistaril), 50 mg. intramuscularly, and meperi-'Present address: Vijfstrassen, 162 Sint Niklaas, Waas, Belgium.

dine (Demerol), 75 mg. intravenously, just before theprocedure. Local anaesthesia was used after routineskin preparation over the femoral artery. A flexiblespring wire was inserted through a Cournand needleinto the femoral artery, and it was passed under televisionimage amplification control into the abdominal aorta.The Cournand needle was removed and a flexibleOdman-Ledin radiopaque polyethylene catheter with apre-moulded tip was passed over the flexible spring guidewire. Great care was taken not to stretch the distalcurvature on the catheter as it was placed on the guidewire and as it was passed through the skin into thearterial lumen. The catheter was advanced to the appro-priate level in the aorta depending upon the artery whichwas to be catheterized. For the coeliac artery, for example,the catheter was advanced to the twelfth thoracic vertebra.The guide wire was gradually withdrawn, the tip of thecatheter was rotated anteriorly and turned slightly to theleft side and moved down until the tip entered the coeliacartery. On the anterior-posterior view, the orifice of thecoeliac artery was usually between the twelfth thoracicand first lumbar vertebrae, the extremes ranging betweenthe bodies of the twelfth thoracic and first lumbarvertebrae. Usually the catheter could not be passedmore than 5 cm. into the arterial lumen. The movementof the radiopaque catheter during respiration was greaterin the superior mesenteric artery than in the coeliac artery.During the manoeuvering of the catheter and betweentest injections, the catheter was frequently flushed withheparinized saline to prevent clotting. In order toascertain the location of the catheter, test injections of2 ml. diatrozate sodium and methylglucomide (Renovist)were made repeatedly. Because of these injections a renalpyelogram was usually obtained before angiography.

After the test injections had confirmed the properlocation of the catheter, the patient was placed in asupine position on a rapid film changer. Forty ml. ofcontrast material was injected in three seconds. Transientperiumbilical pain was experienced by the patients duringthe few seconds of rapid injection, but no other sideeffects were attributable to the rapid injection. (Multipleside perforations in addition to the usual opening at the

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M. J. Laurijssens and John T. Galambos

TABLESUMMARY OF 25 CASES IN PRESENT SERIES

Sex Clinical History Diagnosis Angiographic Findings Complications Other Findings

M Chronic alcoholic;weakness; anorexia;jaundice; large, hard,tender liver

G Asymptomatic;abdominal mass

M Weakness; anorexia;weight loss

M Loss of appetite;abdominal pain forthree weeks;hepatomegaly

M Abdominal pain;diarrhoea; diabetes andmalabsorption

M Weakness; anorexia;hepatomegaly

M Vomiting; abdominalpain; hepatomegaly

M Chronic alcoholism;portal hypertensionwith bleeding oeso-phageal varices;hepatic coma

F Vague epigastric dis-comfort; weight loss;hepatomegaly

M Increasing weakness;weight loss; anorexia;generalized abdominalpain

F Chronic alcoholic;abdominal pain; sub-total gastrectomy;pancreatic pseudocyst;cholecystectomy

M Chronic alcoholic;epigastric pain

Hepatoma Abnormal vascularpattern of liver;tumour staining

Bile duct Unsuccessful'hamartoma (cyst)Metastatic cancer to Unsuccessfulliver

Bronchogeniccarcinoma with livermetastasis

Chronic pancreatitis;malnutrition

Colonic carcinomawith metastasis toliverColonic carcinomawith metastasis toliverCirrhosis

Adenocarcinoma ofcolon with livermetastasis

Gastric carcinoma

Chronic relapsingpancreatitis

Subacute hepaticnecrosis with post-necrotic cirrhosis

Tumour staining inliver; distortion ofbranches of hepaticarteriesHepatic arteryoriginates from thesuperior mesentericattery; normalvisualization ofpancreas

Unsuccessful

None H.Ph.S5 cold nodulein centre of liver

Haematoma H.Ph.S. cold mass inliver

None Liver biopsy;metastatic adeno-carcinoma

None Biopsy: metastaticcarcinoma; H.Ph.S.normal

None

None

Distortion and irregu- Nonelarities of finer branchesof hepatic arteryDistortion of third Noneorder branches ofhepatic artery;opacification of portalveinDisplacement of coeliac Noneaxis and distortion offiner branches ofhepatic arteryNormal coeliac Noneangiogram

Abnormal arterial Arteriopattern femors

Mechanical failure of Nonex-ray equipment

Pancreatic calcifica-tion

Biopsy; metastaticadenocarcinoma

Liver biopsy;adenocarcinoma

Liver biopsy; cirrhosis

Liver biopsy; meta-static adenocarcinoma;H.Ph.S.; cold nodules

Biopsy: normal livergastric cytology:papillary adeno-carcinoma; laparo-tomy

iospasm of Pancreatic insuffici-al artery ency by secretin

test

Liver biopsy; sub-acute hepatic necrosiswith early cirrhosis

'H.Ph.S. = Hepatic photoscan following Au"98 colloidal gold. 2Unsuccessful = Could not catheterize the coeliac artery.

tip of the catheter were essential to prevent the catheterfrom sliding out of the artery into the aorta during therapid, forceful injection of the contrast material.) Thefrequency and duration of the exposures varied dependingon the purpose of the study. When visualization of onlythe arterial system was required, 13 seconds totalexposure time was adequate. On the other hand, exposuresof up to 37 seconds have been used for the visualizationof the portal circulation. In general, the exposures weretwo per second for three seconds, one per second forthree additional seconds, and one every other secondthereafter. The catheter was retained in its position untilthe films were developed and repeated injection either inthe same artery or in another vessel was made whenindicated.

PATIENTS

Nineteen patients were reported earlier (Acker et al.,1964). Twenty-five additional patients are briefly des-cribed in Table I. Five of these patients had metastaticcancer to the liver, two had primary hepatoma withcirrhosis, four had cirrhosis of the liver, four had chronicpancreatitis with pancreatic insufficiency (one of thesealso had cirrhosis of the liver), one had pancreaticcarcinoma and one had a retroperitoneal mass in theregion of the pancreas, two had gastrointestinal bleeding,the source of which in one of these patients was undeter-mined, one had colonic cancer, one had a small gastriccancer, one had ulcerative colitis, one had a bile ducthaematoma, and one had Cruveilhier-Baumgarten

Patient and AgeNumber

1 H.J., 77C11137

2

3

C.J., 67C50493J.K., 64C163206

4 R.M., 76C64841

5 R.A., 32C125689

6 J.S., 64C111934

7 G.B., 63C159941

8 W.G., 58W77723

9 M.E., 75C106201

10 J.M., 63C133904

11 A.G., 37C5556

12 J.B., 46W23223

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Selective abdominal angiography

Sex Clinical History

TABLE continuedSUMMARY OF 25 CASES IN PRESENT SERIES

Diagnosis Angiographic Findings Complications

72

34

M Epigastric pain;weight loss; refluxoesophagitis

M Haematemesis; melaena

43 M Chronic alcoholism;jaundice; epigastricpain

42 F Chronic alcoholism;ascites; loss of weight;steatorrhoea

54 F Epigastric pain;jaundice

54 F Portal hypertension;splenectomy; spleno-renal shunt; ascites;hepatic coma;'cirrhotic' nephropathyand morphologicallynormal liver. Large,patent umbilical vein

59 M Right flank pain;weight loss; massivehepatomegaly withsystolic bruit

69 F Pneumonia; hepato-megaly; anaemia; peri-umbilical mass

50 M Ten mth. history ofdiarrhoea; chroniculcerative colitis

70 M Cirrhosis with portalhypertension; hepaticcoma precipitatedby bleeding varices

76

64

Malabsorption due to Tortuosity of splenicchronic pancreatitis artery; abnormal

vascularization ofpancreas

Gastrointestinal Normal coeliacbleeding of undeter- arteriogrammined cause

Upper gastro- Normal coeliacintestinal bleeding; arteriogramgastric ulcerCirrhosis; chronic Normal coeliacpancreatitis; mal- arteriogramabsorptionCarcinoma of Occlusion of hepaticpancreas artery and portal veinPortal hypertension Distortion andof unknown aetiology tortuosity of branches

of hepatic artery, normaportal vein; normalhepatic vein

Hepatoma

Carcinoma of colon(hepatic flexure)

Active ulcerativecolitis

Cirrhosis

None

None

None

Normal liver biopsy;normal oesophago-scopy; abnormal fatabsorptionNecropsy notpermitted; uraemia

Liver biopsy; mild,non-specific changes

Haematoma Liver biopsy; septalcirrhosis

None

None

Displacement of hepatic Nonevessels by tumour

Superior mesentericangiogram; tumourstainingDistortion of smallvascular patternof colonAbnormally tortuoussmall hepatic arteries;increased capillaryopacity at cholecystec-tomy site

F Postprandial abdominal Suspected abdominal Dissecting aneurysm ?pain, malabsorption, anginaweight loss

M Periumbilical attacks of Suspected mesenteric Normal superior N.postprandial pain artery obstruction mesenteric angiogram

M Weight loss; abdominal Disseminated lympho- Displacement ofpain; hepatomegaly; glandular tuberculosis pancreatico-duodenalepigastric mass artery

disease. In two patients primary vascular disease wassuspected before the study. One of these had thrombosisof a branch of the inferior mesenteric artery and one

patient was suspected of having abdominal angina due tomesenteric artery occlusion.

RESULTS

To date we have performed 44 selective coeliac,superior or inferior mesenteric arteriographies.Nineteen of these coeliac angiograms were reportedpreviously (Acker et al., 1964). Twenty-five additionalcases are described in this report. In four patientswe have been unable to catheterize the artery ofchoice. In one case the examination was unsatis-

N

None

Thrombosis offemoral artery

Haematoma

[one

[one

Laparotomy andbiopsyBiopsy (3 occasions):normal liver; necropsynormal small liver,portal vein-umbilicalvein anastomosis

H.Ph.S.: coldnodules in right lobeof liver, biopsy:hepatomaBiopsy; normal liver,H.Ph.S.: normal

Ulcerative colitis(granulomatous) bybiopsyBiopsy; cirrhosis

Large atheroma atorifice of superiormesenteric arteryLaparotomy retro-peritoneal mass ofof caseating lymphnodes

factory because of mechanical failure of the equip-ment. This compares with about 20o% failures notedby Odman (1958) who performed 61 examinations on58 patients and was unable to enter the coeliac arteryin 12 of these examinations.Normal coeliac angiograms are illustrated in

Figures 1, 2, and 3. During the arterial phase (Fig. 1),the splenic, the left gastric, and the common hepaticarteries were well outlined as they usually originatedfrom the coeliac axis. The gastroduodenal and theright gastric arteries usually originated from thecommon hepatic artery. The left gastroepiploicartery usually came from the splenic artery, and itanastomosed with the right gastroepiploic arterywhich was a branch of the gastroduodenal artery.

Patient and AgeNumber

Other Findings

13 B.B.,W22902

14 G.W.,C138371

1 5 J.G.,W55200

16 J.F.,Cl 2632

1 7 E.H.,C 10080

18 V.P.,W231239

19 J.T.,C30717

20 P.F.,C55505

21 J.B.,W60317

22 A.M.,W63070

23 E.M.,W16459

24 W.H.,W327 16

25 C.D.,C61266

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FIG. 1b.FIG. 1. Normal coeliac angiogram; L. Hep = left hepatic artery; R. Hep = right hepatic artery; Hep. = hepaticartery; C.A. = coeliac axis; L.G. = left gastric artery; Cyst = cystic artery; P-D = pancreatico-duodenal; R.G.-E= right gastroepiploic; L.G.-E = left gastroepiploic; Sp. = splenic.

The cystic artery or arteries came from the righthepatic or the superior pancreatico-duodenal artery,a branch of the gastroduodenal artery.

Variations of the origin of the major branchesof these arteries were commonly seen. Often thehepatic artery originated from the superior mesentery

rather than from the coeliac axis. Anastomosesbetween the branches of the coeliac axis and thesuperior mesenteric artery were often prominent.During the capillary phase (Fig. 2), the opacifica-

tion of the mucosa of the stomach, gall bladder,duodenum, or intestine was readily apparent in

FIG. 2. FIG. 3.

FIG. 2. Capillary phase of Figure 1. The rugal folds of the gastric mucosa are outlined in the area of the gastric airbubble. The fundus is densely opacified. The gall bladder is well defined and its uniformly thin normal wall is readilyseen. The draining veins begin to opacify at this stage.

FIG. 3. The venous phase oJ Figure 1. The mucosal opacification has faded at this stage though the gastric fundus isstill dense. The draining veins are filled now with contrast material. The splenic vein (4 ) crosses behind the stomachand it is partially obscured by it. The portal vein (4 ) is well outlined as it emerges in front ofand to the right of the firstlumbar vertebra. Its intrahepatic branches can be seen though they are obscured by the diffuse opacification ofthe liver.The gastroepiploic veins (-*) are well outlined.

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FIG. 5. Coeliac angiogram, demonstrating the displace-ment of the coeliac axis (I ) to the left and also displace-ment of the branches of the right hepatic artery. Hepaticarteries are attentuated. Tumour staining, that is, opacifica-tion of scattered areas, is seen (-+). This apparently isbecause of the accumulation of contrast material in thenumerous distorted small vessels which perfuse the tumournodules.

FIG. 4. Late venous phase in a normal superior mesentericangiogram. The catheter is in the aorta with its curveddistal 5 cm. in the superior mesenteric artery. The superiormesenteric and the portal veins are sharply outlined. Theright lobe of the liver is densely opacified and the smooth,sharp and delicately wavy edge can be seen clearly. Belowthe liver the right kidney is faintly opacified.

some but not all cases. The appearance of theviscera at this stage resembled a very fine bariumcoating of its mucosa.During the venous phase, the draining veins were

opacified. At this stage the portal vein was welldefined together with the splenic (Fig. 3) or thesuperior mesenteric vein (Fig. 4) during selectivecoeliac or superior mesenteric angiography, respect-ively. The portal vein usually was better opacifiedafter selective superior mesenteric than coeliacangiography. The inferior mesenteric veins were wellvisualized after inferior selective mesenteric angio-graphy.

ILLUSTRATIVE EXAMPLES

CASE 9 M.E., a 75-year-old coloured woman, wasadmitted to hospital because of weight loss, malaise, andincreasing anorexia. She had nausea but no vomiting.About one year before admission her bowel habitschanged and she developed severe constipation progress-ively. The liver was enlarged. A rounded, ill-defined masswas palpated in the right lobe of the liver. There was asystolic bruit over this area. The spleen was not palpable.

No other abdominal masses were felt. A moderateamount of ascites was present. Barium enema demon-strated a suspicious lesion in the caecum. Coeliacangiography demonstrated the features of metastatictumour in the liver (Fig. 5). A hepatic photoscan showeda large 'cold' nodule in the right lobe of the liver, andneedle aspiration biopsy of the liver confirmed thepresence of metastatic adenocarcinoma.

The characteristic features of vascular abnormalitiescaused by metastatic carcinoma in the liver werethe distortion and displacement of small hepaticvessels, and 'tumour staining' due to opacification ofthe large number of tortuous small vessels in thetumour nodules.

CASE 2 A.G., a 37-year-old coloured woman, was aheavy consumer of various spirits. She had previouslybeen admitted to hospital on several occasions becauseof chronic relapsing pancreatitis; for cholecystectomyand sphincterotomy; because of a pseudocyst of thepancreas which was drained into the stomach; andbecause of a bleeding gastric ulcer which was treated bysubtotal gastrectomy. She was admitted on this occasionbecause of chronic pancreatitis and pancreatic insuffici-ency.

Physical examination revealed a malnourished womanwith no additional significant physical abnormalitiesother than several healed operative incisions on herabdomen. Selective coeliac angiography was performedto study the vascular pattern of the pancreas in a patientwith well-documented episodes of pancreatitis andprevious gastric and biliary surgery (Figs. 6a and b).

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FIG. 6a

FIG. 7.FIG. 7. Coeliac angiogram. The coeliac axis is pushed tothe left and the course of the gastroduodenal artery ()is distorted, the hepatic artery is tortuous and is occluded( f ). There are several large anastomotic arteries fromthe splenic and left gastric to the hepatic artery and tosome of its branches beyond the point ofocclusion. (Subse-quent exposures also demonstrated the occlusion of theportal vein without prominent collateral veins.)

F1I. ft.

FIGS. 6a and b. Superior mesenteric angiogram. Thecatheter is in the aorta with its tip in the superior mesentericartery. The contrast material opacifies the branches of thisartery without reflux into the aorta. The first major branchofthe superior mesenteric artery is the hepatic artery whichcommunicates via a large anastomotic vessel with thecoeliac axis. This anastomotic vessel comes off the hepaticartery andfollows the course of the gastroduodenal artery.Behind the hepatic artery this vesseljoins a tortuous arterywhich follows the course of the pancreatico-duodenalartery and runs caudad along the right side of the vertebralcolumn and divides into an abnormal arterial network. Thenormal pancreatic vessels are not seen. The coeliac axisand its two branches, the splenic artery and the ligatedleft gastric artery, are well visualized.

This case illustrates an abnormal arterial groupingin the region of the head of the pancreas and non-visualization of the normal pancreatic vessels in apatient with recurrent pancreatitis. It also demon-strates the simultaneous opacification of the superiormesenteric and coeliac arterial branches through thelarge anastomotic gastroduodenal artery.

CASE 17 H.E., a 54-year-old coloured woman, wasadmitted to hospital because of vomiting, epigastric pain,weight loss, malaise, and jaundice. She had an enlarged,firm liver, but neither the gall bladder nor the spleen wereenlarged. Serum bilirubin was 21 mg. % per 100 ml., andthe alkaline phosphatase 40 Bodansky units, thymolturbidity 8-2 units. The serum albumin was 3 5 g. andtotal globulin 2-8 g. per 100 ml. Selective coeliac angio-graphy was performed to identify the suspected carcinomain the head of the pancreas (Fig. 7).At exploratory laparotomy, a tumour mass was found

in the head of the pancreas, and a transduodenal needlebiopsy confirmed the diagnosis of adenocarcinoma.Vascular invasion was confirmed. A palliative cholecysto-jejunostomy was performed.

Displacement of the gastroduodenal artery isindicative of an enlargement of or a mass in theregion of the head of the pancreas. Arterial andvenous invasion of a pancreatic carcinoma can bedemonstrated by this method. There was no evidencefor any ischaemic liver injury despite the occlusionof both the hepatic artery and portal vein. Arterialblood perfused the liver, however. This was indicatedby the delayed opacification of the branches of theright and left hepatic arteries. The absence ofprominent venous collaterals suggests that the portalvein only recently was occluded.

CASE 25 D.C., a 64-year-old coloured man, was admittedbecause of epigastric pain, weight loss, and night sweats

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Selective abdominal angiographv

FIG. 9. Superior mesenteric angiogram. The catheter is inI _....the aorta and its distal 5 cm. is in the superior mesentericartery. The first branch of this artery is the hepatic artery.The branches to the small intestine are coming off on theleft crossing the radio-opaque catheter. The second major

FIG. 8. Coeliac angiogram. The catheter is in the aorta branch on the right is the right coeliac artery which supplieswith its tip in the coeliac axis which divides into the splenic the hepatic flexure of the colon and gives offa large branchand hepatic arteries. The first major branch of the hepatic which anastomosed with the ileocolic artery (÷- -*). Theartery is the gastroduodenal artery which runs cauded to carcinoma of the colon overlies the lower pole of the rightthe right of the eleventh and twelfth thoracic vertebrae and kidney. During the arterial phase the marked distortion ofdivides into several branches just above the first lumbar the arcuate branches is prominent near the cancer (7).vertebra (LI). One of these branches, the anterior pancrea-tico-diuodenal artery (\) is displaced to the right by a mass -in the i-egion of the head of the pancreas.

for four months. The anorexia and weight loss weremarked. He complained of constant mid-abdominalpain. In the left supraclavicular fossa, a 3 x 3 cm. firmlymph node (Virchow's node) was found, and he also hada firm, fixed, painless epigastric mass. The haematocritwas 33%0, serum albumin 2 g., and globulin 5 3 g. per100 ml. The serum bilirubin was normal; bromsul-phalein retention was 40% in 45 minutes, and alkalinephosphatase was 9-6 Bodansky units. The VDRL waspositive. Gastrointestinal radiographs showed a mass _9which stretched the duodenum and displaced the stomach ,,i -anteriorly. The coeliac angiogram indicated a mass in theregion of the pancreas (Fig. 8). Biopsy of a supra- u..clavicular node and of the liver revealed caseatinggranuloma with acid fast bacilli.

At laparotomy the 'pancreatic' mass proved to be amatted group of caseating retroperitoneal lymph nodes.

Displacement of the anterior pancreaticoduodenalartery is usually associated with pancreatic tumours,but also can be due to retroperitoneal lymphadeno- FIG. 10. Closer view of Figure 9 during the late capillarypathy. phase demonstrating the intense tumour staining of the

colonic cancer. (Dotted line describes the lower pole of theCASE 20 P.F., a 69-year-old coloured woman, was right kidney.) The draining veins begin to opacify ( <).admitted to hospital because of acute pneumonia. During Tumour staining in the area of regional lymph nodes is notroutin- physical examination the liver was palpated 3 cm. observed. The renal pelvis and ureter are well outlined.

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below the costal margin and a periumbilical mass wasthought to be present. Her haematocrit was 36% andstool guaiacs were 4+. A barium enema showed aconstricting lesion in the transverse colon close to thehepatic flexure. A mesenteric angiogram showed thevascular pattern of a colonic cancer (Figs. 9 and 10).Liver biopsy was not remarkable.

Selective catheterization of the superior mesentericartery allowed the visualization of the distortedvascular pattern of cancer of the colon. At operationan adenocarcinoma of the colon was found in thisregion of the hepatic flexure. No metastasis wasdetectable. A curative resection of the tumour wasperformed.

CASE 23 E.M., a 76-year-old white woman, was studiedbecause abdominal angina was suspected. Arteriographywas attempted and the catheter was introduced into theabdominal aorta from both femoral arteries. Contrastmaterial appeared each time in the aortic wall, demon-strating a dissecting aneurysm. Whether this lesion existedbefore the examination or was caused by the examinationcould not be determined with certainty.

DISCUSSION

The clinical use of selective abdominal angiographyfor the diagnosis of visceral diseases is still in itsinfancy, but selective catheterization of the majorintra-abdominal branches of the aorta can beperformed with safety and dispatch. The availabilityof new and non-irritating iodinated compoundspermits the injection of large amounts of contrastmaterial in the catheterized arteries with sufficientspeed to visualize their branches and opacify thecapillaries of the viscera which they supply as well astheir venous drainage systems. Other than transientpain, no untoward reaction was observed after therepeated injections of sodium and methylglucamine(Renovist) totalling 100 ml. during a single examin-ation.The splenic artery is usually tortuous in patients

with portal hypertension. However, we have foundmarked tortuosity of the splenic artery in patientswith chronic pancreatitis in whom the spleen wasnot enlarged and liver function tests and liver biopsyshowed no evidence of liver disease.

In the cirrhotic human liver post-mortem injectionof contrast material in the portal or in the hepaticveins demonstrated abnormalities of hepatic venouspattern without significant abnormalities in theportal venous pattern (Galambos and Schlant, 1962),confirming previously reported observations thatvascular abnormalities in the cirrhotic liver areconfined primarily to the tributaries of the hepatic

vein (Schlant et al., 1963). In this study the intra-hepatic branches of the hepatic arterial system didnot show a uniform pattern in the patients who hadcirrhosis without hepatoma. Tortuosity and attenua-tion of the intrahepatic branches of the hepaticartery have been seen in some of these patients. Thenumber of examinations of cirrhotic patients is notsufficient to give a reliable percentage figure.Tortuosity and attenuation of the intrahepaticbranches of the hepatic artery were marked in oneother patient with Cruveilhier-Baumgarten diseasewho had no morphological abnormality of the liveron three liver biopsies and at necropsy but hadportal hypertension.The visualization of the portal venous system in

patients with portal hypertension may be of greatclinical value. Many of the patients who would becandidates for percutaneous splenoportographycannot be examined either because of an increasedbleeding tendency as a result of their liver disease,or because of previous splenectomy. In such patientsit is possible to obtain delayed films after theinjection of contrast material in the superior mesen-teric artery or the coeliac axis in order to visualizethe portal venous system. Selective splenic arterio-graphy was recently shown to opacify adequatelythe portal vein (Pollard and Nebesar, 1964). Thevisualization of the portal vein through the splenicand superior mesenteric veins following the coeliacand superior mesenteric arteriography respectivelyis illustrated in Figures 3 and 4. In the latter case(Fig. 4), previous splenectomy and splenorenalanastomosis would have precluded percutaneoussplenoportography.

Intrahepatic cancer has an arterial blood supply(Breedis and Young, 1949). Primary or metastaticcarcinomas of the liver were consistently associatedwith distortion and tortuosity of the small hepaticarteries and showed increased vascularity in areaspresumably containing tumour nodules. During thelate capillary phase, the contrast material remainedvisible in small nodular areas giving rise to thedescriptive term of 'tumour staining', which wasnot seen in the absence of intrahepatic cancer.Displacement of larger hepatic arterial brancheswas also associated with intrahepatic cancer.

Angiographic demonstration of an islet celltumour and of a cystadenoma of the pancreas hasbeen reported (Olsson, 1963; Swanson, 1963).Usually the gastroduodenal artery supplies thesuperior pancreatico-duodenal branch which dividesinto the inferior and posterior pancreatico-duodenalarteries. The corresponding inferior pancreatico-duodenal artery usually originates from the superiormesenteric artery; thus, a rich anastomosis existsbetween the coeliac axis and the superior mesenteric

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artery in the pancreatic bed. A vascular arcade isformed between these arterial branches, and numer-ous interlobular arteries arise from it to form theintra-pancreatic plexus (Michels, 1955). Tumour ofthe pancreas is characterized by displacement ofone or several of the arteries and/or veins whichrun close to the pancreas, and invasion of arteriesor veins by tumour of the pancreas was observed incase 17 (Fig. 7). Displacement of the gastroduodenalor pancreatico-duodenal artery may be due topancreatic tumour; however, a mass of caseatingretroperitoneal lymph nodes did likewise; therefore,such displacement, however characteristic, is notpathognomonic of pancreatic cancer.The distorted vascular pattern of a colonic cancer

was documented in case 20 during superior mesen-teric angiography (Figs. 9 and 10). Such adistortion of the vascular pattern has been describedby Margulis and Heinbecker (1961). There wasincrease in the number of tortuous small vessels inthe area of the tumour, branching usually at rightangles instead of at the usual acute angles. Therewas also destruction of the normal vascular arcadesin the tumour. Tumour staining was also observedin this colonic carcinoma. This term described thepersistent opacification of the area of the tumourafter the capillary phase faded in the normal,uninvolved colon.

In a few cases mesenteric arteriography has beenperformed in patients with ulcerative colitis, eitherjust before colectomy or after the removal of thecolon. Brown, Rankin, Meaney, and Tumbull(1964) found no specific vascular abnormalities inulcerative colitis during selective mesenteric angio-graphy. Margulis and Heinbecker (1961), on theother hand, observed tortuosity of the smallervessels during pre-operative mesenteric angiographyor on direct injection of the artery of surgicalspecimens. We have observed such distortion of thenormal arcades supplying the rectosigmoid andsigmoid colon in a patient with chronic ulcerativecolitis (case 2) on a selective inferior mesentericangiogram.

Mesenteric arterial occlusion either by embolusor thrombosis can be demonstrated with selectiveangiography. However, the selective superior mesen-teric angiogram appeared normal in a patient inwhom a lateral aortogram demonstrated narrowing ofthe orifice of the superior mesenteric artery (Galam-bos, 1965). At surgery a large atheromatous plaqueoccluded partially the first 2 cm. of the lumen ofthe superior mesenteric artery. Selective arterio-graphy cannot outline the most proximal portion ofthe artery in which the catheter is inserted but narrow-ing of the arterial orifice can best be documented byplacing the catheter in the aorta just proximal to

the arterial orifice during the rapid injection ofcontrast material and making lateral exposures.

It has been claimed that selective intra-abdominalangiography is capable of localizing gastrointestinalbleeding sites (Margulis, Heinbecker, and Bernard,1960), which have been observed by Baum, NusbaumClearfield, and Tumer (1964) in patients with theMallory-Weiss syndrome, bleeding gastric ulcer,and incomplete rupture of the spleen. In our studythe bleeding site has not been identified withselective coeliac angiography in the two patients whowere examined because of gastrointestinal bleeding.One of the patients had a gastric ulcer, but nodemonstrable gastrointestinal pathology was foundon radiological and endoscopic examinations of theother. In some patients intense mucosal opacificationwas seen in the gastric fundus, antrum, smallintestine, and/or gall bladder. The physiologicalmechanism responsible for these findings in some butnot in most of our patients is currently underinvestigation.

DANGEROUS SIDE EFFECTS OF THE PROCEDURE

The equipment must be examined carefully beforeit is used for selective angiography. Guides andcatheters must be repeatedly autoclaved. We foundit preferable to discard these after a few examin-ations in order to avoid their breaking in the aortaand the necessity for subsequent surgical explorationto remove fragments of guide or catheter. Suchaccidents did not occur during the examination ofthe 44 patients who are reported in this paper, buthave been observed by others.

In selected patients selective intra-abdominalangiography may give valuable information. Theperformance of this procedure, however, must notbe taken lightly as femoral artery thrombosis occur-red twice in these 44 patients. Though it might be acoincidence, both of these patients had ulcerativecolitis. One of these patients had intermittentclaudication and decreased femoral arterial pulsationbefore the angiography, and despite two operativeinterventions, gangrene of the foot ensued. In thesecond case thrombectomy was successful in re-establishing normal femoral blood flow. Bleedingfrom the arterial puncture site can occur after theprocedure and haematomata formed in three patients.The pain that was produced by the rapid injection ofcontrast material in the catheterized artery wastransient and persisted no more than a few seconds.There was no untoward reaction attributable to theinjection of large amounts of contrast material.

SUMMMARY

Selective abdominal angiography has been performed

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486 M. J. Laurijssens and John T. Galambos

in 44 patients, in several of them giving more thanone arterial injection. Thrombosis of the femoralartery occurred in two patients and haematomadeveloped in three. The artery could not be enteredin four and the examination was unsatisfactorybecause of mechanical failure of the equipment inone case.

This procedure was well tolerated by clinically illpatients. Cancers in the liver were consistentlyidentified correctly. The procedure has demonstratedmass formation in the pancreas, distorted arterialpattern associated with chronic pancreatitis, withcancer of the colon and with cirrhosis of the liver,and primary vascular lesions of the abdominalviscera. During the venous phase the mesenteric orsplenic and portal veins were satisfactorily visualized.Patients with decreased or absent femoral pulsationshould not be candidates for this procedure.

Since the completion of this manuscript, Nebesar,Pollard, Edmunds, and McKhann (1964) reportedtheir experience with selective abdominal angio-graphy which was similar to that reported in thiscommunication.

We wish to express our thanks for the art work to Dr.McClaren Johnson, Jr., and to Dr. H. Stephen Weensand Dr. Wade Shuford for their guidance.

This study was supported in part by United StatesPublic Health Service Training Grant 2A-5151 andAmerican Cancer Society Research Grant T308.

REFERENCES

Acker, J. J., Galambos, J. T., and Weens, H. S. (1964). Selective celiacangiography. Amer. J. Med., 36, 417-423.

Baum, S., Nusbaum, M., Clearfield, H., and Tumen, H. J. (1964).Clinical use of selective abdominal arteriography with emphasison its values in the diagnosis of intraabdominal bleeding(abstract). Gastroenterology, 46, 730-731.

Boijsen, E., Ekman, C. A., and Olin, T. (1963). Coeliac and superiormesenteric angiography in portal hypertension. Acta chir.scand., 126, 315-325.

Breedis, C., and Young, G. (1949). Blood supply of neoplasms in theliver. Fed. Proc., 8, 351.

Brown, C. H., Rankin, G. B., Meaney, T. F., and Turnbull, R. B. Jr.(1964). Normal mesenteric arteriograms in a case of senileulcerative colitis. J. Amer. Geriat. Soc., 12, 215-220.

Farinas, P. L. (1946). Retrograde abdominal aortography. Amer. J.Roentgenol., 55, 448-451.

Galambos, J. T. (1965). Vascular diseases of the abdominal viscera.In The Heart, edited by J. W. Hurst and R. Logue. McGraw-Hill, New York.

and Schlant, R. C. (1962). Unpublished observations.Glenn, F., Evans, J. A., Halpern, M., and Thorbjarnarson, B. (1964).

Selective celiac and superior mesenteric arteriography. Surg.Gynec. Obstet., 118, 93-100.

Margulis, A. R., and Heinbecker, P. (1961). Mesenteric arterio-graphy. Amer. J. Roentgenol., 86, 103-113.

, and Bernard, H. R. (1960). Operative mesenteric arterio-graphy in the search for the site of bleeding in unexplainedgastrointestinal hemorrhage. Surgery, 48, 534-539.

Michels, N. A. (1955). Blood Supply and Anatomy of the UpperAbdominal Organs, p. 581, J. B. Lippincott Co., Philadelphia.

Nebesar, R. A., Pollard, J. J., Edmunds, L. H. Jr., and McKhann.C. F. (1964). Indications for selective celiac and superiormesenteric angiography. Amer. J. Roentgenol., 92, 1100-1109.

Odman, P. (1958). Percutaneous selective angiography of the coeliacartery. Acta Radiol., suppi., 159.

-- (1959). Percutaneous selective angiography of the superiormesenteric arteriography. Acta Radiol., 51, 25-32.

Olsson, 0. (1963). Angiographic diagnosis of an islet cell tumour of thepancreas. Acta chir. scand., 126, 346-351.

Pollard, J. J., and Nebesar, R. A. (1964). Catheterization of thesplenic artery for portal venography. New Engl. J. Med., 271,234-237.

Schlant, R. C., Galambos, J. T., Shuford, W. H., Rawls, W. J.,Winter, T. S., III, and Edwards, F. K. (1963). The clinicalusefulness of wedge hepatic venography. Amer. J. Med., 35,343-349.

Steiner, R. E., Sherlock, S., and Turner, M. D. (1957). Percutaneoussplenic portal venography. J. Fac. Radiol. (Lond.), 8, 158-177.

Swanson, G. E. (1963). A case of cystadenoma of the pancreasstudied by selective angiography. Radiology, 81, 592-595.



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