Denny, M

English

AJOL - African Journals Online

1006R 60S.A. MEDICAL JOURNAL(Supplement - South African Journal of Radiology)5 October 1963THE RADIOLOGY OF THE ISCHAEMIC KIDNEY IN HYPERTENSIVE DISEASEM. DENNY, Lister Buildings. Johannesburgcatheterization. The catheter tip has entered the artery and its origin is4. Catheter withdrawn slightly and origin of artery nowFigs. 1 - 3. Diagrammatic demonstration of catheterizationof renal artery with 205 polythene catheter.that the 205 polythene catheter retained a preformed curveat blood temperature (Figs. I - 3).We therefore introduce this catheter into the aorta bySeldinger's technique; and opacify it by injecting a smallquantity of ·urografin'. The catheter position is then ascer-tained by use of a 9-inch amplifier, which indicateswhether the curved catheter tip lies freely in the aorta, orhas engaged one of the vessels arising from it. In the lattercase the catheter is manipulated until it lies within theaortic lumen, above the level of the second lumbar verte-bra. 'Scoline' is then administered to the patient and oncessation of voluntary respiration the main injection isgiven, when a half-second exposure is used with a I-mm.focus. Three films are exposed, with the use of the con-ventional Bucky tray. The first film serves to identify thearterial pattern and the latter two, the nephrographicphases. There is no need for high-speed serial radiography,and the use of the Bucky, producing one film showingarterial phases of high detail, is indeed preferable tonumerous high-speed films with possibly rather indifferentdetail.Subsequent pyelographic films are then exposed at 5 - 10minute intervals.When this method is used, in the rare * event of failure to* Rare, at any rate, in our experience.Fig. 4. Selectivenot shown.Fig. 5. Same case as in Fig.shown.The spate of articles in recent literature on the use ofangiography in the diagnosis of ischaemic renal diseasebears eloquent testimony to the value of this examination.I presented to my physician colleagues a review of thistechnique and its results at their Congress held in Durbanin July 1962,' and it is my hope that that review, and thepresent article, will serve to stimulate a more energeticapproach to the problem by an increased demand for thisrewarding procedure.The following refinements in technique have producedan extremely safe and accurate method of diagnosis:1. The abandonment ot the translumbar technique ex-cept in those cases with absent femoral pulses. It is sur-prising that Brukin' still mentions its use in renal studies,and it is to be hoped that this is merely a reflection ofAmerican literature and not a method in current use bythis author. It is encouraging to note that even in the USAthere is a tendency, now, to employ the femoral approachinstead of the lumbar technique, even though in someinstances it is by arteriotomy and not by the percutaneousapproach.'2. The use ot hypotensive anaesthesia. Halothane anaes-thesia was first used for this purpose in the Johannesburgunit about 3 years ago by Or. C. van Hasselt, and it wasfound that only in an insignificant number of cases was itnecessary to use an intravenous 'arfonad' drip to obtain thedesired effect. When, under halothane, the systolic pressurehas dropped to half the pre-anaesthetic level, the arterio-graphic injection is undertaken, and the halothane is dis-continued, allowing a rapid rise of blood pressure to nearthe pre-anaesthetic level. The objection that hypotensionmay predispose to coronary ischaemia proves not to bewell founded, probably because the episode of hypotensionis but transient.3. The use of the pressurepump. This is essential, andthe need has been adequatelymet by the relatively inex-pensive Somerville pump. Apressure of 45 - 50 lb. persquare inch is sufficient, ifthe 50-m!. syringe is used.Should this pressure be ex-ceeded, the 205 polythene-::atheter is liable to rupture,fortunately at its proximalend.4. The abandonment otthe use ot the opaque Od-man-Ledin catheter for selec-tive arteriography. Its usehas been discontinued sinceSeldingen' pointed out to me1007R 61S.A. TYDSKRIF VIR GENEESKUNDE(Byvoegsel- Suid-Afrikaanse Tydskrif vir Radiologie)fill one or other renal artery, the catheter is opacified and,with the aid of the image amplifier and closed-circuittelevision, the tip is then manipulated into the renal artery.I have found that it is advisable to withdraw the tipslightly, so as to allow the catheter to lie across the anglesubtended by the inferior margin of the renal artery andthe aorta (Figs. 1 - 6). This allows opacification not onlyof the renal artery, but of the adjacent aorta, thus pre-cluding the possibility of missing a stenosis of the originof the renal artery, which is often found in atherosclerosis.Pressure GradientsIf recording equipment is available, confirmatorygradients across the stenosis can sometimes be obtained. Ifthe stenosis is proximal, the catheter tip will pass acrossthe narrowing, and on withdrawal the desired tracing canbe obtained. Should the narrowing be more distal, further5 Oktober 1963Fig. 6. Correct position of catheter to show origin of renalartery.Fig. 7. Seldinger guide wire No. 160 inserted to renalhilum to serve as a guide to polythene catheter.insertion of the polythene catheter, depending on the con-figuration of the artery, may have th~ result that thecatheter buckles and disengages itself from the artery. Itthen lies free in the aortic lumen. On occasions insertionof the 160 Seldinger wire, until it reaches the hilum, willguide the catheter to the distal reaches of the vessel (Fig.7). The wire is then withdrawn to be followed by thecatheter now on pressure.Stewart et al: state that any gradient over 20 mm. re-quires operation, and under 10 not. However, they quotecontradictory results in operations based on these criteria,which tend to negate the value of the procedure.We have rarely used this method, because in most casesth~ radiological studies have proved conclusive.Intravenous PyelographyIn our own practice we do not advocate initial pyelo-graphy. This is a sharp break from tradition, but we feelthat there are cogent reasons for it. They are the fol-lowing:1. We have frequently found marked degrees of stenosisin the presence of normal pyelographic findings (Figs.8 and 9).Fig. 8. Stenosis of right renal artery at origin of vessel.Fig. 9. Same case as in Fig. 8, showing normal pyelogram.2. The safety of first-stage arteriography has been ade-quately proved. Since our unit has used the method de-scribed, no mortality or complications have ensued. It maybe pertinent to mention that 'flank pain after the examina-tion is usually caused by the scoline administered, and notby the instrumentation. It is unassociated with other symp-toms and is transient in nature.3. In private practice the cost to the patient is dras-tically reduced by the single combined examination.These considerations do not of course entirely negate thevalue of initial pyelography, for in cases such as the fol-lowing much suggestive information is gained by this pro-cedure:1. Hyperconcentration under conditions of water load-ing is suggestive of an ischaemic kidney. This, however,may also occur in pyelonephritis.2. Isolated or slight general dilatation of the calycealsystem.3. Foreshortening and slight compression of a calyx.This is associated with localized infarction and is presum-ably due to parenchymal oedema in the infarcted area.4. Delayed appearance of contrast medium in the affec-ted kidney. The margins of such a kidney are usuallysmooth, as opposed to the lobulation of the congenitallyatrophic contracted kidney. The pyelonephritic contractedkidney, on the other hand, has a scarred serrated margin.These differentiating features have been well describedby Munk et al.·6. Failure of the kidney to excrete contrast medium.This may be found in sudden thrombosis associated withthe Leriche syndrome or aneurysms of the renal artery.7. Crenation and indentation of the renal pelvis andcalyces due to collaterals.T.'The Incidence of Renal IschaemiaTable I indicates the percentage of cases of ischaemickidney found among patients referred for examinationby this procedure as reported by different radiologi ts.The most reliable figures are probably those from thelarge series of Dustan' in the USA (27%), and Sutton"in the UK (10%). Our own figures show an initial inci-1008R 62S.A. MEDICAL JOURNAL(Supplemenl- South African Journal of Radiology)5 October 1963MFMFFMMM6948303833524248GoodGoodGoodGoodGoodNochangeDiedControlledMedicalMedicalNephrectomyDecompressioncystsNephrectomyNephrectomyTABLE Ill. NATURE OF ISCHAEMIA-PRODUCING LESIONS, ETC., INTHE 8 CASES OF ISCHAEMIC KIDNEY IN TABLE 11Ischaemia-producing Treatment Result Age" SexlesionFibromuscularhypertrophyPolycystic kidneyis the low incidence of 3 cases of pyelonephritis out of50 as opposed to 5 out of 30 in the previous series. Abouttwice as many males were referred for the investigationas females (34: 16). The age range was considerable (from17 to 69 years), which is one reason which seems to sug-gest that the criteria for this investigation should not belimited to those generally accepted. The newly describedfibromuscular hyperplasia (Figs. 12 and 13), also, doesnot seem to have any clearly defined clinical pattern, apartfrom its preponderance in females, and the frequent pre-sence of a broit.It is of interest to note the sloping angle of the renalartery and the predominant involvement of the right sidein our cases (Tables II and III).Secondary hypertensive change, without stenosis, is oc-casionally seen and is associated with similar change inother splanchnic vessels. The aetiology of the primaryHydronephrosisAtherosclerosis R.renal arteryLeriche occlusion R. Medicalrenal arteryAtherosclerosis L.renal arteryArteritis & stenosisaberrant R. renalarteryAtherosclerosis main MedicalR. renal arteryhypertension in such cases is often obscure, but fortunatelythe incidence of this appearance is less than that of cor-rectable ischaemic disease. At this point attention may bedrawn to the occasional detection of significant stenosis ofI the renal artery with noI .assocIated hypertension.Figs. 10 and II illustratea case observed in ourown series.Table III illustrates thenature of the ischaemia-producing lesions in the 8cases of our last series.Kottler" (1962) presentedan incidence of 'renal ar-terial pathology' in 34%of hypertensive" cases.This rather high incidence,as in our first series, pro-bably indicates that a dis-proportionate number ofcases were drawn fromthe pool of refractoryhypertensives. Since theexamination is gainingNo. of cases 5~males 34 (68%), females 16 (32%)Age range 17 - 69 years.TABLE 1I. RENAL ISCHAEMIA. LESIONS FOUND IN 50 CASESEXAMINED BY ARTERIOGRAPHYTABLE I. RENAL ISCHAEMIA (COMPARATIVE SERIES)Author Year No. of cases % ischaemicDustan et al.' 1959 317 27Sutton et al." 1961 260 10Halpem et al." 1961 41 49Moser and Caldwell13 1962 50 66Denny" 1960 30 27Denny 1962 50 16dence of 8 cases out of 30 examined (27%) in 196()U and8 cases out of 50 (16%) in a more recent series. Thedifferent percentages in Table I cannot be used for statisti-cal comparisons. They do indicate, however, that the inci-dence is higher than originally thought and, since the re-sults of modern surgery are so satisfactory, it would seemthat more attention should be paid to accurate diagnosis inthis condition.Our last 50 casesTable II gives an indication of the various lesions foundin our last 50 cases. Of interest perhaps is the preponde-rance of aberrant renal artery on the right side, especiallyin male subjects. Possibly due to a more critical selectionNo. of casesDiagnosis Male Female TotalIschaemic kidney 5 3 8(16%)Pyelonephritis 1 2 3(6%)Aberrant renal arteriesRight side 10 3 13(26%)Left side 0 2 2(4%)Total 10 5 15(30%)Secondary hypertensive changein renal arteries 1 2 3(6%)No apparent disease 17 4 21(42%)Fig. 10. Atherosclerotic narrowing of origin of right renal artery in a normotensive subject.Fig. J I. Same case as in Fig. 10 showing contracted right kidney.5 Oktober 1963 S.A. TYDSKRIF VIR GENEESKUNDE(Byvoegse/ - Suid-Atrikaanse Tydskrit vir Radi%gie)1009R 63SUMMARYStenosis of the renal artery is a not uncommon cause of hyper-tension. The author gives reasons for his opinion that renalangiography by the method described in the article is a safeand valuable procedure, probably exceeding any other singlediagnostic examination in merit. It would appear that fewsurgeons, if indeed any, would be prepared to undertake cor-rective surgery without the benefit of this investigation.Acknowledgements are made to the many colleagues whohave referred cases for investigation.REFERENCESJ. Denny, M. (1962): Paper presented at the Congress of the Associationof Physicians of Soutb Africa, Durban.2. Brukin, M. (1962): S. Afr. Med. J., 36, 962.3. Stewart, B. H. el al. (1962): Arch. Surll., 85, 622.4. Seldinger, S. I. (1961): Personal communication.5. Idem (1953): Acta radiol. (Stoekh.), 39, 368.6. Munk, J. el al. (1962): Clin. Radiol. 13, 265.7. Thomas, R. G. el al. (1961): Brit. J. Radiol., 34, 438.8. Halpem, M. el al. (1962): Radiology, aa, 159.9. Dustan, S. T. el al. (1959): New Engl. J. Med., 261, 647.10. Sutlon, D. el al. (1961): Clin. Radiol., J:Z, SO.I J. Denny, M. (1961): Med. dans le Monde, 37, 76.12. KotUer, R. E. (1962): S. Mr. Med. J.. 36, 521.13. Moser. R. J. and Caldwell, J. R. (1962): Ann. Inlem. Med., 56, 471.14. Halpem, M. el al. (1961): Radiology, 77. 25.ample being the critical selection cited by Moser andCaldwellu in 1962. It is, however, my belief that the cal-culated incidence based on radiological diagnosis will tendto fall, and probably will become stable at a figure be-tween 10 and 15% once the procedure becomes routine inthe investigation of hypertensive disease.Fibromuscular HyperplasiaThe value of arteriography is amply illustrated in Fig. 12,where a marked fibromuscular hyperplasia was demon-strated in a female in whom normal results were obtainedon pyelographic study, and no bruit was to be heard.Dramatic relief followed the insertion of a nylon bypassfrom the aorta to the artery distal to the stenosis (Fig. 13).Bilateral coarctation of the renal arteries in a malepatient aged 38 is clearly illustrated in Fig. 14. A resectedrenal artery showing the appearance of ribbing of the in-tima of the artery in a case of fibromuscular hyperplasiais shown in Fig. 15.Fig. 14. Bilateral coarctation of the renal arteries in acase of fibromuscular hyperplasia.Fig. 15. Ribbing of intima of renal artery involved infibromuscular hyperplasia; thrombi are also present.Fig. 12. Fibromuscular hyperplasia of right renal artery with marked stenosis. Minor changes involve the left.(Dr. R. Saner.)Fig. 13. Same case as in Fig. 12. Nylon graft from aorta to renal artery beyond stenosis. Note atrophy of originalrenal artery. (Mr. P. Theron and Mr. J. Jordaan.)popularity it is to be expected that for some time a rela-tively high incidence will be reported. There appear to bemany factors governing the percentage incidence, an ex-

The radiology of the ischaemic kidney in hypertensive disease

https://www.ajol.info/index.php/samj/article/download/180679/170028

The radiology of the ischaemic kidney in hypertensive disease

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online