Selective Renal Arteriographic Appearance of Necrotic Hypernephroma

Several authors have pointed out that arteriography is not a reliable method in the differential diagnosis between renal cyst and renal tumor (3, 5, 7, 11–13, 17, 18, 20, 21). In these published cases, either translumbar or retrograde aortography was performed with injection of contrast material into the abdominal aorta close to the origin of the renal arteries. Boijsen and Folin and others (2, 9, 19) have shown that such nonselective examinations are not satisfactory for a detailed study of the intrarenal arteries. Large tumors of the kidney with the typical abnormal vascularity can be demonstrated by aortography. Small or necrotic tumors with a limited number of pathological vessels, however, cannot always be visualized by injection into the abdominal aorta. An advantage of selective renal arteriography is that the bolus of contrast material reaching the kidney is more concentrated, although the total amount of contrast material entering the kidney is no larger than in aortography. Other branches of the aorta do not fill during a selective study, and a detailed investigation of the renal vessels is not disturbed by overlying arteries. The disadvantages, recently restated (8), are negligible. Experiments in dogs have shown that repeated selective catheterization of the renal artery and multiple selective contrast material injections over a period of several years did not produce functional or pathologic-histological changes of the vascular bed and the parenchyma of the kidney (16). Aberrant renal arteries can be detected easily by a typical failure of visualization of renal parenchyma (10), and a selective catheterization of that vessel may be performed unless it is so small that aortography is necessitated. Selective renal angiography has been employed, therefore, at The University of Chicago as the method of choice for the differential diagnosis of renal masses. If properly performed, it is a fast and harmless procedure. Introduction of a catheter through the femoral artery into the renal by the Seldinger technic is usually easy. Failure to introduce the catheter into the aorta because of tortuosity of the iliac vessels is, in most cases, overcome by the aid of a guidewire fitted with a long, flexible tip. Eight to ten cubic centimeters of 60 per cent contrast material is delivered by an automatic injector at low pressure. A film-changer should be employed at a speed of 6 films per second during the first two seconds after the beginning of the injection, followed by a rate of 2 films per second for eight further seconds. Two injections are made, and films are obtained in supine and oblique projections. With this technic, 146 selective renal arteriographic studies were performed in 1963. In 6 further cases, owing to lack of success in catheterizing the renal artery or the aberrant renal artery supplying the area in question, aortography was done.