An Assessment of Angiography Used as a Diagnostic Tool in Obscure Intra Abdominal Masses

Dr. M. K. Diwakar

Assistant Professor of Surgery, Govt. Medical College, Rajnandgaon (Chhattisgarh)

*Corresponding Author E-mail: mk.diwakar@rediffmail.com

ABSTRACT:

Background : When clinically it appears impossible to opine regarding the exact nature of the lump by routine and even sometimes special investigations, such lumps are designated as “ Obscure intra abdominal masses”.

Nature of study: A hospital based prospective study.

Objective: Obscure intra abdominal masses have been subjected to Abdominal aortography in an attempt to diagnose them.

Material and method: The procedure was carried out in patients of obscure intra abdominal masses who failed to be diagnosed even after routine and available special investigations and non-invasive procedures. Thus a total of twelve cases were included in this study. By using per-cutaneous trans femoral counter current abdominal aortography to locate the site of origin and nature of the obscure intra abdominal masses.

Results and significance of Aortography: Demonstrable aortographic changes had been noted in primary malignant retro-peritoneal tumours as well as malignant tumours of the viscera which had invaded the retro-peritoneum.At the same time benign Mesothelioma had produced tumour staining while carcinoma of ascending colon and metastaic tumours had not produced any angiographic patterns.

KEYWORDS: Tumour blush, neovascularity, curvelinear stretching.

INTRODUCTION:

Many intra abdominal retro-peritoneal masses cause a change in the normal configuration of the lumbar arteries, Lowman et al(1).Similarly Levin et al(2) have found that intra-abdominal masses displace the renal arteries and kidneys most frequently and many more studies have shown abnormal vascularisation of masses detected on angiography. Mac Donald and Kahn(8) have pointed out the importance of “organ invasion” by the masses as an important diagnostic clue, cited by Levin et al(2).

By keeping in mind the above findings and as recommendation of a committee set by W.H.O. in 1957 that more and more studies must be conducted to get a clear phenomenon of the disease or health problem, Dwivedi et al (3), Garg Narendra K. And Sharma A.B.(4) and Garg Narendra K.(5), the author had under taken this study to locate the site of origin and nature of obscure intra abdominal masses using percutaneous transfemoral counter current abdominal aortography as a diagnostic tool.

MATERIAL AND METHOD:

Abdominal aortography was done on twelve cases of intra-abdominal masses which remained undiagnosed even after routine investigations. Percutaneous transfemoral counter current aortography was done in all selected sampled cases.

After preprocedure aseptic preparation the paient was kept supine with arms above the head on the fluoroscopic table .A nick was made about 1” below the mid inguinal point with a stab knife. Seldinger’s needle was introduced through the nick directed cephalad till the pulsations of femoral artery were felt at the tip of the needle and the needle was quickly introduced with a jabbing motion into the artery. Then the flexible end of the guide wire was introduced through the cannula high in the abdominal aorta for about 8” to 10”. The outer cannula of the Seldinger’s needle was then withdrawn over the guide wire.

The Kifa radio-opague catheter of appropriate bore was then passed over the guide-wire and inserted into the femoral artery for about 10”. After adjusting the roentgenographic factors the catheter’s tip was progressed to the level of 12^th Dorsal vertebra. Depending upon the size of the patient 30-40 c.c. of contrast medium was injected manually. The serial skiagrams were taken before finishing the injection with the patient holding his/her breath.

Sequential skiagrams were taken at different positions depending upon the result of first one every time injecting the same amount of contrast medium. After the desired skiagrams were taken, the catheter was removed and the puncture site was sealed as per procedure with pressure dressing maintained .Adequate after care given to patients in the wards to avoid any post-procedure hematoma at the local site.

Observations and discussions:

The various aortographic findings in connection with their diagnostic significance (Table-I)

(A) Direct arteriographic signs:

1. Tumour staining or Tumour blush-

Tumour staining was noted in 05(41.66%) out of 12cases. Out of these five cases, only one case of benign tumour had shown tumour blush.

2. Neovascularity or Malignant tumour circulation-

Only 4(33.33%) of twelve cases had shown neovascularity. It was evident from this fact that neovascularity was characteristic of malignant tumour masses but its absence did not rule out malignancy as in case of carcinoma of colon.

Levin et al (2) had reported 27 cases of malignant tumours which demonstrated avascularity or hypovascularity. Kreel L.(6) has also reported avascular secondary deposits.

3. Parasitic blood supply-

(Table-I) revealed that in 3 (25%) out of 12 cases parasitic blood supply from lumbar arteries had been demonstrated. From iliac arteries only 01(8.33%), inferior mesenteric artery 01(8.33%) and subcostal artery in 01(8.33%) cases were found involved.

Levin et al (2) found the lumbar arteries were most commonly found to participate in parasitic blood supply of retroperitoneal tumours.

Rossi P. et al (7) and Kahn et al (8) had also reported parasitic blood supply from inferior phrenic while Lowmann et al (12) reported parasitic relationship of celiac axis, mesenteric and renal vessels.

(B):-Indirect Arteriographic signs:

(i) Displacement of Abdominal aorta-

Abdominal aorta was found to be displaced in 04(33.33%) out of twelve cases on one side or the other side of mid line.While in 01(08.33%) cases it was anterior displacement(Table1).Levin et al (2) reported displacement of aorta as a sign of retroperitoneal tumours. Pack et al (8)Synder et al (9)and Damascelli et al (10) also noted the similar findings.

(ii) Curvilinear stretching and Draping effect of Lumbar and subcostal arteries:-

In the present study 01(08.33%) case noted in each drapping effect was costal and ileo-lumbar arteries. Kahn et al (8)Lindgren. E.(11) and Lowmann et al (12) had well described the phenomenon of curvilinear stretching and drapping of lumbar vessels around the tumour mass both in benign as well as in malignant tumours.

(iii) Displacement of Renal arteries:

Four (33.33%) cases showed clear cut stretching and elongation of renal arteries as well as displacement of kidney.Levin et al (2) considered the displacement of kidneys and renal arteries as the commonest feature.

(iv) Displacement of other arteries:

One (08.33%) case in the study showed displacement of right common iliac artery.

CONCLUSION:

From above observations and discussions the author reached to the conclusion that –

(1)Anatomical localization of masses has been done by demonstrating the change in abdominal vasculature.

(2)It is possible, to some extent, to recognize the pathological nature of the mass by studying the angiographic pattern.

REFERENCES:

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2. Levin David C, Robin C Watson, Marold A Baltaxe: Arteriography of retroperitoneal masses. Radiology 108:543-551, 1973.

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7. Rossy P and Ruzicka F.F. Jr: Differentiation of Intrahepatic and Extrahepatic masses by arteriography, Radiology 93, 1969:771-780.

8. Kahn P.C., Frates R.E.: The value of angiography of small branches of Abdominal aorta. American Journal of Roentgenlogy, Feb 1968:102-407.

9. Snyder W.H., Hastings T.N. and Pollock W.: Retroperitoneal tumours, PaediatricSurgery.Vol2: P 860-1963. Edited by W.T. Mustard.

10. Damacelli B., Musumeci R., Petrillo R., Spagnoli I.: Angiography of Retroperitoneal tumours-A review. American Journal of Roentgenology. Radiotherapy and Nuclear Medicine 124:565-570; 1975.

11. Lindgram E.: Technique of Abdominal aortography. Acta Radiologica, 33:389-404; 1953 as quoted by 1.

12. Lowman R.M., Graja V., Pack D.R., Osborn D. and Love L.: Angiographic pattern in primary Retroperitoneal masses, role of lumbar arteries. Radiology; 104:259-268; 1972.

Received on 04.04.2016 Modified on 10.04.2016

Research J. Pharmacology & Pharmacodynamics.2016; 8(2): 55-57

DOI: 10.5958/2321-5836.2016.00010.0