Selective Arteriography as a Localizing and Provocative Test in the Diagnosis of Pheochromocytoma

Abstract

The diagnosis of pheochromocytoma is suspected in patients with paroxysmal or sustained hypertension associated with symptoms of headache, excessive perspiration, and palpitation (1). Many patients have nonspecific symptoms, however, and additional diagnostic evidence is sought from chemical, pharmacologic, or radiologic studies. Standard roentgen examinations, e.g., urography or laminagraphy, have not been sufficiently accurate for the diagnosis and localization of pheochromocytoma (2–4). The specialized radiographic technics such as retroperitoneal gas insufflation and arteriography may provide direct visualization of the tumor, but they carry a risk and have been associated with fatalities. Air embolism may be a complication of retroperitoneal gas insufflation. Death after aortography undertaken in patients with pheochromocytoma was reported by Saltz and his associates (6), and by Koonce, Pollock, and Glassy (7). In the two cases, the blood pressure was elevated after aortography, and vasomotor collapse ensued. The potential action of contrast material to stimulate the release of catecholamines and to produce elevation of blood pressure in the patient is the basis of this report. A carefully controlled method using selective arteriography as a localizing and provocative test for pheochromocytoma is presented with two case reports. Materials and Methods Fifteen patients in whom pheochromocytoma was suspected from clinical features and borderline or definitely abnormal pharmacologic tests were studied by selective arteriography and constant monitoring of blood pressure. Before selective catheterization of arteries, a slow intravenous infusion of 5 per cent dextrose and water was begun in order to make a vein immediately accessible should phentolaminc2 injection be required during the study. A strain gauge attached to the catheter and a direct-writing recorder permitted the continuous recording of arterial blood pressure as soon as the arterial catheter entered the aorta. Selective catheterization of the renal or adrenal arteries was performed after using the Seldinger technic for the percutaneous introduction of a catheter through the femoral artery. A radiopaque polyethylene Ödman-Ledin catheter with a premolded tip was employed in all patients. The angiographic method was the same as previously reported (9). Selective catheterization of the renal arteries was performed without first obtaining an aortogram. When each renal artery was catheterized, from 0.5 to 1.0 ml diatrizoate sodium (Hypaque 50 per cent) was introduced and the blood pressure response observed. Depending on the pressor response, from 4 to 6 ml of contrast medium was injected and angiograms were obtained. The blood pressure response to this second injection was observed. After the procedure was performed on each renal artery, two separate aortograms were made.