History

The first ex vivo angiogram was obtained in 1896 by Haschek and Lindenthal [10] by injecting contrast in the arteries of an amputated upper limb. In 1923 Berberich and Hirsch [1] reported the first experimental in vivo human angiograms using radio-opaque contrast and in the following year Barney Brooks [2] conceived a potential clinical use for this procedure to determine the amputation level by injecting the lower limb arteries with sodium iodinated contrast.

The discovery of angiography of the entire vascular system and the demonstration of its clinical relevance represents a major contribution made by Portugal to the medical sciences.

The early experiences with X-rays to visualize the vessels stimulated Egas Moniz, a neurologist facing the clinical problem of diagnosing cerebral tumours, to conceive a technique of visualizing the arteries in the brain that would be displaced by a tumour, thus providing an objective method for its diagnosis. The first in vivo cerebral angiogram was performed in 1927 [19] by surgical exposure of the common carotid artery and intra-arterial injection of a sodium iodinated contrast. Its value as a major diagnostic tool to be used in several clinical settings was immediately recognized by Moniz and co-workers, who reported the first cases of in vivo internal carotid occlusion in patients with strokes [20]. The initial technique carried a higher incidence of contrast-related complications (2.6% of the 302 cases performed between 1927 and 1931) [29], leading to the use of torotrast as a radiological marker.

Translumbar Aortogram Technique
Fig. 1.6.2 Translumbar aortography

Modifications of the original technique were introduced and in 1936 Loman and Myerson [21] demonstrated the feasibility of cerebral arteriography by direct percutaneous injection into the common carotid artery.

Demonstration of occlusive lesions in the cervical arteries by arteriography was a major development in the understanding of the importance of these lesions in both intra- and extracranial vessels in the pathogenesis of stroke.

Reynaldo dos Santos in 1929 conceived the application of the Moniz technique to the study of lower limb arterial circulation by direct injection into the abdominal aorta via the translumbar approach, starting a new era for the comprehension of the role of occlusive lesions in the arterial system of the lower limbs in the pathogenesis of gangrene [22] (Fig. 1.6.1b).

Modern arteriography followed the development of new methods for distant contrast injection as proposed by Loman and Myerson (1936), FariƱas (1941) and Radner (1948). These contributions led to the method of percutaneous retrograde catheterization described by Sven-Ivar Seldinger [27] in 1953, through the common femoral artery, which became the standard arteriographic technique. Other arteries were used as entry points into the arterial system, such as the axillary, brachial and popliteal arteries.

The association of computer technology with angio-graphic equipment enabled new digital subtraction techniques, leading to great improvements in image quality and safety of the procedure.

Visualization of the veins in a cadaveric arm was first reported by Berberich and Hirsch [1] in 1923, but the first in vivo phlebogram was obtained by J. Cid dos Santos in 1933, by direct exposure and injection of the long saphenous vein (Fig. 1.6.1c). The technique was modified subsequently with percutaneous vein puncture to inject the contrast material, and several techniques were described using direct free-flow ascending visualization and descending techniques with retrograde filling of the venous system to study valvular function [16, 27].

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