Percutaneous transfemoral renal artery occlusion in patients with renal carcinoma. Preliminary report

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus

INTRODUCTION AND OBJECTIVES

Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0).

MATERIAL AND METHODS

Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n = 9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications.

RESULTS

There were no significant differences in the overall complication rate (11.1% vs. 32.4%, p = 0.19), major complication rate (0% vs. 8.1%, p = 0.51), or transfusion rate (11.1% vs. 19%, p = 0.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR: 0.11, 95%CI 0.01-2.86; p = 0.18) nor transfusion (OR: 0.46, 95%CI 0.02-7.38; p = 0.58).

CONCLUSIONS

In our study on left RCC with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus

INTRODUCTION AND OBJECTIVES

Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0).

MATERIAL AND METHODS

Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n=9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications.

RESULTS

There were no significant differences in the overall complication rate (11.1% vs. 32.4%, P=.19), major complication rate (0% vs.8.1%, P=.51), or transfusion rate (11.1% vs. 19%, P=.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR:0.11, 95%CI 0.01-2.86; P=.18) nor transfusion (OR:0.46, 95%CI 0.02-7.38;P=.58).

CONCLUSIONS

In our study on left renal cell carcinomas with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Creation of an ex-vivo bovine kidney flow model for testing embolic agents: work in progress

Objectives

To develop an ex- vivo perfusion flow model using a bovine kidney for future testing of embolic agents in an inexpensive and easy way.

Methods

Six bovine adult kidneys were used for this study. Kidneys were cannulated and perfused via a roller pump. Three embolic agents, coils, Gelfoam, and a glue mixture of Histoacryl + Lipiodol, were deployed by targeting three secondary segmental arteries per kidney via a 5Fr catheter under fluoroscopic guidance. Cannulation time, success rate of segmental artery selection and embolic agent deployment, total operational time, and fluoroscopy dose were recorded.

Results

Average kidney weight was 0.752 +/− 0.094 kg. All six bovine kidneys were successfully cannulated in 21.6 min +/− 3.0 min. Deployment of coils and glue was achieved in every case (12/12); however, Gelfoam injection was not successful in one instance (5/6, 83%). Coil deployment demonstrated no embolic effect while Gelfoam and glue injections demonstrated decreased distal contrast filling post-embolization. Mean dose area product was 12.9 ± 1.8 Gy·cm2, fluoroscopy time was 10 ± 4 min and operational time was 27 ± 8 min.

Conclusions

We describe the creation of an ex vivo bovine kidney flow model for the preclinical evaluation of different embolic materials. The flow model can be modified to provide extensive bench testing and it is a promising tool for hands -on training in basic and advanced embolization techniques .

Value of preoperative renal artery embolization in reducing blood transfusion requirements during nephrectomy for renal cell carcinoma

PURPOSE

The authors evaluated the effectiveness of preoperative ethanol renal artery embolization in reducing transfusion requirements during nephrectomy for renal cell carcinoma.

PATIENTS AND METHODS

Of 93 consecutive patients who underwent nephrectomy for renal cell carcinoma from 1980 to 1990, 24 patients underwent embolization within 24 hours of nephrectomy. Finding in this group were compared with those in 69 control patients who underwent surgery without preoperative embolization.

RESULTS

Embolized tumors were larger than nonembolized ones (mean volume, 595 vs 257 mL) (P < .05). Patients with large hypervascular tumors (volume over 250 mL) who underwent complete embolization received significantly smaller mean blood transfusion volumes than control patients (250 vs 800 mL; P = .01). The transfusion volume associated with incomplete embolization was higher than that associated with no embolization.

CONCLUSION

Complete alcohol embolization significantly reduces the volume of blood transfused during nephrectomy for large hypervascular renal cell carcinomas, and incomplete embolization is associated with larger transfusions. Preoperative embolization must be complete and should be performed more widely.

Arterial embolization in patients with renal carcinoma

The literature concerning embolization of the renal artery in patients with renal cell carcinoma is reviewed. Based on this review it is concluded that the method is useful in this patient group as it will facilitate the surgical procedure if nephrectomy is performed afterwards. Used as a palliative method, embolization reduces haematuria. It was not possible to draw conclusions concerning survival rates or eventual immuno-stimulating effects of embolization.

Long-term follow-up of neonatal renovascular hypertension

Twelve neonates with hypertension have been followed for a mean of 5.75 years. At onset of hypertension, mean peak blood pressure was 159/99 mm Hg. Ten infants had umbilical artery catheters, 9 placed above the origin of the renal arteries. Radionuclide renal scan and/or angiography demonstrated renovascular disease, primarily renal artery thrombosis, in 11 infants. One-third of infants were asymptomatic, one-third had normal urinalyses and two-thirds had elevated peripheral plasma renin activities. Blood pressure normalized with medical therapy in all infants and remained normal when therapy was discontinued. Ten infants have normal creatinine clearances on follow-up but 5/11 have unilateral renal atrophy. Radionuclide scans have remained abnormal, even in infants without renal atrophy. In summary, neonatal renovascular hypertension is frequently secondary to renal artery thrombosis, associated with umbilical artery catheterization. Blood pressure usually normalizes with conservative medical management and remains normal off medications. Persistent abnormalities in renal size and function are common.

Hemorrhagic pancreatitis: a complication of transcatheter embolization treated successfully by total pancreatectomy

Since pancreatitis can be produced experimentally in dogs by embolization of microspheres into the pancreatic arterial circulation, there has been speculation that intentional or inadvertent embolization of the pancreas in human subjects could also produce pancreatitis. Although such therapeutic embolization has increased, no pathologically documented case of this complication has been recorded. We have reported the first such case occurring in a patient with a large, highly vascular, nonfunctioning islet cell carcinoma of the tail of the pancreas preoperatively embolized with Gianturco coils and Gelfoam particles suspended in sodium tetradecylsulfate solution to facilitate distal pancreatectomy. The resultant hemorrhagic pancreatitis and duodenal necrosis required a total pancreatectomy. We conclude that, by itself, occlusion of the origin of the splenic and gastroduodenal arteries with coils would have been effective and without complication; however, the addition of Gelfoam particles in a sclerosing solution reduced the microscopic pancreatic circulation to a critical point and resulted in hemorrhagic pancreatitis.

The value of transvascular embolization in the treatment of renal carcinoma

In a consecutive series of 62 patients with renal carcinoma transvascular embolization has been evaluated in regard to its limitations, complications, influence on the surgical procedure and success of treatment. Of 47 planned embolizations 36 could be accomplished. Total embolization was achieved in 29 of the 36 cases (81 per cent). One case was complicated due to displacement of the embolization material to the femoral artery. The subjective impression of the surgeon was that embolization facilitated nephrectomy, although this could not be proved by objective measurement of the duration of operation and perioperative blood loss. Survival after embolization and nephrectomy was no better than after nephrectomy alone.

The role of preoperative embolization in renal cell carcinoma

A prospective study was done to assess the effect of embolization on the technical ease of nephrectomy, change in the immunological status of the patient and subsequent behavior of tumors and/or metastases in 55 patients with renal cell carcinoma. We found that embolization makes the operation easier technically. No changes in responses to delayed hypersensitivity skin tests were found after embolization with or without nephrectomy. There may be a response following embolization and adjuvant radical nephrectomy in some patients with limited lung metastases. No significant regression of renal cell carcinoma and/or metastases after embolization alone or with nephrectomy and hormonal/chemotherapeutic treatment was demonstrated. Survival of patients with metastatic renal cell carcinoma was longer for those who underwent embolization and nephrectomy than for those who underwent embolization alone.

Pain control following renal infarction/ablation using continuous epidural combined anesthesia/analgesia

A technique for anesthesia during pre-nephrectomy renal infarction or ablation using standard epidural anesthesia procedures is described. Additionally, post-infarction analgesia using epidural meperidine is discussed. This technique has been used successfully in 8 patients undergoing infarction or ablation of renal adenocarcinoma and shows promise as an adjunct to standard analgesia in other patients undergoing radical surgical procedures.

Angioinfarction plus nephrectomy for metastatic renal cell carcinoma--an update

We treated 100 patients with metastatic renal cell carcinoma by angioinfarction of the primary tumor followed by radical nephrectomy. Of the patients 88 also received postoperative parenteral progesterones. We achieved an over-all response rate of 28 per cent (complete regression of all metastatic lesions in 7 patients, regression greater than 50 per cent in 8 and stabilization for at least 1 year in 13). Patients with parenchymal pulmonary metastases only have the best survival rate (64 per cent at 1 year) and are most likely to benefit from angioinfarction and nephrectomy. The presence of hilar or mediastinal adenopathy, pleural effusion or nonpulmonary metastases confers a worse prognosis. These patients do not appear to survive longer with preoperative angioinfarction than if treated by nephrectomy alone. Our data demonstrate that it is critically important to stratify patients by site and volume of disease when results are reported and compared for any patient undergoing treatment for metastatic renal cell carcinoma.

Culture of peripheral monocytes in vitro in patients with renal cell carcinoma: a possible prognostic indicator

An in vitro assay has been applied in 23 patients with renal cell carcinoma. A mononuclear cell-rich fraction was cultured from peripheral blood of patients with renal cell carcinoma. The number of monocytes maturing into macrophages was quantitated over a period of 7 days. Monocyte maturation was significantly lower in patients with renal cell carcinoma than in normal individuals. Of 10 patients tested both pre- and post-nephrectomy, 8 patients showed clinical improvement after surgery. In all 8, the posttreatment macrophage yield improved significantly from the pretreatment values to approach normal values. In 2 patients found to have metastasis postoperatively, the macrophage yield continued below normal levels. Our results suggest that the in vitro maturation of macrophages from mononuclear cells may parallel clinical events.

New indications for renal infarction

Two patients with stage D transitional cell carcinoma of the kidney presented with recurrent massive hematuria. Both had prompt cessation of bleeding following renal infarction. Another patient had malignant hypercalcemia related to metastatic renal cell carcinoma and became normocalcemic after renal infarction. Angiographic renal infarction offers a rational alternative to conventional therapy in the management of these 2 problems.

Complications of the Gianturco coil in preoperative infarction of renal cell carcinoma

Percutaneous artery occlusion has been described for a multitude of clinical problems, including preoperative infarction of the kidney for renal cell carcinoma. The Gianturco wool coil provides a relatively new method for occlusion. Few complications with this device have been reported. We describe our experience with complications in 3 patients and discuss methods of their prevention.

Embolization for genitourinary disorders

Fourteen patients with various genitourinary disorders underwent arterial embolization. The procedure was useful in facilitating surgical removal of hypernephromas, in decreasing tumor-induced hypercalcemia, and in diminishing proteinuria secondary to renal failure. Patients with priapism due to excessive arterial inflow responded well. Results of embolization performed because of bleeding varied. When bleeding was localized to a single vessel or to an area supplied by such a vessel, embolization was successful. However, when hemorrhage was diffuse or due to multiple vessel inflow, arterial embolization was not entirely effective.

Hypernephroma embolisation--is it worthwhile?

Transcatheter embolisation was performed in 16 patients with hypernephroma, using either Oxycel, Gelfoam, or steel wire coil(s). Thirteen patients proceeded to early nephrectomy. Surgery was facilitated in four patients with large hypervascular tumours, three of whom had vena caval occlusion. Patients with small, or only moderately vascular tumours, did not benefit from the technique as assessed at nephrectomy. The technique was used as a palliative procedure in three patients, haematuria stopped in two, and abolition of high-output heart failure was achieved in one. Owing to the danger of this technique, it is suggested that its use be restricted to (a) rendering patients with large hypervascular tumours more suitable for surgery, and (b) in palliation of inoperable patients who have symptoms such as severe haematuria. The effect of the technique on survival time remains uncertain.

Renal artery aneurysm: a complication of Gianturco coil embolization of renal adenocarcinoma

A complication of Gianturco coil infarction of a massive renal carcinoma with caval obstruction is presented. The immediate response was excellent but at 4 months the patient became hypertensive and potassium-depleted. A large aneurysm of the renal artery had developed at the site of the coils, necessitating nephrectomy.

Renal metastasis of adenocarcinoma of the lung: massive hematuria managed by therapeutic embolization

The rare complication of massive hematuria secondary to metastatic infiltrating adenocarcinoma of the lung to the kidney was managed with steel coil therapeutic embolization. The angiographic and pathologic picture as well as the advantages of this therapeutic modality in this clinical setting are discussed.

Widespread dissemination of gelfoam particles complicating occlusion of renal circulation

Embolization of renal circulation by Gelfoam particles in a thirty-two-year-old man with renal carcinoma was followed by retrograde regurgitation of the injected particles upstream, with resultant occlusion of the celiac trunk and the superior mesenteric artery. This was followed by a stormy clinical course, which the patient survived. Several possible explanations are offered for the occurrence of this complication.

Spontaneous regression of renal cell carcinoma metastases after preoperative embolization of primary tumor and subsequent nephrectomy

Preoperative arterial embolization and infarction of a large renal cell carcinoma followed by radical nephrectomy seven days later led to spontaneous regression of pulmonary metastases. However, a cerebral metastatic deposit manifested itself fourteen months after surgery, requiring craniotomy. Presently, the patient is alive and well with no evidence of disease twenty-one months after his original surgery. The immunologic implications of this favorable response to treatment are discussed, and immunologic testing of similar cases is encouraged.

Preoperative renal embolization as adjunct to radical nephrectomy

Radical nephrectomy preceded by preoperative renal artery embolization using Gianturco-Anderson-Wallace steel coils has objective value as determined by comparing records of 15 patients who had adjunctive embolization with 15 patients who did not. Embolization of the major renal artery facilitated surgery allowing initial renal vein ligation resulting in reduction of blood loss and operative time. The described experience and current literature review support adjunctive embolization and document minimal risk to the patient.

Resection of the suprarenal inferior vena cava for retroperitoneal malignant disease

Minimal renal dysfunction was noted in 4 of 5 patients undergoing right nephrectomy with resection of the inferior vena cava and ligation of the left renal vein. However, the results of this series confirm previous reports that patients with locally advanced right renal carcinoma requiring vena caval resection are cured rarely by an operation alone. In the absence of effective adjunctive therapy for renal cell carcinoma this procedure will most likely benefit patients with neoplasms responsive to either chemotherapy or radiation therapy.

Transcatheter embolization of the kidney with butyl-2-cyanoacrylate: experimental and clinical results

The technique and efficacy of therapeutic catheter embolization of the kidney with butyl-2-cyanoacrylate (Histoacryl) were studied in 80 rabbits (including control groups) and in 10 dogs. A mixture of butyl-2-cyanoacrylate, 50% glucose, and tantalum powder was used for the embolization. Complete and permanent vascular occlusion was found in nearly all cases. The main complication observed was a reflux of embolizing material into the lumbar arteries, which occurred in seven rabbits. Clinically therapeutic embolization was performed in six patients with hypernephroma. The indication for embolization in these patients, as well as in two others with iatrogenic lesions, was pronounced hematuria. Cessation of bleeding was achieved in all cases. For embolization the coaxial catheter technique is recommended; in special cases with extensive arteriovenous shunts, adjunctive balloon occlusion would be advisable.

T and B lymphocyte levels in renal cancer patients: influence of preoperative transcatheter embolization and radical nephrectomy

The mean percentage of T and B lymphocytes in peripheral blood was tested in 6 patients with renal cancer before and after preoperative transcatheter embolization and radical nephrectomy. While no significant difference was found in B lymphocyte levels compared to those in healthy control subjects a clear impairment in circulating T lymphocyte levels was observed in renal cancer patients who had not been treated. This reduction in T lymphocyte levels persisted after embolization but there was a significant increase after radical nephrectomy.

Renal cell carcinoma involving the inferior vena cava: radiologic evaluation and surgical management

The evaluation and management of 3 patients with renal cell carcinoma and varying degrees of vena caval involvement are described. Extrinsic compression, intraluminal tumor thrombus and direct invasion have characteristic features on the inferior venacavograms. With knowledge of the nature and extent of vena caval disease total removal of the tumor is possible in most cases with an acceptably low morbidity. Extensive vena caval pathology by no means precludes long-term survival and should not be regarded as a sign of inoperability.

Therapeutic renal infarction

Pre-nephrectomy therapeutic renal infarction by injecting gelfoam into the renal artery was done in 10 patients with hypernephroma. This technique facilitates nephrectomy and decreases blood loss. A post-infarction syndrome characterized by flank pain, fever and nausea occurred in most patients. In addition, a dialysis patient underwent bilateral renal infarction with improvement of blood pressure control. Distal embolization of gelfoam occurred in this patient, resulting in significant gangrene of 1 foot.

Nephrectomy for renal cell carcinoma with metastases

The percentage of patients with renal cell carcinoma who also have identifiable metastases when first seen is increasing. In the past metastases were considered justification for excluding nephrectomy in the management of the patient. However, numerous opportunities for therapy which are abetted by removal of the primary tumor are presented. It is concluded, depending on several variables, that the advantages of nephrectomy usually justify the procedure.

The role of adjunctive nephrectomy in patients with metastatic renal cell carcinoma

The results of therapy for 78 patients with disseminated renal cell carcinoma are evaluated. Symptoms related to the primary tumor were noted in only 28 per cent of the patients and were not difficult to manage in those patients not undergoing nephrectomy. Adjuctive nephrectomy, therefore, is a more appropriate term than palliative nephrectomy when referring to removal of the primary tumor as part of an aggresive combined therapeutic approach. Of patients receiving an adjunctive nephrectomy those with osseous metastases only had a better 1-year survival rate (36 per cent) than those with metastases to other sites (18 per cent). Complete regression of metastases was noted in 12 per cent of patients treated with medroxyprogesterone acetate and adjunctive nephrectomy. The role of adjunctive nephrectomy combined with embolic infarction, hormonal therapy, chemotherapy and/or immunotherapy is discussed.

Intractable bladder hemorrhage: therapeutic angiographic embolization of the hypogastric arteries

Malignant intractable bladder hemorrhage in an elderly, high risk patient was controlled effectively with bilateral hypogastric artery occlusion by angiographic placement of oxycel autologous clot emboli. Therapeutic alternatives for intractable bladder hemorrhage are reviewed briefly with particular emphasis on angiographic arterial occlusion. Appropriate anatomic and physiologic aspects of this therapy are discussed.

Intravascular occlusive therapy: use of interventional radiology in cancer patients

Selective transcatheter intravascular occlusion in the treatment of cancer patients is a valuable extension of interventional diagnostic radiology. Intra-arterial embolization may be performed with various substances, including autologous clot, autologous subcutaneous tissue, Gelfoam, and stainless steel coil. Clinical applications in cancer patients include control of gastrointestinal and genitourinary hemorrhage, preoperative reduction of tumor vascularity, control of local symptoms, and therapeutic reduction of tumor bulk. The technique has been used for preoperative and palliative treatment of neoplasms of the head and neck, kidney, liver, spleen, and soft tissue and bone. Transcatheter intravascular occlusion should be performed only by radiologists experienced in angiographic techniques. Inadvertent occlusion of a normal vessel and thromboembolism are possible complications.