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Hayashi H, Kiyosue H, Tamura Y, Ueda H, Yonemura M, Sasaki G, Hokamura M, Ishiuchi S, Kanaya H, Uetani H, Oda S, Kawanaka K, Hirai T. Transarterial Embolization of Renal Arteriovenous Malformations: Treatment Outcomes According to Angiographic Classification. J Vasc Interv Radiol 2024; 35:979-988.e1. [PMID: 38537737 DOI: 10.1016/j.jvir.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/29/2024] [Accepted: 03/19/2024] [Indexed: 05/20/2024] Open
Abstract
PURPOSE To assess the different adjunctive catheter techniques required to achieve complete occlusion of renal arteriovenous malformations (rAVMs) of different angioarchitectural types. MATERIALS AND METHODS Overall, data on 18 patients with rAVM (Type 1, n = 7; Type 2, n = 2; Type 3, n = 9; mean age, 53.8 years) who underwent 25 procedures between 2011 and 2022 were reviewed. The clinical presentations, endovascular techniques, arteriovenous malformation (AVM) occlusion rate, adverse events (including the incidence of renal infarction), and clinical symptoms and outcomes (including recurrence/increase of AVM) were analyzed according to the Cho-Do angioarchitectural classification. Posttreatment renal infarction was classified as no infarction, small infarction (<12.5%), medium infarction (12.5%-25%), and large infarction (>25%) using contrast-enhanced computed tomography or magnetic resonance imaging. RESULTS Hematuria and heart failure were presenting symptoms in 10 and 2 patients, respectively. The embolic materials used were as follows: Type 1 rAVM, coils alone or with n-butyl-2-cyanoacrylate (nBCA); Type 2 rAVM, nBCA alone or with coils; and Type 3 rAVMs, nBCA alone. Fourteen patients underwent adjunctive catheter techniques, including flow control with a balloon catheter and multiple microcatheter placement, alone or in combination. Immediate postprocedural angiography revealed complete occlusion in 15 patients (83%) and marked regression of rAVM in 3 (17%). Small asymptomatic renal infarctions were observed in 6 patients with Type 3 rAVMs without any decrease in renal function. No major adverse events were observed. All symptomatic patients experienced symptom resolution. Recurrence/increase of rAVM was not observed during the mean 32-month follow-up period (range, 2-120 months). CONCLUSIONS Transarterial embolization using adjunctive catheter techniques according to angioarchitectural types can be an effective treatment for rAVMs.
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Affiliation(s)
- Hidetaka Hayashi
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan.
| | - Hiro Kiyosue
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yoshitaka Tamura
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Ueda
- Department of Diagnostic Radiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Mari Yonemura
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Goh Sasaki
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Masamichi Hokamura
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Soichiro Ishiuchi
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Kanaya
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Uetani
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Koichi Kawanaka
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Toshinori Hirai
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Gomella PT, Solomon J, Ahdoot M, Gurram S, Lebastchi AH, Levy E, Krishnasamy V, Kassin MT, Chang R, Wood BJ, Linehan WM, Ball MW. Timing, incidence and management of delayed bleeding after partial nephrectomy in patients at risk for recurrent, bilateral, multifocal renal tumors. Urol Oncol 2024; 42:222.e1-222.e7. [PMID: 38614921 DOI: 10.1016/j.urolonc.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/16/2024] [Accepted: 03/06/2024] [Indexed: 04/15/2024]
Abstract
INTRODUCTION Delayed bleeding is a potentially serious complication after partial nephrectomy (PN), with reported rates of 1%-2%. Patients with multiple renal tumors, including those with hereditary forms of kidney cancer, are often managed with resection of multiple tumors in a single kidney which may increase the risk of delayed bleeding, though outcomes have not previously been reported specifically in this population. The objective of this study was to evaluate the incidence and timing of delayed bleeding as well as the impact of intervention on renal functional outcomes in a cohort primarily made up of patients at risk for bilateral, multifocal renal tumors. METHODS A retrospective review of a prospectively maintained database of patients with known or suspected predisposition to bilateral, multifocal renal tumors who underwent PN from 2003 to 2023 was conducted. Patients who presented with delayed bleeding were identified. Patients with delayed bleeding were compared to those without. Comparative statistics and univariate logistic regression were used to determine potential risk factors for delayed bleeding. RESULTS A total of 1256 PN were performed during the study period. Angiographic evidence of pseudoaneurysm, AV fistula and/or extravasation occurred in 24 cases (1.9%). Of these, 21 were symptomatic presenting with gross hematuria in 13 (54.2%), decreasing hemoglobin in 4(16.7%), flank pain in 2(8.3%), and mental status change in 2 (8.3%), while 3 patients were asymptomatic. Median number of resected tumors was 5 (IQR 2-8). All patients underwent angiogram with super-selective embolization. Median time to bleed event was 13.5 days (IQR 7-22). Factors associated with delayed bleeding included open approach (OR 2.2, IQR(1.06-5.46), P = 0.04 and left-sided surgery (OR 4.93, IQR(1.67-14.5), P = 0.004. Selective embolization had little impact on ultimate renal functional outcomes, with a median change of 11% from the baseline eGFR after partial nephrectomy and embolization. One patient required total nephrectomy for refractory bleeding after embolization. CONCLUSIONS Delayed bleeding after PN in a cohort of patients with multifocal tumors is an infrequent event, with similar rates to single tumor series. Patients should be counseled regarding timing and symptoms of delayed bleeding and multidisciplinary management with interventional radiology is critical for timely diagnosis and treatment.
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Affiliation(s)
- Patrick T Gomella
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Julie Solomon
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael Ahdoot
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Sandeep Gurram
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Amir H Lebastchi
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Elliot Levy
- Interventional Radiology Section, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Michael T Kassin
- Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD; Interventional Radiology Section, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Richard Chang
- Interventional Radiology Section, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Bradford J Wood
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD; Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD; Interventional Radiology Section, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - W Marston Linehan
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Mark W Ball
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD.
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Peng Q, Wang S, Han J, Huang C, Yu H, Li D, Qiu M, Cheng S, Wu C, Cai M, Fu S, Chen B, Wu X, Du S, Xu T. Thermal and Magnetic Dual-Responsive Catheter-Assisted Shape Memory Microrobots for Multistage Vascular Embolization. RESEARCH (WASHINGTON, D.C.) 2024; 7:0339. [PMID: 38550780 PMCID: PMC10976590 DOI: 10.34133/research.0339] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/20/2024] [Indexed: 08/20/2024]
Abstract
Catheters navigating through complex vessels, such as sharp turns or multiple U-turns, remain challenging for vascular embolization. Here, we propose a novel multistage vascular embolization strategy for hard-to-reach vessels that releases untethered swimming shape-memory magnetic microrobots (SMMs) from the prior catheter to the vessel bifurcation. SMMs, made of organo-gel with magnetic particles, ensure biocompatibility, radiopacity, thrombosis, and fast thermal and magnetic responses. An SMM is initially a linear shape with a 0.5-mm diameter at 20 °C inserted in a catheter. It transforms into a predetermined helix within 2 s at 38 °C blood temperature after being pushed out of the catheter into the blood. SMMs enable agile swimming in confined and tortuous vessels and can swim upstream using helical propulsion with rotating magnetic fields. Moreover, we validated this multistage vascular embolization in living rabbits, completing 100-cm travel and renal artery embolization in 2 min. After 4 weeks, the SMMs maintained the embolic position, and the kidney volume decreased by 36%.
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Affiliation(s)
- Qianbi Peng
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Shu Wang
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
| | - Jianguo Han
- Department of Neurosurgery, South China Hospital, Medical School,
Shenzhen University, Shenzhen, China
| | - Chenyang Huang
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Hengyuan Yu
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
| | - Dong Li
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
| | - Ming Qiu
- Department of Neurosurgery, South China Hospital, Medical School,
Shenzhen University, Shenzhen, China
| | - Si Cheng
- Department of Neurosurgery, South China Hospital, Medical School,
Shenzhen University, Shenzhen, China
| | - Chong Wu
- Department of Neurosurgery, South China Hospital, Medical School,
Shenzhen University, Shenzhen, China
| | - Mingxue Cai
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
| | - Shixiong Fu
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Binghan Chen
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Xinyu Wu
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
| | - Shiwei Du
- Department of Neurosurgery, South China Hospital, Medical School,
Shenzhen University, Shenzhen, China
| | - Tiantian Xu
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
- The Key Laboratory of Biomedical Imaging Science and System, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
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Shah JN, Gandhi D, Prasad SR, Sandhu PK, Banker H, Molina R, Khan S, Garg T, Katabathina VS. Wunderlich Syndrome: Comprehensive Review of Diagnosis and Management. Radiographics 2023; 43:e220172. [PMID: 37227946 DOI: 10.1148/rg.220172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Wunderlich syndrome (WS), which was named after Carl Wunderlich, is a rare clinical syndrome characterized by an acute onset of spontaneous renal hemorrhage into the subcapsular, perirenal, and/or pararenal spaces, without a history of antecedent trauma. Patients may present with a multitude of symptoms ranging from nonspecific flank or abdominal pain to serious manifestations such as hypovolemic shock. The classic symptom complex of flank pain, a flank mass, and hypovolemic shock referred to as the Lenk triad is seen in a small subset of patients. Renal neoplasms such as angiomyolipomas and clear cell renal cell carcinomas that display an increased proclivity for hemorrhage and rupture contribute to approximately 60%-65% of all cases of WS. A plethora of renal vascular diseases (aneurysms or pseudoaneurysms, arteriovenous malformations or fistulae, renal vein thrombosis, and vasculitis syndromes) account for 20%-30% of cases of WS. Rare causes of WS include renal infections, cystic diseases, calculi, kidney failure, and coagulation disorders. Cross-sectional imaging modalities, particularly multiphasic CT or MRI, are integral to the detection, localization, and characterization of the underlying causes and facilitate optimal management. However, large-volume hemorrhage at patient presentation may obscure underlying causes, particularly neoplasms. If the initial CT or MRI examination shows no contributary causes, a dedicated CT or MRI follow-up study may be warranted to establish the cause of WS. Renal arterial embolization is a useful, minimally invasive, therapeutic option in patients who present with acute or life-threatening hemorrhage and can help avoid emergency radical surgery. Accurate diagnosis of the underlying cause of WS is critical for optimal patient treatment in emergency and nonemergency clinical settings. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Jignesh N Shah
- From the Department of Radiology, University of Texas Health Science Center at Houston, McGovern Medical School (J.N.S., R.M., S.K.); Department of Radiology, University of Tennessee Health Science Center, Memphis, Tenn (D.G., P.K.S., H.B.); Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.R.P.); Department of Radiology, Sheth G S Medical College and KEM Hospital, Mumbai, India (T.G.); and Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Tex (V.S.K.)
| | - Darshan Gandhi
- From the Department of Radiology, University of Texas Health Science Center at Houston, McGovern Medical School (J.N.S., R.M., S.K.); Department of Radiology, University of Tennessee Health Science Center, Memphis, Tenn (D.G., P.K.S., H.B.); Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.R.P.); Department of Radiology, Sheth G S Medical College and KEM Hospital, Mumbai, India (T.G.); and Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Tex (V.S.K.)
| | - Srinivasa R Prasad
- From the Department of Radiology, University of Texas Health Science Center at Houston, McGovern Medical School (J.N.S., R.M., S.K.); Department of Radiology, University of Tennessee Health Science Center, Memphis, Tenn (D.G., P.K.S., H.B.); Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.R.P.); Department of Radiology, Sheth G S Medical College and KEM Hospital, Mumbai, India (T.G.); and Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Tex (V.S.K.)
| | - Preet K Sandhu
- From the Department of Radiology, University of Texas Health Science Center at Houston, McGovern Medical School (J.N.S., R.M., S.K.); Department of Radiology, University of Tennessee Health Science Center, Memphis, Tenn (D.G., P.K.S., H.B.); Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.R.P.); Department of Radiology, Sheth G S Medical College and KEM Hospital, Mumbai, India (T.G.); and Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Tex (V.S.K.)
| | - Hiral Banker
- From the Department of Radiology, University of Texas Health Science Center at Houston, McGovern Medical School (J.N.S., R.M., S.K.); Department of Radiology, University of Tennessee Health Science Center, Memphis, Tenn (D.G., P.K.S., H.B.); Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.R.P.); Department of Radiology, Sheth G S Medical College and KEM Hospital, Mumbai, India (T.G.); and Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Tex (V.S.K.)
| | - Ryan Molina
- From the Department of Radiology, University of Texas Health Science Center at Houston, McGovern Medical School (J.N.S., R.M., S.K.); Department of Radiology, University of Tennessee Health Science Center, Memphis, Tenn (D.G., P.K.S., H.B.); Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.R.P.); Department of Radiology, Sheth G S Medical College and KEM Hospital, Mumbai, India (T.G.); and Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Tex (V.S.K.)
| | - Salman Khan
- From the Department of Radiology, University of Texas Health Science Center at Houston, McGovern Medical School (J.N.S., R.M., S.K.); Department of Radiology, University of Tennessee Health Science Center, Memphis, Tenn (D.G., P.K.S., H.B.); Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.R.P.); Department of Radiology, Sheth G S Medical College and KEM Hospital, Mumbai, India (T.G.); and Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Tex (V.S.K.)
| | - Tushar Garg
- From the Department of Radiology, University of Texas Health Science Center at Houston, McGovern Medical School (J.N.S., R.M., S.K.); Department of Radiology, University of Tennessee Health Science Center, Memphis, Tenn (D.G., P.K.S., H.B.); Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.R.P.); Department of Radiology, Sheth G S Medical College and KEM Hospital, Mumbai, India (T.G.); and Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Tex (V.S.K.)
| | - Venkata S Katabathina
- From the Department of Radiology, University of Texas Health Science Center at Houston, McGovern Medical School (J.N.S., R.M., S.K.); Department of Radiology, University of Tennessee Health Science Center, Memphis, Tenn (D.G., P.K.S., H.B.); Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.R.P.); Department of Radiology, Sheth G S Medical College and KEM Hospital, Mumbai, India (T.G.); and Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Tex (V.S.K.)
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Takao H, Abe O. Triple-balloon-assisted n-butyl-2-cyanoacrylate embolization of a cirsoid renal arteriovenous malformation. VASA 2019; 49:147-150. [PMID: 31414618 DOI: 10.1024/0301-1526/a000817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We report a patient with a cirsoid renal arteriovenous malformation (AVM) causing massive hematuria that was successfully embolized by n-butyl-2-cyanoacrylate under triple-balloon occlusion. Proximal balloons were placed in the renal artery and vein for flow control, and a coaxial microballoon was placed in a feeding artery of the AVM to control the delivery of n-butyl-2-cyanoacrylate. Under triple-balloon occlusion, n-butyl-2-cyanoacrylate embolization achieved complete occlusion of the AVM with no procedure-related complications, such as renal infarction. This triple-balloon-assisted technique enabled us to control blood flow and the delivery of n-butyl-2-cyanoacrylate, allowing complete occlusion of the AVM. This approach may prevent proximal embolization and distal migration of n-butyl-2-cyanoacrylate.
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Affiliation(s)
- Hidemasa Takao
- Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Osamu Abe
- Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Influence of symptomatic pseudoaneurysms on postoperative renal function after partial nephrectomy: results of a matched pair analysis. Int Urol Nephrol 2018; 51:33-40. [PMID: 30421098 DOI: 10.1007/s11255-018-2024-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/03/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE A symptomatic pseudoaneurysm (SPA) is a rare but severe complication after partial nephrectomy (PN). Selective trans-arterial embolization (TAE) is the treatment of choice with high success rates. However, the influence of this intervention on postsurgical renal function has not been studied. METHODS Between 2005 and 2016 we performed 1047 PNs at our institution. Postsurgical SPA occurred in 40 patients (3.8%). Patients with and without SPA were matched in a 1:2 ratio concerning tumor complexity (RENAL) and pre-operative renal function (CKD stage). Any CKD upstage and a relevant CKD progression (CKD ≥ III) were defined as endpoints. Furthermore, the influence of the amount of contrast agent applied during TAE was assessed. RESULTS All patients with SPA were treated successfully with TAE. No significant difference could be detected concerning clinical, functional and surgical aspects. Median follow-up time accounted for 12.5 (6.75-27.5) months. Kaplan-Meier analyses detected an increased rate of any CKD upstage (p = 0.066) and relevant CKD progression (p = 0.01) in patients with SPA. Multivariate analysis identified post-operative SPA to be an independent predictor for a relevant CKD progression (HR 4.15, p = 0.01). The amount of contrast agents used did not have an impact on the development of a relevant CKD progression (p = 0.72). CONCLUSION Patients treated with TAE after PN show an additional risk for an impairment of renal function over time. Hence, those patients should explicitly be informed about possible consequences and closely monitored by nephrologists.
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