Emergency Transcatheter Arterial Embolization for Acute Renal Hemorrhage

Enhancing procedural decision making with cone beam CT in renal artery embolization

Cone-beam computed tomography (CBCT) has proven to be a safe and effective adjunctive imaging tool for interventional radiology. Nevertheless, limited studies have examined the application of CBCT in renal artery embolization (RAE). The objective of this study is to evaluate the role of CBCT in intra-procedural decision-making for RAE. This multicenter retrospective study included 40 consecutive patients (age: 55.9 ± 16.5 years; male, 55%) who underwent CBCT during RAE from January 2019 to January 2023. The additional information provided by CBCT was classified into Category 1 (no additional information), Category 2 (more information without changing the treatment plan), and Category 3 (valuable information that led to a change in the treatment plan). CBCT did not add unique information for four patients (10%) classified as Category 1. CBCT clarified ambiguous angiographic findings and confirmed the existing treatment plan for 19 patients (47.5%) graded as Category 2; complex vascular anatomy was explained (n = 13), and a correlation between vascular territory and target lesion was established (n = 6). CBCT offered valuable information that was not visible on digital subtraction angiography and changed the treatment plan for 17 patients categorized as Category 3; a mismatch between the vascular territory and the target lesion led to the identification of alternative (n = 3) and additional feeders (n = 8); and the extent of embolization was reduced by using automatic feeder detection software (n = 6). CBCT is an efficient tool that aids in the decision-making process during the embolization procedure by providing supplementary imaging information. This additional information enables the confident identification of target vessels, facilitates superselective embolization, prevents non-target embolization, and helps locate missing feeders.

Weeping sponge kidney: an unusual phenomenon that should be considered in cases of severe renal haemorrhage

AIM

To describe the clinical presentation, imaging evaluation, endovascular management, and outcomes of multifocal renal capsular haemorrhage, "weeping sponge kidney", and to identify associated risk factors and the pathophysiological mechanism behind this condition.

MATERIALS AND METHODS

This is a case series in which clinical information for each of the cases was collected retrospectively from electronic patient notes as well as the radiology information and picture archiving and communication systems.

RESULTS

Four consecutive cases were included in the series. All of the cases were treated successfully with embolisation. Three of the four patients had chronic renal failure with renal atrophy, which are patient factors that appear to be associated with multifocal renal capsular haemorrhage. Based on the procedural findings and the published literature, a pathophysiological mechanism is described to explain this condition and the relevance of the collateral arterial supply to the kidney in such cases is discussed.

CONCLUSION

Small subcapsular haematomas are usually self-limiting but in patients with renal failure, there may be an increased risk of developing a weeping sponge kidney, which can be life-threatening. The endovascular treatment for multifocal haemorrhage differs from that for a single bleeding point, especially if preservation of renal function is not a priority.

Treatment of a hemorrhage secondary to nephrostomy tube placement for derivation of monstrous hydronephrosis in upper tract urothelial carcinoma

A 85-year-old female patient underwent nephrostomy tube insertion for a huge hydronephrosis due to a papillary mass involving the right ureteral ostium diagnosed by at computed tomography scan. As soon as the nephrostomy tube was inserted, a pulsatile bleeding was found and a renal angiography was done. A massive bleeding from the main and unique right renal artery was found such as to require prompt endovascular embolization. A transurethral resection of the bladder was performed and the pathology report confirmed high-grade pTa transitional cell carcinoma. An open drainage was then placed to empty the contents of the pyelocalyceal system of the kidney. Once obtained the volumetric reduction of the abdominal mass the patient underwent the right nephroureterectomy.

Transarterial embolization of acute non-neurologic bleeding using Ethylene Vynil Alcohol Copolymer: a single-Centre retrospective study

BACKGROUND

To evaluate feasibility, safety and effectiveness of transarterial embolization of acute non-neurologic hemorrhage with Ethylene Vynil Alcohol Copolymer (EVOH).

METHODS

Between January 2018 and June 2021, 211 patients (male 123, mean age 69.7 y + 17.9) who underwent transarterial embolization with Onyx™ for acute non-neurologic arterial bleeding were retrospectively reviewed. Most frequent etiology of bleeding was post-operative (89/211, 42.2%), trauma (62/211, 29.4%) and tumor (18/211, 8.5%). Technical success was defined as the angiographic evidence of target vessel complete occlusion. Clinical success was defined as resolution of bleeding. Any rebleeding within the primitive site, requiring a new intervention during the first 30-days following embolization, was considered a clinical failure. Occurrence of procedure-related complication and mortality within 30 days of the embolization were examined.

RESULTS

A total of 229 embolization procedures was performed in 211 pts.; technical success rate was 99.5% (210/211 pts). Clinical success rate was 94.3% (199/211 pts). In 11 patients (5.2%) a reintervention was needed because of a rebleeding occurring within the primitive site, whereas in five patients (2.4%) rebleeding occurred within a site different from the primitive. Factors more often associated with clinical failure were coagulopathy/ongoing anticoagulant therapy (5/11, 45.4%), and post-operative etiology (3/11, 27.3%). EVOH was used as the sole embolic agent in 214/229 procedures (93.4%), in association with coils in 11 cases (4.8%), and with microparticles in 4 cases (1.7%). In the present series, major complications occurred in 6 cases (2.8%): respectively, four cases (1.9%) of colonic ischemia and two groin hematomas (0.9%) with active extravasation were observed. 26 (12.3%) patients died during the follow-up.

CONCLUSION

Embolization of acute arterial bleeding with EVOH as a first-line embolic agent is feasible, safe and effective.

Perirenal hematoma and delayed contrast metabolism after cerebral intravascular therapy: A case report

RATIONALE

Hematomas after percutaneous angiography often occur in the thigh, retroperitoneal, intraperitoneal, or abdominal wall. Renal hematoma after percutaneous angiography is very rare.

DIAGNOSES

Herein, we present a case of perirenal hematoma and delayed contrast metabolism after cerebral angiograph, which may be caused by improper operation.

INTERVENTIONS

Conservative treatments which development by multi-disciplinary collaboration.

OUTCOMES

After treatment, the clinical symptoms of the patients gradually disappeared and the imaging results became negative.

CONCLUSION

Though the patient missed timely diagnosis and treatment, fortunately no catastrophic events occurred. Meanwhile, the potential causes, diagnosis, and therapeutic management were all discussed.

Ultrasound-Guided Thrombin Injection for the Treatment of Bleeding Following Kidney and Liver Biopsies

The purpose of this study was to describe the technique and outcomes of percutaneous thrombin injection into the superficial aspect of actively bleeding liver and kidney biopsy tracks identified with color Doppler ultrasound with the aim of hemorrhage termination. After percutaneous thrombin injection, 15/16 (94%) patients did not require further intervention. Ultrasound-guided thrombin injection into the superficial site of active bleeding is an effective technique for terminating bleeding in the immediate post-procedure period following kidney and liver biopsies and should be considered if active bleeding persists on color Doppler after ≥30 minutes of compression and observation.

The role of interventional radiology in hepatic and renal hemorrhage embolization: single center experience and literature review

Background and aim:

Intraabdominal hemorrhage secondary to liver and kidney injury is a major cause of morbidity and mortality. Endovascular arterial embolization is an established interventional radiology technique used to treat active bleeding, and its role in managing abdominal hemorrhages is growing, given the increasing trend for conservative treatment. Our study aims to retrospectively evaluate the technical and clinical results and the possible complications of arterial embolization procedures performed in emergency, in post-traumatic, iatrogenic, and pathological hepatic and renal bleedings.

Methods:

We performed a ten-year, single-center retrospective survey (from January 2010 to December 2019) of all patients treated in emergency by intra-arterial embolization of liver and kidney bleeding. Preliminary CT angiography studies were evaluated, as well as the angiographic findings. Materials used, procedural data, and clinical outcomes, including complications, were recorded.

Results:

The diagnostic angiography showed a single source of bleeding in 20 cases (66.7%), two bleeding vessels in 4 cases (13.3%), and multiple hemorrhagic sources in 6 cases (20%). All bleeding sources were successfully embolized; in 12 patients (40%), complete embolization was achieved with coils and 18 patients (60%) with hemostatic sponges. In one case, a second embolization procedure was performed for the persistence of hemodynamic instability. No major post-procedural complications were recorded. The mean procedure duration was 65.1 minutes.

Conclusions:

Based on our experience and literature data, the treatment of endovascular embolization in acute abdominal bleeding of hepatic and renal origin represents the treatment of choice, as it can provide complete therapeutic success in hemodynamically stable patients. (www.actabiomedica.it)

Spontaneous Renal Hemorrhage: A Case Report and Clinical Protocol

Spontaneous renal hemorrhage is an uncommon entity with potentially serious consequences. We present a 68-year-old female with a three-day history of progressively worsening left-sided flank pain due to spontaneous left renal hemorrhage without a history of trauma or anticoagulation. The patient’s symptoms improved with conservative management and she was discharged after several days of observation. However, the patient was readmitted the next day with progressively worsening pain due to hematoma expansion from active extravasation. On the second admission, interventional radiology successfully embolized the affected vessels and the patient improved rapidly. The hematoma decreased in size on follow-up exams but no etiology was discovered. Early arterial embolization may have improved outcomes in this case and we argue that it should be considered early in the management of all patients with spontaneous renal hemorrhage.

Renal Arteries Revisited: Anatomy, Pathologic Entities, and Implications for Endovascular Management

The renal arteries (RAs) are important vessels that usually arise from the abdominal aorta and supply the kidneys; thus, these arteries play a vital role in physiologic functions such as hemofiltration and blood pressure regulation. An understanding of the basis for embryologic development and the frequently variable anatomy of the RAs is necessary to fully appreciate the range of diseases and the implications for procedural planning. Hemorrhage from an RA is relatively common and is typically traumatic or spontaneous, with the latter form often seen in association with underlying tumors or arteriopathy. Accurate diagnostic evaluation of RA disease due to conditions such as atherosclerosis, fibromuscular dysplasia, vasculitis, aneurysm, arteriovenous shunt, embolic disease, and dissection is dependent on the use of multimodality imaging and is essential for selecting appropriate clinical management, with endovascular therapy having a key role in treatment. Surgical considerations include extra-anatomic renal bypass, which remains an important treatment option even in this era of endovascular therapy, and RA embolization as an adjunct to tumor surgery. A novel area of research interest is the potential role of RA denervation in the management of refractory hypertension. ^©RSNA, 2021.

Endovascular Interventional Radiology of the Urogenital Tract

Interventional radiology of the male urogenital system includes percutaneous and endovascular procedures, and these last consist mostly of transcatheter arterial embolizations. At the kidney level, arterial embolizations are performed mainly for palliative treatment of parenchymal tumors, for renal traumas and, less frequently, for arteriovenous fistulas and renal aneurysms and pseudoaneurysms. These latter may often require emergency intervention as they can cause renal or peri-renal hematomas or significant hematuria. Transcatheter arterial embolization is also an effective therapy for intractable severe bladder hematuria secondary to a number of neoplastic and inflammatory conditions in the pelvis, including unresectable bladder cancer and radiation-induced or cyclophosphamide-induced hemorrhagic cystitis. Endovascular interventional procedures for the penis are indicated for the treatment of post-traumatic priapism. In this article, we review the main endovascular radiological interventions of the male urogenital system, describing the technical aspects, results, and complications of each procedure at the various anatomical districts.

Clinical outcome and safety of selective renal artery embolization using permanent occlusive agents for acute renal bleeding

Background

To evaluate how far is selective renal artery embolization (RAE) using permanent agents effective in treating acute renal artery bleeding. We retrospectively reviewed the medical records of patients (n = 45) with renal bleeding who were managed by selective RAE using coils, N-butyl-cyanoacrylate glue (NBCA glue), and polyvinyl alcohol (PVA). Data retrieved included the cause, number, and type of the bleeding lesions as well as the results of the embolization for 1 year after RAE. Clinical success was the primary outcome while re-bleeding and complications were the secondary outcomes.

Results

There were 55 bleeding lesions detected by angiography in the included 45 patients. Coils were used in 23/45 patients (51.1%), NBCA glue in 15/45 patients (33.3%), and PVA in 7 patients (15.6%). Bleeding could be controlled with embolization in a single session in 41/45 patients with primary clinical success 91.1%. Four patients needed re-embolization sessions to control bleeding and only one patient was controlled, giving secondary clinical success of 92.3%. Three patients failed to respond to embolization and nephrectomy was done. Iatrogenic dissection of the segmental branch was seen in one patient. Post embolization syndrome was seen in 14/45 patients (31.1%). Non-target embolization was seen in 2 patients: one during treatment with NBCA glue and the other with PVA. No other complications were recorded. No significant differences between clinical success among coil, NBCA glue, and PVA subgroups (P > 0.05).

Conclusion

Selective RAE using permanent agents is effective in controlling renal bleeding and no significant difference among coil, NBCA glue, and PVA.

Superselective Renal Artery Embolization Management of Post-percutaneous Nephrolithotomy Hemorrhage and Its Methods

Objective: The purpose of this study was to evaluate the therapeutic efficacy and safety of superselective renal arterial embolization (SRAE) in the treatment of patients with renal hemorrhage after percutaneous nephroscopy (PCNL). In addition, embolization techniques and embolization materials during operation were also worthy of further discussion.

Methods: From February 2015 to December 2019, clinical data of 49 consecutive patients with renal hemorrhage after PCNL were retrospectively analyzed. Demographic and clinical data of patients were recorded, changes in serum creatinine values were analyzed, and the safety and efficacy of TAE were evaluated. Clinical experience was also recorded.

Results: A total of 49 patients underwent angiography, of which 46 patients received SRAE due to positive hemorrhagic foci detected by angiography, and the technical success rate of 46 patients was 100%. Among the three patients who did not receive embolization, one patient underwent nephrectomy, and two patients improved with conservative treatment, with a clinical success rate of 98%. There was no statistically significant difference between serum creatinine before PCNL and 7 days after SRAE (101.6 ± 36.5 to 100.5 ± 27.1 μmol/L; P = 0.634), and no significant change was observed in serum creatinine at the last follow-up (99.4 ± 34 μmol/L, P = 0.076). No major complications occurred after embolization.

Conclusions: SRAE is safe and effective in patients with renal hemorrhage after PCNL. The experience of interventional therapy and the choice of embolization materials in this study may provide certain benefits for the treatment of patients with renal hemorrhage after PCNL.

Embolization for acute arterial bleeding: use of the triaxial system and N-butyl-2-cyanoacrylate

PURPOSE

The aim of this study was to evaluate the usefulness of transcatheter arterial embolization (TAE) using the triaxial system with N-butyl-2-cyanoacrylate (NBCA) for acute arterial bleeding in comparison to TAE using the triaxial system with gelatin sponges (GS)　and/or coils.

MATERIAL AND METHODS

Between October 2013 and November 2018, 95 patients with acute arterial bleeding underwent emergency TAE using the triaxial system. Six patients underwent multiple TAEs and thus, 104 TAEs using the triaxial system were performed. In 26 of the 104 cases, TAE were performed with NBCA (NBCA group), and in the remaining 78 cases, TAE were performed with GS and/or coils (control group).

RESULTS

Hemorrhagic shock and coagulopathy more often occurred in the NBCA group. Procedure time was shorter in the NBCA group. The technical success rate was 100% in both groups (p > 0.99). The clinical success rate in the NBCA and control groups was 92% and 96%, respectively (p = 0.6). There was one minor complication (4%, 1/26) of liver dysfunction in a patient of the NBCA group, but no complication in the control group (p = 0.26).

CONCLUSION

TAE using the triaxial system with NBCA may be useful for acute arterial bleeding, especially in patients with hemorrhagic shock and coagulopathy.

[Interventional treatment of hemorrhage after percutaneous nephrolithotomy]

OBJECTIVE

To evaluate the effectiveness of super-selective renal artery embolization in treatment of post-percutaneous nephrolithotomy bleeding, and to analyse the causes of failure embolization.

METHODS

In the study, 65 post-percutaneous nephrolithotomy patients with severe renal bleeding and hemodynamic instability were treated by super-selective renal artery embolization. First of all, we performed selective renal arteriography. After clarifying the location of the bleeding, superselective intubation of the injured vessel with a microcatheter was carried out. Then the injured vessel was embolized with Tornado micro-coil. When complete embolization was not achieved with micro-coil, a small amount of gelatin sponge particles were added. If there was no positive finding of the beginning selective renal arteriography, the following measures could be taken to prevent missing lesions: (1) Abdominal aorta angiography was performed to determine whether there were anatomical variations, such as accessory renal arteries or multiple renal arteries; (2) Ultra-selective intubation angiography next to the nephrostomy tube path was performed; (3) Renal arteriography was repeated; (4) Renal arteriography after removing the nephrostomy tube while retaining the puncture channel. We evaluated the different angiographic findings and analysed the causes of embolization failure.

RESULTS

Bleeding was successfully controled in 60 patients (62 kidneys) whose renal arteriography was postive. Positive findings included: pseudoaneurysm formation, patchy contrast extravasation, pseudoaneurysm combined with arteriovenous fistula, contrast agent entering the collection system, extravascular perinephric leakage of contrast. After first embolization, bleeding was controled in 53 patients (55 kidneys). The success rate after the first and second embolization was 88.7% and 96.7% respectively. The second session was required because of failure to demonstrate bleeding arteries during the first session (4 patients, 57.1%) and recurrent hemorrhage of the embolized injured arteries (2 patients, 28.6%). In 5 patients with no positive findings, after conservative treatment, hematuria disappeared. All the patients were followed up for 3, 6, and 12 months after embolization, and no hematuria occurred again, and no sustained and serious renal insufficiency.

CONCLUSION

Super-selective renal artery embolization is an effective treatment for post percutaneous nephrolithotomy bleeding. The main cause of failure is omitting of injured arteries during renal arteriography. Renal artery branch injury has various manifestations. Attention should paid to the anatomical variation of the renal artery, and patient and meticulous superselective intubation angiography is the key to avoiding missing the lesion and improving the success rate of embolization.

[Interventional treatment of hemorrhage after percutaneous nephrolithotomy]

OBJECTIVE

To evaluate the effectiveness of super-selective renal artery embolization in treatment of post-percutaneous nephrolithotomy bleeding, and to analyse the causes of failure embolization.

METHODS

In the study, 65 post-percutaneous nephrolithotomy patients with severe renal bleeding and hemodynamic instability were treated by super-selective renal artery embolization. First of all, we performed selective renal arteriography. After clarifying the location of the bleeding, superselective intubation of the injured vessel with a microcatheter was carried out. Then the injured vessel was embolized with Tornado micro-coil. When complete embolization was not achieved with micro-coil, a small amount of gelatin sponge particles were added. If there was no positive finding of the beginning selective renal arteriography, the following measures could be taken to prevent missing lesions: (1) Abdominal aorta angiography was performed to determine whether there were anatomical variations, such as accessory renal arteries or multiple renal arteries; (2) Ultra-selective intubation angiography next to the nephrostomy tube path was performed; (3) Renal arteriography was repeated; (4) Renal arteriography after removing the nephrostomy tube while retaining the puncture channel. We evaluated the different angiographic findings and analysed the causes of embolization failure.

RESULTS

Bleeding was successfully controled in 60 patients (62 kidneys) whose renal arteriography was postive. Positive findings included: pseudoaneurysm formation, patchy contrast extravasation, pseudoaneurysm combined with arteriovenous fistula, contrast agent entering the collection system, extravascular perinephric leakage of contrast. After first embolization, bleeding was controled in 53 patients (55 kidneys). The success rate after the first and second embolization was 88.7% and 96.7% respectively. The second session was required because of failure to demonstrate bleeding arteries during the first session (4 patients, 57.1%) and recurrent hemorrhage of the embolized injured arteries (2 patients, 28.6%). In 5 patients with no positive findings, after conservative treatment, hematuria disappeared. All the patients were followed up for 3, 6, and 12 months after embolization, and no hematuria occurred again, and no sustained and serious renal insufficiency.

CONCLUSION

Super-selective renal artery embolization is an effective treatment for post percutaneous nephrolithotomy bleeding. The main cause of failure is omitting of injured arteries during renal arteriography. Renal artery branch injury has various manifestations. Attention should paid to the anatomical variation of the renal artery, and patient and meticulous superselective intubation angiography is the key to avoiding missing the lesion and improving the success rate of embolization.

MVP (Micro Vascular Plug®) embolization of severe renal hemorrhages after nephrostomic tube placement

Background

We report our experience in managing iatrogenic renal bleedings after nephrostomic procedures by transarterial embolization using Micro Vascular Plug (MVP) (Medtronic, USA) as single or complementary embolization device with parenchimal sparing.

Materials and methods

Five patients have been treated in a single center with transarterial embolization because of renal hemorrhages occurring after positioning of nephrostomic drainages.

All patients presented with back pain, severe hematuria and/or bright red blood into the nephrostomic bag, with fall in hemoglobin value.

After contrast enhanced CT scan confirming arterial active bleeding, rescue embolization was performed using MVP.

The renal parenchimal loss was estimated on final postembolization DSA. Creatinine values were monitored before and after the procedure.

Results

Technical and clinical successes were obtained in all patients.

Two patients presented with extraluminal blush, one with multiple pseudoaneurysms, one with pseudoaneurysm with arterovenous fistula, one with extraluminal blush with arterovenous fistula.

MVP models were choosen oversized because of vasospasm that would underestimate the effective caliber of target vessel; MVP 3Q and MVP 7Q were adopted in one patient each, while MVP 5Q was released in three cases.

MVP was the sole embolizing agent in four patients; in one patient, MVP was employed after microcoils failed to obtain complete embolization.

The percentage of renal parenchimal lost was lower than 20%; no increase in Creatinine values was detected at dismission.

Conclusions

According to proposed data, MVP seems to be a safe, effective and fast embolizing device that interventionalists could consider when facing renal bleedings, even as sole agent.

Ethylene Vinyl Alcohol Copolymer Embolization for Acute Renal Hemorrhage: Initial Experience in 24 Cases

OBJECTIVE. The purpose of this study was to assess the efficacy and safety of ethylene vinyl alcohol (EVOH) copolymer (Onyx, Medtronic) for embolization for acute renal hemorrhage. MATERIALS AND METHODS. Between October 2006 and June 2018, 24 consecutive patients were treated by embolization with EVOH copolymer for acute renal hemorrhage at Hôpital Bichat-Claude-Bernard. CT angiography was performed in all patients before treatment. Technical success was defined as the complete occlusion of the bleeding artery on final renal angiogram. Clinical success was defined as the absence of rebleeding after embolization. Complications mid procedure, infarcted renal area on final angiogram, and renal function 1 week after embolization were retrospectively analyzed. RESULTS. Active bleeding was observed in all cases. The causes of acute renal hemorrhage were iatrogenic in 12 patients, vascular malformation in four patients, renal tumor in four patients, and unknown in four patients. EVOH copolymer was the sole embolic agent used in 16 patients. In eight patients, EVOH copolymer was used after persistent bleeding after embolization with coils. Technical and clinical success rates were 100%. No patient required surgery or new embolization during a mean follow-up period of 35 months (range, 6-86 months). No serious complications were attributable to EVOH copolymer. The mean infarcted renal area was 10% (range, 5-30%). Renal function, available for 16 (67%) patients, was not altered 1 week after embolization. CONCLUSION. EVOH copolymer is safe and effective for embolization of acute renal hemorrhage, either as a first-line embolic agent or after failure of coil embolization.

Selective transarterial embolization of acute renal hemorrhage: a retrospective study

Introduction: Selective transarterial embolization (STAE) is a minimally invasive treatment method developed as am alternative to surgery for acute renal haemorrhage (ARH). The aim of this study was to evaluate the efficacy and outcome of STAE in ARH patients.Material and methods: The data of patients who underwent STAE with signs of ARH were collected retrospectively. The etiology of renal haemorrhage, localization and type of lesion, embolizing agent used, the amount of contrast material given, duration of fluoroscopy and perioperative and postoperative complications were recorded. Lesions were classified as pseudoaneurysm (PA), arteriovenous fistula (AVF), arterio pelvic fistula (ACF), pathological tumoral vasculature and extravasation.Results: A total of 51 patients were included in the study. The most common symptom was gross hematuria (76.4%) and the most common underlying cause was iatrogenic renal injury (64.7%). Embolizing agents used were n-BCA-iodized oil in 29 patients, coils alone in six patients, coils + n-BCA in four patients, ethanol-iodized oil in three patients, combination of n-BCA-iodized oil and ethanol-iodized oil in two patients, polyvinyl alcohol particles in three patients and covered stent in one patient. Technical success was 100% in all patients and there was no need for reintervention.Conclusions: STAE is a safe, effective and minimally invasive method in emergency treatment of ARH.

[Arterial embolization of polycystic kidneys as an alternative to ergonomic nephrectomy in renal pre-transplantation. Monocentric retrospective study]

PURPOSE

This study aims at providing a retrospective assessment of the decrease in renal volume after renal artery embolization (RAE) among a group of patients with autosomal dominant polycystic renal disease and for whom transplantation, for ergonomic reasons was temporarily advised against.

MATERIAL AND METHODS

Between November 2014 and March 2017, as part of pre-transplantory procedure 15 patients, including 11 men and 4 women benfited from renal embolization (RAE) in a context of preparation for transplant in Lille University Hospital. All of the patients were suffering from autosomal dominant polycystic renal disease (ADPKD) at a severe or terminal stage of renal disease.

RESULTS

The original mean total kidney volume (TKV) was 2550.6 cm³±1771 (1102 cm³; 7310 cm³), the average TKV at 3 months was 1684 cm³±1539 (648 cm³; 6930 cm³) with an average decrease of 33% in the volume (5.2%; 83.9%) (95% confidence interval [0.229-0.436]) (P<0.01) and 1632±1743 (599 cm³; 6758 cm³) at 6 months with an average decrease of 40.7% (7.6%; 64.1%) (IC95% 0.306-0.508) (P<0.01). Among the 15 patients, 13 had their contraindication removed and to date 7 have had successful transplants. One failure due to a very high initial volume (7310cm³) required a secondary nephrectomy. No post-embolization syndrome has been noticed, 2 minor complications occurred (13%) involving a difficult resumption of transit and there was one case of hematuria.

CONCLUSION

ERA procedures must have a place in the ergonomic transplant strategy of patients with ADPKD with a low complication rate and a high efficiency. Nephrectomy indications before transplantation must therefore be reconsidered due to a major postoperative risk. Our results are in line with larger scale studies. Nevertheless, these results need to be confirmed by a large-scale randomized prospective study.

LEVEL OF EVIDENCE

4.

The Efficacy and Safety of Transcatheter Arterial Embolization to Treat Renal Hemorrhage after Percutaneous Nephrolithotomy

Purpose

The aim of this study was to evaluate the safety and efficacy of transcatheter arterial embolization (TAE) in patients with renal hemorrhage after percutaneous nephrolithotomy (PCNL) and evaluate the risk factors that may result in severe bleeding requiring TAE.

Methods

We retrospectively reviewed 121 patients with post-PCNL renal hemorrhage. Thirty-two patients receiving endovascular embolization were compared with 89 patients only receiving conservative treatment. The demographic and clinical data were recorded and compared between the two groups. The values of estimated glomerular filtration rate (eGFR) and serum creatinine (SCr) were recorded preoperatively, postoperatively, and at last follow-up and analyzed to evaluate the safety and efficiency of TAE.

Results

The successful hemostasis rate of conservative therapy was 73.6% (89/121) and that of TAE was 100% (32/32). SCr and eGFR were not significantly different before PCNL and after the last follow-up of TAE (SCr: 0.95 vs. 0.95 mg/dl, P=0.857; eGFR: 86.77 vs. 86.18 ml/min/1.73m², P=0.715). The univariate analysis demonstrated that advanced age, urinary tract infection, and diabetes mellitus were significantly associated with severe bleeding during PCNL. Multivariate analysis further identified that diabetes mellitus was an independent risk factor for severe bleeding needing TAE [odds ratio (OR): 3.778, 95% confidence interval (CI):1.276-11.190, and P=0.016].

Conclusion

TAE is a safe and effective procedure to treat renal hemorrhage that cannot be resisted by conservative treatment after PCNL. Diabetes mellitus was associated with high risks of severe bleeding needing TAE after PCNL.

Unexpected renal hemorrhage after endovascular repair of complicated type B aortic dissection: two cases report

Background

Thoracic endovascular aortic repair (TEVAR) is the therapeutic choice for type B aortic dissection. One of the most unfavored complications of this procedure is hemorrhage, which has a low incidence but high mortality. Renal hemorrhage (RH) after endovascular aortic repair has been rarely reported. We presented two cases of unexpected RH after TEVAR for complicated type B aortic dissection, and the potential causes, diagnosis and therapeutic management were discussed.

Case presentation

A 67-year-old female developed hypotension and progressively decrease of hemoglobin within 5 h after TEVAR for acute complicated type B dissection. Bedside ultrasonography and abdominal computed tomography angiography revealed a massive right perinephric hematoma. The right renal angiography detected multiple tortuous vascular branches with diffuse perinephric bleeding. The main trunk of right renal artery was embolized. The patient recovered uneventfully and presented with normal renal function 6 months later. Another patient was a 69-year-old male who was admitted for endovascular repair of a chronic complicated type B aortic dissection. The patient presented with hemodynamic instability early after TEVAR. Bedside ultrasonography showed a giant left retroperitoneal hematoma. The abdominal angiography revealed two active bleeding sits located in the distal branches of left renal artery. A super-selective embolization of the two arteries was performed, however the patient developed abdominal compartment syndrome and died of multiple organ failure.

Conclusions

Unexpected RH after endovascular repair of aortic dissection might be associated with iatrogenic and idiopathic factors. Close surveillance and clinician’s awareness of this rare complication is crucial for accurate and prompt diagnosis. Renal angiography and subsequent selective embolization of bleeding vessels are effective interventions for treating this fatal condition.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0440-1) contains supplementary material, which is available to authorized users.

Subcostal artery bleeding after percutaneous nephrolithotomy: a case report and literature review

Postoperative bleeding is a dangerous complication after percutaneous nephrolithotomy (PCNL). Pseudoaneurysm, arteriovenous fistula, and arterial laceration are the three most common causes of post-PCNL bleeding. Subcostal artery bleeding is a rare cause. We herein present a clinical case involving a 43-year-old man who presented with right renal complex calculi and was managed by PCNL in the prone position using an inferior calyceal puncture approach. Intermittent extreme bleeding occurred 1 day postoperatively, and immediate renal angiography was performed. However, we found no sign of a pseudoaneurysm, arteriovenous fistula, or arterial laceration. Another well-trained and experienced doctor also found no pseudoaneurysm, arteriovenous fistula, or arterial laceration. After adjusting the catheter position, subcostal artery bleeding finally appeared and was successfully controlled by coils. This finding indicates that subcostal artery damage is one cause of post-PCNL bleeding. We suggest that clinicians should carefully and patiently perform angiography and/or embolization to avoid misdiagnosis and mistreatment.

Full realization of internal mammary artery injury after blunt chest trauma

Due to the substantial and continual increase in the number of motorized vehicles globally, clinicians are faced with an enormous population at risk for suffering internal mammary artery injuries after blunt chest trauma. Nevertheless, very little attention has been paid to this issue by relevant health practitioners. In addition, there is a scarcity of extant research data, as well as societal guidelines, regarding internal mammary artery injury. In cases with undetected internal mammary artery injury, however, the outcome may be catastrophic or fatal. Thus, investigating and reviewing the anatomy, etiology, diagnostic approaches, and treatment strategies for patients with internal mammary artery injury are urgently needed.

[Massive bleeding of the urogenital tract]

Massive bleeding of the urogenital tract is, in the same way as acute bleeding from all other organs, a medical emergency and necessitates precise diagnostics and treatment. In this article the topic is addressed in four main categories: first the inflammatory causes are discussed, followed by surgical, traumatic and neoplastic causes of massive bleeding. Subsequently, the rare but clinically relevant causes of acute and massive bleeding are described.

Emergency transcatheter arterial embolization for massive gastrointestinal arterial hemorrhage

To evaluate the different arteriographic manifestations of acute arterial massive hemorrhage of the gastrointestinal (GI) tract and the efficacy of emergency transcatheter arterial embolization (ETAE).A total of 88 patients with acute massive GI bleeding who experienced failure of initial endoscopy and/or conservative treatment were referred to our interventional department for acute GI arteriography from January 2007 to June 2015. After locating the source of bleeding, appropriate embolic agents, such as spring coil, hydroxyl methyl acrylic acid gelatin microspheres, polyvinyl alcohol (PVA) particles, etc., were used to embolize the targeted vessels. The angiographic manifestations and the effects of embolization of acute arterial massive hemorrhage of the GI tract were retrospectively analyzed.Of the 88 patients, 54 were diagnosed with arterial hemorrhage of the upper GI tract and 34 with arterial hemorrhage of the lower GI tract. Eighty cases were associated with positive angiography, which showed the following: contrast extravasation (only); gastroduodenal artery stenosis; pseudoaneurysm (only); pseudoaneurysm rupture with contrast extravasation; pseudoaneurysms merged with intestinal artery stenosis; GI angiodysplasia; and tumor vascular bleeding. Eight cases were diagnosed with negative angiography. Seven-two patients underwent successful hemostasis, and a total of 81 arteries were embolized. The technical and clinical success rates (no rebleeding within 30 days) in performing transcatheter embolization on patients with active bleeding were 100% and 84.71%, respectively (72 of 85). Within 30 days, the postoperative rebleeding rate was 15.29% (13/85). Of these rebleeding cases, 2 patients were formerly treated with "blind embolization," 7 underwent interventional embolic retreatment, and 3 had surgical operations. All cases were followed-up for 1 month, and 3 patients died from multiple organ failure. No serious complications such as bowel ischemia necrosis were observed.ETAE is a safe, effective, and minimally invasive treatment; because of the diversified arteriographic manifestations of acute GI hemorrhage, the proper selection of embolic agents and the choice of reasonable embolization method are essential for successful hemostasis.