Superselective renal artery embolization for bleeding complications after percutaneous renal biopsy: a single-center experience

A systematic review and meta-analysis on the efficacy of preoperative renal artery embolization prior to radical nephrectomy for renal cell carcinoma: Is it necessary?

INTRODUCTION

Radical nephrectomy for Renal Cell Carcinoma (RCC) is still the treatment of choice for all stages except for stage I and IV, which need patient selectivity. The purpose of Renal Artery Embolization (RAE) pre-operative before radical nephrectomy is to facilitate resection, reduce bleeding, and reduce the time to surgery, but the necessity of this procedure is still debatable. This study investigates the efficacy of pre-operative Renal Artery Embolization (PRAE) before radical nephrectomy for RCC patients.

METHODS

The systematic searches based on PRISMA guidelines were conducted in Pubmed, Scopus, Web of Science, Medrxiv, and ScienceDirect databases with pre-defined keywords. Both analyses, quantitative and qualitative, were performed to assess blood loss, transfusion rate, surgical time, Intensive Care Unit (ICU) stay, and hospital stay.

RESULTS

A total of 921 patients from 8 eligible studies were included. The blood loss was significantly lower in the PRAE group compared to the control group (p = < 0.00001; SMD -20 mL; 95%CI -0.29, -0.12). There is no statistically significant difference between RAE and without RAE in the transfusion rate nephrectomy (p = 0.53, OR 0.65; 95% CI 0.16, 2.57), mean operative time (p = 0.69; SMD 5.91; 95% CI -23.25, 35.07), mean length of hospital stay (p = 0.05; SMD 0.56; 95% CI 0.00, 1.12), and mean length of stay in the ICU (p = 0.45; SMD 11.61; 95% CI -18.35, 41.57) Conclusions: PRAE before radical nephrectomy significantly reduces blood loss in RCC patients but is similar in the surgical time, transfusion rate, and length of hospital stay and ICU stay.

THE ROLE OF INTERVENTIONAL RADIOLOGISTS IN THE TREATMENT OF COMPLICATIONS IN UROLOGIC PATIENTS

Higher turnaround of urologic patients in the tertiary clinical center can lead to more accompanying complications, ranging from 1% to 55% for various procedures, with the incidence of vascular injuries varying from 0.43% up to 9.5%. In patients with impaired renal function, it is imperative to prevent the loss of normal kidney function and potential hemodialysis. Being minimally invasive, endovascular procedures such as renal artery embolization (RAE) can treat major and life-threatening complications, but good and prompt communication between urologists and interventional radiologist is necessary for fast and effective treatment. Absolute contraindications for RAE are the presence of acute infection and previously known anaphylactic reaction to the iodine contrast media, while previous mild or moderate allergic reactions to iodine contrast media are not contraindications for RAE. Currently used embolic agents can be divided into temporary and permanent embolization agents. While the temporary embolization agent available is a gelatin sponge that could be used as complementary material or stand-alone, for permanent embolization interventional radiologists use microparticles, microspheres, liquid embolic agents, coils, and microcoils. RAE procedures are considered to be safe with a low incidence of complications, with non-target embolization being the most serious one. Postembolization syndrome is considered to be the most common adverse effect and it involves around 90% of patients. The overall results show that RAE is a safe, minimally invasive procedure that can effectively treat significant complications caused by other urologic procedures, with the reported success rates of 87%-100%.

Ultrasound-Guided Lauromacrogol Injection for the Treatment of Active Bleeding After Renal Biopsy

Background: This study aimed to describe the technique and outcomes of hemostasis for ultrasound-guided lauromacrogol injection for active bleeding after renal biopsy. Methods: Data from patients with active bleeding after renal biopsy between January 2018 and December 2020 were retrospectively collected. Patients who still had active bleeding after 30 min of compression were then injected with lauromacrogol under ultrasound guidance. The patient's symptoms before and after operation were collected to assess whether they had severe complications. Changes in hemoglobin and serum creatinine values were collected. Results: Data from a total of 15 patients with active bleeding after renal biopsy were collected, including data of 6 men and 9 women. After the operation, there were 11 cases of mild back pain; 1 case of chills, cold sweats, and back pain; 1 case of cold sweats and blood pressure reduction, and 2 cases with no obvious symptoms. No severe complications occurred in this study, and active bleeding was stopped in all patients. After the operation, compared with before the operation, there was no statistically significant difference in the hemoglobin value and serum creatinine value (p = 0.10 > 0.05, p = 0.78 > 0.05). Conclusion: Ultrasound-guided lauromacrogol injection is a relatively simple, safe and feasible method, which could be helpful in treating active bleeding in the immediate post-procedure period after renal biopsy.

Ultrasound-guided percutaneous embolization of post renal biopsy gonadal artery pseudoaneurysm

Hemorrhage is the most frequently encountered post renal biopsy complication; reported in 12% to 14% of patients. Although the vast majority of these are due to renal artery injury, involvement of gonadal arteries is also rarely seen. These may be managed by the endovascular route, which has several limitations in this subset of patients. We report a case of a 69-year-old male with rapidly progressive glomerulonephritis, who underwent renal biopsy and developed a testicular artery pseudoaneurysm (PA). Successful embolization of this PA was performed under ultrasound guidance using a direct percutaneous approach. This is the first such case reported in the literature.

Post-Traumatic Intraparenchymal Renal Hemorrhages: Correlation between CT and DSA Vascular Findings for Superselective Embolization Procedures

BACKGROUND

This study aims to investigate the correlation between computed tomography (CT) and digital subtraction angiography (DSA) findings in patients affected by acute post-traumatic intraparenchymal renal hemorrhages and evaluate their conservative management with superselective embolization.

METHODS

This retrospective multicenter analysis focuses on patients affected by renal bleedings detected by contrast-enhanced CT and treated with superselective endovascular embolization. CT findings were compared to DSA. Embolization procedural data were analyzed and renal function was evaluated before and after the intervention.

RESULTS

Twenty-seven patients were retrospectively evaluated in one year. Compared to DSA, CT showed 96.3% diagnostic accuracy in terms of hemorrhage recognition; concerning the type of vascular lesion, there was discrepancy between CT and DSA in five cases. The technical success rate of embolization was 100%, while primary clinical success was 88.9%. The inferior parenchymal third was the most frequent site of renal injury. Microcoils were the most adopted embolics. Renal function did not change significantly before and after embolization.

CONCLUSIONS

CT has elevated diagnostic accuracy in detecting post-traumatic intraparenchymal renal hemorrhages; in a small percentage, the type of vascular lesion may differ from the findings observed at DSA. In this scenario, superselective embolization presents high clinical success with a low complication rate.

Amplatzer vascular plug in renal artery embolization: case report and review of the literature

Background

Arterial embolization constitutes a safe and effective therapeutic possibility in the treatment of numerous renal pathologies in election and in urgency. Over the years, numerous embolizing materials have been proposed: fibrin (temporary occlusion), glues, coils, and microspheres. The use of St. Jude Amplatzer vascular plug (AVP) constitutes a more recent and less widespread therapeutic choice, and its use in the renal district is not yet widespread although potentially very valid.

Case presentation

We present 3 renal arterial embolizations performed with AVP performed between January 2019 and February 2020: two patients had a very bulky renal heteroplastic lesion and were candidates for nephrectomy, and a third patient instead was affected by a high-flow FAV post-biopsy. In our experience, the use of AVP for the treatment of renal arteriovenous fistula and neoplastic masses has given excellent results without any complications during and after the treatment. In all cases, a single plug was used which perfectly adapted to the target artery resulting in complete occlusion of the vessel in a short time.

Conclusion

Renal artery embolization performed with AVP has growing potential and numerous advantages in terms of the time of the procedure, speed of embolization, and precision of occlusion, but with a relative increase in costs.

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.

Post-Renal Biopsy Acute Kidney Injury and Page Kidney from Intra-Renal Hematoma Aggravated by Reversible Contrast-Induced Nephropathy Following Renal Arterial Embolization

Patient: Male, 73-year-old

Final Diagnosis: Page kidney from intra-renal hematoma aggravated by reversible contrast-induced nephropathy following renal arterial embolization

Symptoms: Flank pain • nausea • vomiting

Medication: Apixaban

Clinical Procedure: Kidney biopsy and subsequent renal arterial embolization

Specialty: Nephrology