Predictive factors of selective transarterial embolization failure in acute renal bleeding: a single-center experience

PURPOSE

Transarterial embolization of renal artery branches (RTE) is a minimally invasive procedure commonly performed in life-threatening renal bleeding of different etiologies. Despite the widespread use of RTE, no consensus guidelines are currently available. Our aim was to investigate clinical and technical efficacy and to identify potential predictors for clinical failure of this procedure.

METHODS

All the RTE procedures performed in our Interventional Radiology unit in last 10 years were retrospectively collected and analyzed. All selected patients underwent both pre-procedural computed tomography angiography (CTA) and post-procedural CTA within 30 days. Clinical success was considered as primary endpoint. Demographic, laboratory, and diagnostic findings predictive of clinical failure of RTE were identified.

RESULTS

Over a total of 51 patients enrolled, 27 (53%) were females and 33 (64.7%) had a renal bleeding of iatrogenic origin. Technical and clinical success was 100% and 80.4%, respectively. Hematoma volumes > 258.5 cm3 measured at CTA, higher pre- and post-procedural serum creatinine (Scr) levels, an increase in Scr value > 0.135 mg/dl after the procedure, a worse post-procedural estimated glomerular filtration rate (eGFR), a post-procedural reduction of eGFR < 3.350 ml/min, and a post-procedural reduction of platelet count (PLT) > 46.50 × 103/mmc showed a significantly higher rate of clinical failure.

CONCLUSION

RTE is a safe and effective procedure in the management of acute renal bleeding of various origins. Hematoma volume, Scr, PLT, and eGFR values were found to be predictive factors of poor clinical outcome and should be closely monitored.

Succinate Dehydrogenase Defects Giant Renal Cell Carcinoma

Succinate dehydrogenase (SDH)-deficient renal cell carcinoma (RCC) is a new subtype of RCC included in the 2016 edition of the WHO classification in RCC. SDH-defective RCC accounts for 0.05-0.2%, and preoperative diagnosis is difficult. We report a severe adherent RCC of inferior vena cava that underwent open radical nephrectomy after preoperative renal artery embolization. Postoperative histopathological examination diagnosed SDH-defective RCC; the clinicopathological stage was pT2b. After 10 months of follow-up, the patient had no evidence of disease recurrence. For patients with large RCC, interventional embolization can be selected to reduce intraoperative bleeding and blood transfusion, and it is recommended to complete interventional surgery within 3-4 h before surgery. SDH-deficient RCC is difficult to distinguish from other renal tumors in imaging, so immunohistochemical examination of SDHB is recommended for young and middle-aged patients, especially those under 45.

Massive bilateral polycystic kidneys, successful treatment with embolization and nephrectomy: A case report

Polycystic kidney disease (PKD) is a genetic disorder characterized by the formation of multiple cysts in the kidneys. We present a case of a 47-year-old male with PKD on dialysis who underwent bilateral renal artery embolization followed by bilateral nephrectomy via a median incision. The specimen weight was 5 kg for the left kidney and 8 kg for the right one. Renal artery embolization can be a useful tool in managing polycystic kidney disease in cases where nephrectomy is indicated. This case highlights the importance of timely intervention and the role of minimally invasive techniques in managing this rare condition.

Efficacy and safety analysis of TACE + sunitinib vs. sunitinib in the treatment of unresectable advanced renal cell carcinoma: a retrospective study

BACKGROUND

Since renal cell carcinoma(RCC) is insensitive to conventional chemoradiotherapy, molecularly targeted drugs are commonly used treatments for unresectable advanced RCC. The aim of this study was to explore the efficacy and safety of TACE + sunitinib vs. sunitinib in the treatment of unresectable advanced RCC.

METHODS

This study included 98 patients with unresectable advanced RCC who were treated in Union Hospital from January 2015 to December 2018, and they met the criteria. They were divided into two groups: TACE + Sunitinib group (N = 47) and Sunitinib group (N = 51). We conducted a retrospective study to analyze the efficacy and safety of the two groups of patients.

RESULTS

(1)TACE + Sunitinib group: 4 patients (8.5%) achieved CR, 27 patients (57.5%) achieved PR, 9 patients (19.1%) achieved SD, and 7 patients (14.9%) achieved PD. Sunitinib group, 0 patients (0%) achieved CR, 20 patients (39.2%) achieved PR, 14 patients (27.5%) achieved SD, and 17 patients (33.3%) achieved PD. (P = 0.017) (2)ORR: TACE + sunitinib group, 66.0%; sunitinib group, 39.2%. (P = 0.009) (3)DCR: TACE + sunitinib group, 85.1%; sunitinib group, 66.7%. (P = 0.038) (4) In the TACE + sunitinib group, mPFS was 15.6 months, mOS was 35.0 months; in the sunitinib group, the mPFS was 10.9 months, mOS was 25.7 months. (P < 0.001) (5) The incidence of abdominal pain, fever, and vomiting was higher in the TACE + sunitinib group than in the sunitinib group (abdominal pain: 55.3% vs. 13.7%; fever: 61.7% vs. 7.8%; vomiting: 40.4% vs. 19.6%; P < 0.05). The technical success rate of TACE in TACE + Sunitinib group is 100%.

CONCLUSIONS

The TACE + sunitinib group had higher ORR and DCR, longer OS and PFS than the sunitinib alone group. TACE combined with sunitinib can play a complementary role and is a safe and effective treatment for advanced RCC.

Technical aspect in renal artery embolization in renal tumors: A case series

Introduction

Renal artery embolization aims to reduce blood loss during surgery. Various embolizing agents are available, each of which has its own indications appropriate for various vascular anatomy and renal pathology.

Presentation of case

We report three cases of renal artery embolization prior to surgical nephrectomy using vascular plug and other embolizing agents. In two cases, complete blood flow occlusion was achieved with minimal blood loss during the subsequent surgery. One case only achieved reduced blood flow, but subsequent nephrectomy and patient recovery was successful.

Discussion

Renal artery embolization prior to malignant mass resection is a well-known, potentially beneficial procedure. The rationale that supports this procedure is clear, but its reported outcome in the literature is still inconclusive. It is important to understand its benefits, complications, and pitfalls to achieve better outcome.

Conclusion

In our cases, renal artery embolization provided satisfactory reduction in bleeding during nephrectomy, and therefore has the potential to be employed as a standard procedure for future surgeries.

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Arterial embolization in renal pathology currently has no clinical guidelines

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The use of vascular plug in renal vascular pathology is feasible

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Careful consideration is needed regarding the choice of renal arterial embolization

No effect of desmopressin administration before kidney biopsy on the risk of major post-biopsy bleeding

BACKGROUND/AIMS

The most important complication of kidney biopsy is bleeding, and it is unclear whether desmopressin is effective in preventing it. Thus, the study was conducted to compare post-biopsy bleeding with or without desmopressin prescription prior to percutaneous kidney biopsy.

METHODS

In this single-centered, retrospective, and observational study, 3,018 adult patients who underwent kidney biopsy between January 1, 2003 and March 31, 2019 at our institute were recruited. Of these, 776 patients received desmopressin. To compare the differences in major bleeding events between patients administered and not administered with desmopressin, propensity score matching was performed.

RESULTS

Before propensity score (PS) matching, it was observed that patients in the desmopressin group were significantly older (p<0.001) and had a higher blood pressure (p<0.001), higher serum creatinine (p<0.001), lower hemoglobin levels (p<0.001), and lower platelet counts (p=0.001) than those in the no-desmopressin group. Furthermore, the incidence of renal artery embolization was not significantly different between the two groups (p=0.077); however, blood transfusions occurred significantly more frequently in the desmopressin group (p<0.001). A comparison of the two groups after PS matching did not reveal any differences in the incidence of renal artery embolization (p=0.341), blood transfusion (p=0.579), and total major bleeding events (p=0.442). Furthermore, there was no difference in the incidence of perinephric hematoma on computed tomography or ultrasound (p=0.120).

CONCLUSIONS

We do not recommend desmopressin administration before kidney biopsy.

No effect of desmopressin administration before kidney biopsy on the risk of major post-biopsy bleeding

BACKGROUND/AIMS

The most important complication of kidney biopsy is bleeding, and it is unclear whether desmopressin is effective in preventing it. Thus, the study was conducted to compare post-biopsy bleeding with or without desmopressin prescription prior to percutaneous kidney biopsy.

METHODS

In this single-centered, retrospective, and observational study, 3,018 adult patients who underwent kidney biopsy between January 1, 2003 and March 31, 2019 at our institute were recruited. Of these, 776 patients received desmopressin. To compare the differences in major bleeding events between patients administered and not administered with desmopressin, propensity score matching was performed.

RESULTS

Before propensity score (PS) matching, it was observed that patients in the desmopressin group were significantly older (p<0.001) and had a higher blood pressure (p<0.001), higher serum creatinine (p<0.001), lower hemoglobin levels (p<0.001), and lower platelet counts (p=0.001) than those in the no-desmopressin group. Furthermore, the incidence of renal artery embolization was not significantly different between the two groups (p=0.077); however, blood transfusions occurred significantly more frequently in the desmopressin group (p<0.001). A comparison of the two groups after PS matching did not reveal any differences in the incidence of renal artery embolization (p=0.341), blood transfusion (p=0.579), and total major bleeding events (p=0.442). Furthermore, there was no difference in the incidence of perinephric hematoma on computed tomography or ultrasound (p=0.120).

CONCLUSIONS

We do not recommend desmopressin administration before kidney biopsy.

Renal artery embolization in the treatment of urinary fistula after renal duplication: A case report and review of literature

BACKGROUND

Duplicate renal malformation is a congenital disease of the urinary system, with an incidence rate of 0.8%. Surgical treatment is suitable for symptomatic patients. Urinary fistula is one of the complications of heminephrectomy. Long-term urinary fistula has a great impact on patients' lives.

CASE SUMMARY

This article mainly reports on a 47-year-old man with duplication of kidney deformity, long urinary fistula after partial nephrectomy, and no improvement after conservative treatment. We have achieved positive results in the arterial embolization treatment of the residual renal artery, indicating that selective arterial embolization is a good way to treat urinary fistula after partial nephrectomy. It is worth noting that this patient violated the Weigert-Meyer law, which also gave us more consideration.

CONCLUSION

Renal artery embolization may be a simple and safe method to treat urinary fistula inefficacy with conservative treatment.

Renal artery embolization for spontaneous hemorrhage in patients with acquired cystic kidney disease: A 20-year single-center experience

Objectives

To evaluate the safety and effectiveness of transcatheter arterial embolization for controlling spontaneous hemorrhage in patients with acquired cystic kidney disease (ACKD).

Methods

This retrospective study included 18 patients with ACKD (M:F=13:5; mean age, 56 years) who underwent renal artery embolization to control spontaneous hemorrhage between January 2001 and September 2020. The underlying etiology and clinical presentations were reviewed and previous computed tomography (CT) findings were analyzed. Furthermore, angiographic and embolization details, technical and clinical successes, and complications were assessed.

Results

Subcapsular, perirenal, and pararenal hematomas were observed on CT scans for all patients. Contrast extravasation was observed in 15 / 17 patients (88%) on contrast-enhanced CT scans. Angiography showed active bleeding in 14 patients (78%; contrast extravasation [n=6], pseudoaneurysm [n=3], and both [n=5]), suspicious bleeding in 1 (5%), and no bleeding in 3 (17%). The technical and clinical success rates were 100% and 94% (17/18), respectively. Total and partial embolization was performed in 14 (78%) and 4 (22%) cases, respectively. Subsequent surgical nephrectomy was required for one patient with clinical failure due to recurrent bleeding despite total embolization. Procedure-related complications included mild post-embolization syndrome in one patient and contrast-induced nephropathy in five patients (28%) without long-term complications.

Conclusions

Renal artery embolization is safe and effective for controlling spontaneous renal hemorrhage in patients with ACKD.

Gestational choriocarcinoma presenting with bilateral kidney and lung metastases with unknown primary: An uncommon clinical scenario

Gestational choriocarcinoma with kidney and lung metastases with delayed presentation after term pregnancy is rare event and not described frequently in literature. We describe a rare case of 24-year-old female with hematuria after 3 years of term delivery. Management includes chemotherapy and even renal embolization in case of life threatening hematuria.

Management of acute post-operative hemorrhage following partial nephrectomy with renal artery embolization

Hemorrhage after robotic-assisted partial nephrectomy (RAPN) is uncommon but can cause significant morbidity. We present a case of acute hemorrhage isolated to the collecting system that was managed with renal artery embolization (RAE).

A 76-year-old male developed sudden onset transfusion-dependent hematuria and hypotension following uncomplicated RAPN. He had no signs of intra-abdominal bleeding and his hypotension was responsive to volume resuscitation. Renal angiography identified a segmental artery with extravasation into the collecting system. RAE eliminated the patient's hematuria, the need for further transfusion, and allowed preservation of renal function. RAE is a viable option for collecting system hemorrhage following RAPN.

The effect of renal denervation in an experimental model of chronic renal insufficiency, The REmnant kidney Denervation In Pigs study (REDIP study)

BACKGROUND

Renal denervation (RDN) is a promising therapeutic method in cardiology. Its currently most investigated indication is resistant hypertension. Other potential indications are atrial fibrillation, type 2 diabetes mellitus and chronic renal insufficiency among others. Previous trials showed conflicting but promising results, but the real benefits of RDN are still under investigation. Patients with renal insufficiency and resistant hypertension are proposed to be a good target for this therapy due to excessive activation of renal sympathetic drive. However, only limited number of studies showed benefits for these patients. We hypothesize that in our experimental model of chronic kidney disease (CKD) due to ischemia with increased activity of the renin-angiotensin-aldosterone system (RAAS), renal denervation can have protective effects by slowing or blocking the progression of renal injury.

METHODS

An experimental biomodel of chronic renal insufficiency induced by ischemia was developed using selective renal artery embolization (remnant kidney porcine model). 27 biomodels were assessed. Renal denervation was performed in 19 biomodels (denervated group), and the remaining were used as controls (n = 8). The extent of renal injury and reparative process between the two groups were compared and assessed using biochemical parameters and histological findings.

RESULTS

Viable remnant kidney biomodels were achieved and maintained in 27 swine. There were no significant differences in biochemical parameters between the two groups at baseline. Histological assessment proved successful RDN procedure in all biomodels in the denervated group. Over the 7-week period, there were significant increases in serum urea, creatinine, and aldosterone concentration in both groups. The difference in urea and creatinine levels were not statistically significant between the two groups. However, the level of aldosterone in the denervated was significantly lower in comparison to the controls. Histological assessment of renal arteries showed that RDN tends to produce more damage to the arterial wall in comparison to vessels in subjects that only underwent RAE. In addition, the morphological damage of kidneys, which was expressed as a ratio of damaged surface (or scar) to the overall surface of kidney, also did not show significant difference between groups.

CONCLUSIONS

In this study, we were not able to show significant protective effect of RDN alone on ischemic renal parenchymal damage by either laboratory or histological assessments. However, the change in aldosterone level shows some effect of renal denervation on the RAAS system. We hypothesize that a combined blockade of the RAAS and the sympathetic system could provide more protective effects against acute ischemia. This has to be further investigated in future studies.

Pre-operative renal artery embolization and suprarenal IVC filter placement for prevention of fat embolization in renal angiomyolipoma with venous extension

Though generally considered benign, angiomyolipomas can invade through the renal vein into the inferior vena cava, putting patients at risk of catastrophic pulmonary fat embolization. Venous invasion is thus an indication for surgical resection but is thought to increase the risk of adverse operative outcomes including intraoperative hemorrhage and embolization of fat and/or tumor thrombus. We report a novel approach to mitigating these complications illustrated in the case of a 43-year-old woman with IVC-invasive renal AML who underwent successful radical nephrectomy after concurrent pre-operative renal artery embolization and placement of a retrievable suprarenal IVC filter.

Multiple Renal Artery Pseudoaneurysms in Patients Undergoing Renal Artery Embolization Following Partial Nephrectomy: Correlation with RENAL Nephrometry Scores

PURPOSE

To describe the incidence of multiple renal artery pseudoaneurysms (PSA) in patients referred for renal artery embolization following partial nephrectomy and to study its relationship to RENAL nephrometry scores.

MATERIALS AND METHODS

The medical records of 25 patients referred for renal artery embolization after partial nephrectomy were retrospectively reviewed for the following parameters: size and number of tumors, RENAL nephrometry scores, angiographic abnormalities, technical and clinical outcomes, and estimated glomerular filtration rates (eGFRs) after embolization.

RESULTS

Twenty-four patients had primary renal tumors, while 1 patient had a pancreatic tumor invading the kidney. Multiple tumors were resected in 4 patients. Most patients (92 %) were symptomatic, presenting with gross hematuria, flank pain, or both. Angiography revealed PSA with (n = 5) or without (n = 20) AV fistulae. Sixteen patients (64 %) had multiple PSA involving multiple renal vessels. Higher RENAL nephrometry scores were associated with an increasing likelihood of multiple PSA. Multiple vessels were embolized in 14 patients (56 %). Clinical success was achieved after one (n = 22) or two (n = 3) embolization sessions in all patients. Post-embolization eGFR values at different time points after embolization were not significantly different from the post-operative eGFR.

CONCLUSION

A majority of patients requiring renal artery embolization following partial nephrectomy have multiple pseudoaneurysms, often requiring selective embolization of multiple vessels. Higher RENAL nephrometry score is associated with an increasing likelihood of multiple pseudoaneurysms. We found transarterial embolization to be a safe and effective treatment option with no long-term adverse effect on renal function in all but one patient with a solitary kidney.

Severe proteinuria secondary to amyloidosis requiring bilateral renal artery embolization

In the case reported here, after prolonged medical therapy resistance, severe proteinuria subsided following bilateral renal artery embolization (RAE). Thereafter, respiratory distress, anasarca edema, muscle mass, and serum albumin level improved after regular hemodialysis. Although RAE is reported to be a safe and effective therapeutic procedure, it is rarely used for severe proteinuria with prolonged medical therapy resistance. The limited use of bilateral RAE for nephrological purposes may be partly related to its tendency to destroy renal function, which results in anuria and subsequent regular dialysis. However, delayed RAE could cause the patient to reach a life-threatening cachexic state and could increase the risk of morbidity and mortality due to severe proteinuria-induced hypoalbuminemia. Our case and selected previous reports reveal important information for physicians and patients while discussing prognoses and considering the pros and cons of bilateral RAE.

Renal artery embolization: application and success in patients with renal cell carcinoma and angiomyolipoma

Renal artery embolization is a procedure primarily performed by interventional radiologists that can be utilized for treatment of renal tumors, both malignant and benign. It has many applications, including pretreatment of renal cell carcinomas prior to planned resection to decrease hemorrhagic complications intraoperatively, treatment of malignant renal tumor in patients who are not deemed suitable surgical candidates, as well as treatment of benign renal tumors and their potential hemorrhagic complications. There are many different techniques. We describe how the procedure is approached at the University of Florida-Gainesville and provide examples of two cases, a renal cell carcinoma and an angiomyolipoma, treated at our institution with transcatheter embolotherapy.