Amplatzer vascular plug IV in the treatment of high flow renal arteriovenous fistula: Case considerations

Renal arteriovenous fistula is classified into idiopathic, acquired and congenital. Endovascular therapy has become the gold standard compared to surgery. We present the embolization procedure of a renal fistula postbiopsy in a 57-year-old female patient through the use of St. Jude Medical Amplatzer vascular Plug IV. Although numerous embolizing agents are available, plug type IV has numerous advantages in terms of procedure times, speed of embolization and precision of the occlusion, but with a relative increase in costs.

Immediate preoperative renal artery embolization in the resection of complex renal tumors (UroCCR-48 Reinbol study)

PURPOSE

We evaluated the feasibility and outcomes of immediate preoperative renal artery embolization (IPRAE) before complex nephrectomy for locally advanced RCC ± inferior vena cava thrombus (IVCT).

METHODS

A comparative retrospective (2007-2017) multicenter study which included 145 patients with locally advanced RCC ± IVCT: 99 radical nephrectomies vs. 46 radical nephrectomies with IPRAE identified in the prospective UroCCR national database (CNIL DR 2013-206; NCT03293563). IPRAE was performed under local anesthesia the day of nephrectomy (< 4 h prior to nephrectomy). The primary endpoint was peroperative blood loss (mL). Secondary outcomes were: tolerance of embolization (pain visual scale), success rate of IPRAE defined by complete devascularization of the kidney, perioperative complications according to Clavien score and postoperative GFR.

RESULTS

The baseline characteristics of IPRAE and the control groups were similar. Tumor staging was 14% T2b, 41% T3a, 27% T3b, 13% T3c, 6% T4. The success rate of IPRAE was 98%. Median artery embolizated per patient was 2 (Agochukwu and Shuch in World J Urol 32:581-589, 2014; Marshall et al. in J Urol 139:1166-1172, 1988; Yap et al. in BJU Int 110:1283-1288, 2012;Gill et al. in J Urol. 194:929-938, 2015; Wang et al. in Eur Urol 69:1112-1119, 2016). No severe complications occurred after IPRAE. Postembolization syndrome was reported in 7% (Clavien I-II). Mean peroperative blood losses in the IPRAE and control groups were: 726 ± 118 ml and 1083 ± 114 ml (P = 0.03). In a multivariate analysis that included: age, Karnofsky index, IPRAE (yes vs. no), IVCT (yes vs. no), tumor size and synchronous metastasis, no IPRAE and IVCT were significantly associated with increased peroperative bleeding.

CONCLUSION

IPRAE before nephrectomy for locally advanced and/or IVCT tumors was well tolerated, was associated with lower peroperative bleeding and did not increase the incidence or severity of postoperative complications.

Endovascular management of vascular renal injuries: outcomes and comparison between traumatic and iatrogenic settings

PURPOSE

To evaluate the efficacy of endovascular treatment for vascular renal injuries (VRIs) like bleeding, pseudoaneurysm and artero-venous fistula (AVF) and to compare patients with blunt trauma (T-VRIs) with those with iatrogenic damage (I-VRIs).

METHODS

We retrospectively assessed 49 renal artery embolizations performed to treat T-VRIs (26.5%) and I-VRIs (73.5%). Different embolic materials were used based on the type of lesion. Technical success was defined as the complete occlusion of target arteries with no further visualization of VRIs. Clinical success was defined if no recurrence was present and if renal function (difference between creatinine after and before treatment <0.5 mg/dl) was preserved after 1 month.

RESULTS

Angiography showed bleeding in 27 patients, pseudoaneurysm in 29 and an AVF in 6. Embolic agents used were coils in 39 procedures, coils with sponge in four and others in six. Technical success was 100% while clinical success was 85.7% due to seven patients with recurrence. The group I-VRIs showed a higher rate of clinical success than the group T-VRIs (94.4% vs 61.5%; p < 0.05). Moreover, the group I-VRIs had a higher incidence of pseudoaneurysms and AVFs compared with the group T-VRIs (69.4% vs 30.8% and 16.7% vs 0%; p < 0.05).

CONCLUSION

Endovascular treatment for VRIs showed satisfactory results and no patient had a worsening of renal function. I-VRIs had better clinical success and more frequently appeared as pseudoaneurysms compared to T-VRIs: probably iatrogenic injury is localized and pseudoaneurysm is easily identifiable and treatable with endovascular treatment.