|Year : 2020 | Volume
| Issue : 3 | Page : 210-214
Renal artery embolization: A minimally invasive technique in the treatment of acute intractable iatrogenic hematuria – Experience at a tertiary care center
Saikat Bhattacharjee1, Virender Malik1, Atul Mishra2, Kamal Pathak1, Narendra Jain3, K Uday Bhanu3
1 Military Hospital Cardiothoracic Centre, Affiliated to Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Radiodiagnosis and Intervention Radiology, Army Hospital (R and R), New Delhi, India
3 Department of Radiodiagnosis and Intervention Radiology, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||21-Jul-2019|
|Date of Decision||16-Nov-2019|
|Date of Acceptance||03-Jan-2020|
|Date of Web Publication||3-Jun-2020|
Military Hospital Cardiothoracic Centre, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Hematuria following iatrogenic trauma or renal vascular malformations is less common but important causes warranting definite emergency procedure in cases not responding to conservative management. Endovascular embolization is accepted as an effective technique for the treatment of acute intractable hematuria. Considering the need of microcatheter for selective embolization, its use during the procedure increases the procedural cost significantly. The purpose of the present study is to assess the effectiveness and safety of selective renal artery embolization in patients with intractable hematuria using a 4-F glide catheter (GC). The microcatheter usage during our study was intended to be restricted to cases where the GC was not navigable to the optimal site for embolization. Materials and Methods: A retrospective analysis was done for 21 cases with acute intractable hematuria referred to our center between January 2015 and February 2019. Fifteen male and 6 female patients were included. Seventeen cases followed iatrogenic injury during a renal biopsy, 2 cases were due to renal neoplasm, and 1 each due to PCN and abdominal trauma. Embolization was carried out after selective catheterization of the feeding artery, with a 4-F GC using polyvinyl alcohol (PVA) particles in combination with pushable coils in all cases. Results: The source of bleeding was identified as arteriovenous fistula (AVF) in 14, AVF with pseudoaneurysm (PA) in 3, PA alone in 2, and abnormal tumor vascularity in 2 patients. In all but 2 cases, the hematuria stopped within 24 h after embolization. In the remaining 2 cases, hematuria stopped completely within 72 h. One patient developed minor puncture site bleed with no major procedural complications or recurrence on follow-up. Conclusion: Endovascular embolization is a highly effective minimally invasive technique for the treatment of acute intractable hematuria. Good results were achieved without using any microcatheter (hence cost-effective) with no clinically significant nontarget embolization.
Keywords: Endovascular, hematuria, interventional radiology, renal artery embolization
|How to cite this article:|
Bhattacharjee S, Malik V, Mishra A, Pathak K, Jain N, Bhanu K U. Renal artery embolization: A minimally invasive technique in the treatment of acute intractable iatrogenic hematuria – Experience at a tertiary care center. Med J DY Patil Vidyapeeth 2020;13:210-4
|How to cite this URL:|
Bhattacharjee S, Malik V, Mishra A, Pathak K, Jain N, Bhanu K U. Renal artery embolization: A minimally invasive technique in the treatment of acute intractable iatrogenic hematuria – Experience at a tertiary care center. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Jul 5];13:210-4. Available from: http://www.mjdrdypv.org/text.asp?2020/13/3/210/285761
| Introduction|| |
Hematuria is one of the most alarming conditions for both the patient and the treating physician. The common causes of hematuria include urinary tract infection, nephroureterolithiasis, genitourinary neoplasms, trauma, and benign prostatic hyperplasia. Other less common causes include iatrogenic trauma (during a biopsy or percutaneous nephrostomy) or renal vascular malformations. Angiogram and embolization may be required as an emergency procedure in cases not responding to conservative management.,,
Endovascular embolization is accepted as an effective technique for the treatment of acute intractable hematuria. Considering the need of microcatheter for selective embolization, its use during the procedure increases the procedural cost significantly. The purpose of the present study is to assess the effectiveness and safety of selective renal artery embolization (RAE) in patients with intractable hematuria using a 4-F glide catheter (GC). The microcatheter usage during our study was intended to be restricted to cases where the GC was not navigable to the optimal site for embolization.
| Materials and Methods|| |
This study was undertaken at a tertiary care interventional radiology center where cases from nearby hospitals are referred for angiography or intervention.
This is a descriptive study based on the retrospective analysis of cases after obtaining the necessary approval of the Institutional Ethics Committee. Medical record review of all the patients who underwent RAE from January 2015 to June 2018 at our center was done. The inclusion criteria were the presence of acute hematuria not responding to conservative management and clinical suspicion of an underlying vascular etiology as the source. The angiographic findings, vascular abnormality, type of embolization agent, and the method used were recorded. Immediate outcome (clinical change in hematuria within 24 h) in all the treated patients and their short-term (up to one week) follow-up in the hospital/outpatient department was also analyzed. The patients lost to short-term follow-up or with unavailable records were excluded from the study.
All the patients in the study were referred for an angiogram after the failure of a trial of conservative management. Twenty-one patients had a steady drop in hemoglobin and required a blood transfusion due to ongoing hematuria. Although overall the decision to transfuse was made based on the patient's hemoglobin level and hemodynamic status, in most cases, transfusion was initiated at a hemoglobin level of 7–8 g/dL. Four patients had moderate-to-severe pain in the abdomen and intermittent hematuria.
Iatrogenic trauma was the most common etiology (18/21), with renal biopsy accounting for all (17/21) cases, but one followed percutaneous nephrostomy. The other etiology encountered in our study was renal tumor-related bleed (2/21) and blunt abdominal trauma consequent to a road traffic accident (1/21) [Table 1].
The biopsy was performed by the radiologist in all cases, with the patient in the prone position, under ultrasound guidance, using the percutaneous route and a 16–18-G needle.
The renal artery embolization technique
All the procedures were performed by trained interventional radiologists. The available images (ultrasound and/or computed tomography) were reviewed prior to each procedure, suspected site of bleed localized based on the imaging findings, and selectively targeted during RAE.
Access was obtained through the transfemoral arterial route under local anesthesia. The renal arteries were cannulated with 4-F diagnostic GC (renal double curve or cobra catheters).
GCs with a hydrophilic coating (Terumo Inc., Japan) were preferred, given its excellent trackability and less traumatic properties. The 4-F GC showed excellent trackability, with no difficulty encountered navigating the catheter selectively into the feeding artery. Digital subtraction images were obtained after injection of iodinated contrast and abnormal vascularity identified in the form of presence of pseudoaneurysm (PA), AV fistula, or abnormal vascular blush. The feeding vessels were then selectively cannulated and embolization was performed using various agents as gel foam, polyvinyl alcohol (PVA) particles, and coils. PVA administration followed by pushable coil deployment was used for embolization in all but three cases (18/21). Gelfoam administration followed by pushable coil deployment was used for embolization in rest three cases. Contemplating the risk of nontarget embolization in these cases with the use of PVA, large-sized PVA particles (up to 750 μm) or Gelfoam were used with 4-F GC tip parked optimally proximal to the fistulous site. Particle mixing with a contrast agent aided in the detection of any non-target embolization at the earliest. The endpoint of embolization was the disappearance of abnormal vascularity and the appearance of stasis in feeding vessels [Figure 1], [Figure 2], [Figure 3]. Postembolization angiography was performed to rule out additional feeders.
|Figure 1: A case of post renal biopsy hematuria embolized with polyvinyl alcohol and coils (a) right renal artery angiogram shows a small ovoid sac (blue arrowhead) with early draining vein near the lower pole (red arrow) and opacification of inferior vena cava (red left-right arrow), suggestive of small pseudoaneurysm with arteriovenous fistula. (b) Selective lower renal artery branch depicts the fistula conspicuously. (c) Disappearance of pseudoaneurysm and fistula following polyvinyl alcohol embolization. (d) A pushable coil (blue block arrow) has been deployed at the origin of the feeding branch to avoid recanalization of the fistula. All other branches are well contrast opacified|
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|Figure 2: Another case of post renal biopsy hematuria treated with polyvinyl alcohol and coils, (a) Left renal artery Digital substraction angiogram (DSA) shows early draining vein (red arrow) due to arteriovenous fistula in mid-one-third of the left kidney. (b) Selective DSA of the feeding artery showed abnormal vascularity and arteriovenous fistula from two smaller peripheral branches (double red arrows). (c)Postpolyvinyl alcohol embolization image showing the disappearance of abnormal vascularity and arteriovenous fistula. (d) Postcoiling image shows coil in situ (blue block arrow) and exclusion of the abnormal vessel|
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|Figure 3: A case of left renal cell carcinoma while awaiting surgery presented with hematuria, embolized with polyvinyl alcohol and coil embolization, and operated 3 days later. (a) Pigtail angiogram showing left renal mass with abnormal tumor vascularity. The left renal artery is duplicated (red arrow and left-right arrow), with the proximal artery (red arrow) supplying the tumor predominantly. (b) Selective proximal renal artery DSA showing tumor blush (red arrow). (c) Postpolyvinyl alcohol embolization shows a significant reduction in tumor blush. (d) Postcoiling image shows coil in situ (blue block arrow) with no tumoral blush|
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The initial embolization agents used were PVA particles in most (18/21) cases, ranging from 300 to 750 μm and Gelfoam slurry in remaining (3/21) cases, which was followed by the deployment of pushable fibered metal coils (Cook, Inc., Bloomington, IN, USA) selectively in the feeding arteries. All the patients were observed in the intensive care unit (ICU) for 24–48 h at least for immediate control of the bleeding postprocedure (if any) and recurrence or any complication. All the patients were then observed in the ICU for at least 24–48 h, closely observing for postprocedural bleed or any other complication.
| Results|| |
A total of 21 patients underwent the RAE from January 2015 to June 2018 at our center. The median follow-up was 12 days (range 7–17 days). The mean age was 37 years (range 12–68 years). Fifteen male patients and six female patients were included in the study.
The source of bleeding was identified as AVF in most (14/21) patients, followed by AVF with PA and PA alone in 3 and 2 patients, respectively. The neoplastic group (2/21) demonstrated abnormal tumoral blush and corkscrew vessels.
Immediate and short-term outcomes of the renal artery embolization in controlling the hematuria
On immediate follow-up (within 24 h postprocedure), total cessation of hematuria was achieved in 19/21 patients (90.4%). The remaining 2 patients showed partial immediate response with subsequent complete resolution of hematuria over 72 h with conservative management. None of the patients had clinically noticeable hematuria at 1 week follow-up. No patient had a recurrence of hematuria during the short follow-up available (7–17 days).
The most common postprocedure sequel was mild abdominal pain or discomfort for 24–48 h (14/21 patients). Among the procedure-related complications, one patient developed puncture site small hematoma in the right groin that resolved completely at 1-week follow-up. None of the patients developed renal complications as oliguria, significant vascular injury, or urinary tract infection. Serum creatinine was measured in all 21 patients before and post the embolization procedure. Only 2 patients had >0.5 mg/dl increase in the creatinine value postembolization (compared to preprocedure levels) and were optimally managed conservatively in the ICU.
| Discussion|| |
Hematuria may occur due to multiple etiologies, with most responding well to conservative management. Iatrogenic hematuria due to renal parenchymal vascular injury, following biopsy or percutaneous nephrostomy, is not uncommonly met in the clinical practice and may not always respond to conservative management.,, Other rare causes of intractable hematuria as neoplasms or trauma may also cause significant hemodynamic effects and need to be addressed at the earliest. In the past, at times, the patient had to undergo partial or total nephrectomy for intractable hematuria despite the associated risk of significant morbidity and even mortality with the procedure.,,,, The first reports of an endovascular alternative to open surgery were published in the 1970s.
With the development and advancements in endovascular interventional techniques, availability of smaller catheters, and varied embolizing material options, it is now possible to super-selectively catheterize and embolize even the tiny arterial feeder, so providing a less invasive treatment option with minimal parenchymal loss and complications compared to surgery.,,,,
RAE provides a quick and effective way to control acute hematuria with very low complication rates.,,,,,
Different embolic materials have been reported to be used in RAE, including PVA, embospheres, gel foam, coils, and glue as reported in various studies.,,,,,,,,
In our study, immediate clinical success was seen in 19/21 patients (90.4%) and the short-term success rate in our patients was 100%, which is comparable to other series in the literature reported by Sofocleous et al., who used different types of embolic materials and also Cantasdemir et al. and Nuri et al. who used glue exclusively as the embolizing material in their studies. We did not have any patient with the recurrence of hematuria following its cessation initially [Table 2].
|Table 2: Renal artery embolization in the treatment of acute hematuria: Literature review|
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The selective technique of targeting the embolization of abnormal blood vessels significantly reduces the extent of renal parenchymal damage, resulting in excellent preservation of functioning renal tissue. None of our patients developed any new onset or exacerbation of preexisting renal insufficiency postembolization.
Contemplating the risk of nontarget embolization in these cases with the use of PVA,large-sized PVA particles (up to 750 μm) or Gelfoam were used with 4-F GC tip parked optimally proximal to the fistulous site. Furthermore, the intention was to avoid or at least reduce the number of coils to be used. Although there exists a theoretical risk of nontarget embolization, the combined effect of the use of large-sized particles (or gel foam) and the GC tip parked optimally proximal to the fistulous site (and not at the fistulous site) prevented any clinically significant nontarget embolization.
None of our patients developed serious complications such as a perinephric abscess, acute renal failure, or significant nontarget embolization. This strengthens our belief that endovascular treatment has a high safety profile and should always be offered whenever possible.
The limitations of this study were its small patient population, availability of only short-term direct follow-up, and its retrospective nature.
| Conclusion|| |
To the best of our knowledge, the present study is one of the largest series of RAE in the treatment of acute intractable iatrogenic hematuria. Furthermore, in our study, we were able to achieve good results without using any microcatheter (hence cost-effective) with no inadvertent clinically significant nontarget embolization. Our study emphasizes that RAE is a less invasive and safe alternative to surgery with high technical success in patients with intractable hematuria. It may prove to be life-saving in a few cases with hemodynamic instability. The procedure has very little morbidity and mortality compared to the surgical alternative. The procedure should, therefore, be offered as the first treatment alternative in all cases of acute intractable hematuria.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]