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Transcatheter embolization for iatrogenic renal hemorrhage: a single center experience / Iyatrojenik bobrek kanamalarinda transkateter embolizasyon: tek merkez deneyimi.

Introduction

Renal vascular injuries are the main complications of percutaneous procedures and require close observation. Although the majority of these patients can be managed with conservative treatments, a number of complications such as prolonged hematuria, persistence of bleeding with unstable condition, arteriovenous fistula formation and pseudoaneurysm require active operative or angiographic intervention. Renal biopsy, nephrostomy placement, partial nephrectomy and percutaneous nephrolithotomy (PNL) are some of the procedures that may cause massive bleeding, which can be treated successfully by transcatheter embolization (TCE). (1) Additionally, the introduction of smaller catheters and novel embolic agents has decreased the morbidity associated with this technique. (2)

Over the last decade, PNL became one of the most frequently applied surgeries in urology departments. Concurrently, the complications of PNL have recently been the subject of numerous publications. It has been reported that bleeding is one of the most common complications after PNL. (3) It is therefore important for urologists to work in close collaboration with interventional radiologists if worrisome renal hemorrhaging is to be prevented with minimally invasive techniques.

In this study, we aimed to report our experience with TCE in 18 consecutive patients with massive renal bleeding after renal procedures. In addition, we investigated whether the increasing number of TCE procedures for iatrogenic renal injuries at a single hospital was associated with the performance of PNL.

Materials and methods

From 2005 to 2010, eighteen patients underwent twenty TCE procedures for iatrogenic renal injury at our institution. Embolization procedures used for the elective cases including; treatment of angiomyolipoma, before nephrectomy for renal mass and end-stage renal disease were excluded from the study. Patient age, gender, Clavien classification, transfusion units, indications for TCE and embolic material were noted. The numbers of TCE and PNL performed during the years were reviewed retrospectively. The TCE-related complications were obtained from the medical records. The data are represented as the mean[+ or -]standard deviation.

All TCE procedures were performed at the same angiography unit (Siemens Axion Artis FA, Germany) of our institution by the same interventional radiologist (KCC). The decisions to perform TCE were made after consultations between the departments and after informed consent was obtained from the patients. Duplex ultrasound of the kidneys (n=8) and/or computed tomography (CT) angiography (n=14) was performed prior to TCE treatment in each patient. Prophylactic antibiotics and analgesics were administered and pre-procedural anxiolytics were given, depending on the indication and context. The patients were appropriately hydrated before the embolization to avoid any deterioration of renal function.

The Seldinger method was used for introduction from the right femoral arterial access site under local anesthesia. Aortography was initially performed via insertion of a pig-tail catheter and followed by selective renal arteriography to elucidate any pathology related to the iatrogenic injury. A total of 25 mL of non-ionic contrast material was used at 15 mL/second for visualization. After determination of the renal artery ostia, a 5F catheter was used to facilitate the advancement into the renal artery. Additionally, a 2.7F micro-catheter was used for the superselective catheterization into the distal branches. Subsequently, any vascular structures causing bleeding were identified. Embolizing materials used for the treatment are listed as follows: periferic coil (Hilal microcoil 0.18 COOK, Azur hydrocoil pushable 0.18 TERUMO), glue (liquiband MEDLOGIC), and Onyx-18 (MTI-EV3, Irvine, CA, USA). The embolizing materials were selected according to the lesion diameter and the type of hemorrhage.

The serum creatinine and hemoglobin levels, blood pressure and vital status of the patient were monitored closely prior to and after the procedure. TCE was repeated if any failure of the embolization was detected. Technical success was defined as occlusion of the lesion documented by immediate post-procedural angiography. Clinical success was defined as complete cessation of hematuria and the return of normal hemoglobin and creatinine values with no recurrence within 4 weeks.

Results

Of the 18 patients (12 male, 6 female) whose charts were reviewed, the mean patient age was 39.3[+ or -]12.0 years (range 18-to-65). The mean time for the TCE performance after the main procedure leading to iatrogenic renal hemorrhage was 4.8[+ or -]4.0 days (range 1 to 14). The mean hemoglobin value was 7.8[+ or -]1.4 mg/dL (range 5 to 11) prior to TCE. The Clavien grade was IIIa for 17 patients and IVa for one patient. The mean number of transfusion units prior to TCE was 2.9[+ or -]2.2 (range 1 to 8). The procedures leading to severe renal hemorrhage were renal biopsy (n=2), nephrostomy placement (n=1), partial nephrectomy (n=3) and PNL (n=12).

In total, there were 3 performances of TCE for iatrogenic injuries in the first two years, 9 in the second two years and 6 in the remaining two years. In accordance, the numbers of PNL procedures performed during these defined periods were 92, 208 and 143, respectively. The proportion of the PNL over the other causative procedures leading to TCE is shown in Figure 1. Of the 18 patients, angiography revealed pseudoaneurysm as the main cause of bleeding in 10 (Figure 2). In the rest of the patients, arteriovenous fistula (AVF) was detected in 2, and persistent bleeding into the collecting system was detected in 6 (Figure 3). A total of 16 patients underwent single endovascular intervention, whereas two patients (11.1%) required a second TCE procedure to stop the bleeding. Technical success was achieved in 17 of the patients, whereas clinical success was achieved in 15. The overview of patient characteristics, including the embolizing agents, is summarized in Table 1. One patient, in whom PNL was the causative procedure of massive hemorrhage requiring TCE, had undergone nephrectomy. Regardless of the technically successful TCE performance, prolonged hematuria developed, and the patient became hemodynamically unstable. After performance of nephrectomy, the hematuria ceased, and the patient became stable within the following week.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]
Table 1. Overview of the characteristics of the patients
undergoing TCE.

Ptno. Age Causative Clavien Hgb mg/dL Embolizing Technical
 procedure score material success

1 65 Biopsy 3 7 PVA+glue Yes

2 34 PNL 3 9 Glue Yes

3 18 Nephrostomy 8 PVA Yes

4 44 PNL 3 10 Coil Yes

5 51 Partial 8 Glue Yes
 nephr.

6 35 PNL 4a 5 Coil Yes

7 25 Biopsy 10 Coil Yes

8 39 PNL 3 8 Glue Yes

9 38 PNL 3 10 Coil+glue Yes

10 53 PNL 3 11 Glue Yes

11 33 PNL 3 8 Coil Yes

12 60 PNL 3 8 Coil Yes

13 32 PNL 9 Glue No

14 48 Partial 3 10 Glue Yes
 nephr.

15 28 PNL 10 Onyx Yes

16 35 PNL 3 8 Glue Yes

17 33 PNL 3 9 Onyx Yes

18 38 Partial 3 10 Onyx Yes
 nephr.

Ptno. Clinical
 Success

1 Yes

2 Yes

3 Yes

4 Yes

5 No

6 No

7 Yes

8 Yes

9 Yes

10 Yes

11 Yes

12 Yes

13 No

14 Yes

15 Yes

16 Yes

17 Yes

18 Yes


Following TCE, two of our patients experienced flank pain in the early period, but the rest of the cases did not experience any TCE-related complications, such as pyrexia, ectopic coil placement, renal intimal dissection, renal abscess or renal deterioration.

Discussion

TCE is a minimally invasive, safe and effective procedure for stopping problematic renal bleeding after iatrogenic injury. We have found that the frequent performance of PNL has resulted in increasing performance of TCE at our institution.

The most frequently performed institutional procedures that may cause iatrogenic renal injury are renal biopsy, percutaneous nephrostomy placement, laparoscopic or open partial nephrectomy and PNL. (1) When compared to the other procedures, although practiced for almost 30 years, the number of PNL performances significantly increased after the superiority of this procedure on open stone removal was proven over the last decade. Regardless of large stone sizes or anatomically abnormal kidneys, PNL became a method of choice in the majority of the urology departments in which this technology was available because of its less invasive nature. (4), (5) Technical advances in the design of nephroscopes have encouraged the compact use of PNL for the treatment of renal calculi. Continuously evolving fiberoptic visualization, downsizing of the devices, safer use of fluoroscopy and improvements in stone fragmentation have all broadened the indications of PNL. In 2005, PNL became available at the urology departments in our hospital and soon replaced open surgical procedures for kidney stone removal.[6] Even though PNL is a safe and minimally invasive procedure, surgical difficulties may still occur, some of which have lasting consequences. Renal hemorrhage is the most serious complication of PNL, which has been previously addressed elsewhere. (7) Massive bleeding may occur during needle passage, tract dilation, stone fragmentation, manipulation of the amplatz sheath or nephrostomy placement. Tube clamping, hydration, and tamponade placement are some of the bleeding prevention methods that are used. Nevertheless, the incidence of severe bleeding requiring angiography and embolization is approximately 1.4%. (8) In our series, 2.7% (12 of 443) of the patients required TCE following PNL, which is slightly higher than the current data, most likely because of our tendency to choose a safer treatment in patients with severe bleeding. When the numbers of our PNL and TCE procedures were separated by year, we noted that 3 TCE procedures were performed in the first two years, 9 in the second two years and 6 in the remaining two years. The numbers for PNL performance during these defined periods were 92, 208 and 143, respectively. Accordingly, when we evaluated the proportion of the causative procedures leading to renal hemorrhage requiring TCE, we observed that the numbers of PNL performance directly affected the overall performance of TCE in the defined periods at our institution (Figure 1).

[FIGURE 1 OMITTED]

Another procedure that may cause severe renal hemorrhage due to iatrogenic renal injury is the partial nephrectomy operation. It has been previously reported that partial nephrectomy can cause bleeding in 0 to 4.5% of cases. (9) Three of our patients experienced severe renal bleeding following this procedure. Although technical success was achieved in these three patients after TCE, one experienced prolonged hematuria and required another session of TCE to stop the bleeding. Finally, all patients were successfully treated without the need for total nephrectomy.

Kidney biopsy is another important procedure frequently used by nephrologists and radiologists that may lead to severe bleeding. Soares and colleagues reported on 289 renal biopsy cases in an investigation of amyloidosis in the absence of abnormal international normalized ratio (INR). (10) They observed severe hemorrhage in 5 of the patients (1.7%) who received embolization for the treatment. In our series, 2 of 18 patients received TCE because of renal biopsy. Pseudoaneurysm formation was detected in both cases, and both were successfully treated after appropriate embolization.

Typically, segmental arteries rather than small intrarenal vessels are the cause of severe renal hemorrhage. The most common reasons for bleeding from these vessels are AVF and pseudoaneurysm formations. Srivastava et al., (8) reported 13 pseudoaneurysms and 6 AVFs between 27 TCE procedures. In our series, we also detected pseudoaneurysm as the most common angiographic appearance leading to hemorrhage in our population (Figure 2a, b). 10 out of 18 patients were treated because of pseudoaneurysm formation, and 2 of our patients had AVFs (Figure 3a, b). The rest of the patients had persistent bleeding from different segmental arteries.

Although the majority of percutaneous renal procedures are safe with minimal morbidity, it has been reported that renal vascular injuries requiring blood transfusion may occur in 1 to 11% of cases. (1) However, only a few of those patients become clinically unstable despite transfusion, appropriate medication and simple maneuvers to stop bleeding and consequently require further intervention. Therefore, in these circumstances, percutaneous angiography with superselective embolization is superior to open surgical exploration because of its lower morbidity, lower hospital costs, high success rate and lower risk of nephrectomy. (11), (12) Breyer et al., (13) performed a review of 10 published case series of embolization therapy for renal trauma. They found that the overall technical success rate was 90% (151 of 167), and the clinical success rate was 79% (132 of 167). In our series, the rate of technical success was 94.4%, and the clinical success rate was 83.3%, which makes our results comparable with those of previous studies. Considering the existing data, TCE, a preferred method of treatment at our institution, is safe and effective for stopping problematic renal bleeding after iatrogenic injury.

In conclusion, TCE is a minimally invasive, safe and effective procedure for stopping serious renal bleeding after iatrogenic injury. Wide performance of PNL has resulted in increasing performance of TCE at our institution. At centers where PNL is frequently performed, both the urologists and interventional radiologists should collaborate on the treatment of vascular complications.

Conflict of interest

No conflict of interest was declared by the authors.

Submitted: 14.12.2011

Accepted: 28.03.2012

Correspondence:

Mesrur Selcuk Silay

Adnan Menderes Bulvari, Vatan

Caddesi, Fatih 34093

Istanbul, Turkey

Phone: +90 505 645 40 05

E-mail: selcuksilay@gmail.com

[c]Copyright 2012 by Turkish Association of Urology

Available online at www.turkishjournalofurology.com

References

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(2.) Keller FS. Interventional radiology: New paradigms fort he new millenium. J Vasc Interv Radiol 2000;11:677-81. [CrossRef]

(3.) Michel MS, Trojan L, Rassweiler JJ. Complications in percutaneous nephrolithotomy. Eur Urol 2007;51:899-906. [CrossRef]

(4.) Cracco CM, Scoffone CM, Scarpa RM. New developments in percutaneous techniques for simple and complex branched renal stones. Curr Opin Urol 2011;21:154-60. [CrossRef]

(5.) Miller NL, Matlaga BR, Handa SE, Munch LC, Lingeman JE. The presence of horseshoe kidney does not affect the outcome of percutaneous nephrolithotomy. J Endourol 2008;22:1219-25. [CrossRef]

(6.) Tanriverdi O, Boylu U, Kendirci M, Kadihasanoglu M, Horasanli K, Miroglu C. The learning curve in the training of percutaneous nephrolithotomy. Eur Urol 2007;52:206-11. [CrossRef]

(7.) Kurtulus F, Fazlioglu A, Tandogdu Z, Karaca S, Salman Y, Cek M. Analyses of factors related with bleeding in percutaneous nephrolithotomy using balon dilatation. Can J Urol 2010;17:5483-9.

(8.) Srivastava A, Singh KJ, Suri A, Dubey D, Kumar A, Kapoor R, et al. Vascular complications after percutaneous nephrolithotomy: are there any predictive factors? Urology 2005;66:38-40. [CrossRef]

(9.) Polasjik TJ, Pound CR, Meng MV, Partin AW, Marshall FF. Partial nephrectomy: technique, complications and pathological findings. J Urol 1995;154:1312-8. [CrossRef]

(10.) Soares SM, Fervenza FC, Lager DJ, Gertz MA, Cosio FG, Leung N. Bleeding complications after transcutaneous kidney biopsy in patients with systemic amyloidosis: single-center experience in 101 patients. Am J Kidney Dis 2008;52:1079-83. [CrossRef]

(11.) Fisher RG, Ben-Menachem Y, Whigham C. Stab wounds of the renal artery branches: Angiographic diagnosis and treatment by embolization. AJR Am J Roentgenol 1989;152:1231-5.

(12.) Poulakis V, Ferakis N, Becht E, Deliveliotis C, Duex M. Treatment of renal-vascular injury by transcatheter embolization: Immediate and long-term effects on renal function. J Endourol 2006;20:405-9. [CrossRef]

(13.) Breyer BN, McAninch JW, Elliott SP, Master VA. Minimally invasive endovascular techniques to treat acute renal hemorrhage. J Urol 2008;179:2248-52. [CrossRef]

Kosti Can Caliskan (1), Mesrur Selcuk Silay (2), Orhan Tanriverdi (3), Sitki Mert Ulusayl (1), Emin Cakmakci (1), Zeki Karpat (1), Cengiz Miroglu (3)

(1) Department of Radiology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey

(2) Department of Urology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey

(3) Department of 2nd Urology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey
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Author:Caliskan, Kosti Can; Silay, Mesrur Selcuk; Tanriverdi, Orhan; Ulusay, Sitki Mert; Cakmakci, Emin; Ka
Publication:Turkish Journal of Urology
Date:Sep 1, 2012
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