Renal devitalization using 95 per cent ethyl alcohol

Percutaneous transcatheter renal ablation with absolute ethanol for uncontrolled hypertension or nephrotic syndrome: results in 11 patients with end-stage renal disease

PURPOSE

Retrospective review of authors' experience with percutaneous transcatheter renal ablation in patients with uncontrolled hypertension and/or nephrotic syndrome.

MATERIALS AND METHODS

Between April 1987 and September 1995, renal ablation was performed on 11 patients aged 10 months to 21 years. All patients had end-stage renal disease (ESRD) with uncontrolled hypertension (10 patients) and/or nephrotic syndrome (four patients). Uncontrolled hypertension was defined as diastolic pressure greater than 90 mm Hg despite multidrug antihypertensive therapy. Nephrotic syndrome was defined as proteinuria exceeding 960 mg/m2 per day, serum albumin level less than 3 g/dL, and generalized edema. Embolization was performed with absolute ethanol from a common femoral artery approach. In most cases, a balloon catheter was used to prevent alcohol reflux into the aorta or nontarget renal artery branches, such as the adrenal arteries. Angiographic stasis of contrast material in the renal arteries was the endpoint.

RESULTS

All patients experienced a postembolization syndrome of 3-5 days duration, clinically manifested by variable degrees of nausea, vomiting, fever, and pain. Long-term improvement in hypertension was observed in nine patients. Improvement in hypertension was defined as diastolic blood pressure below 90 mm Hg while the patient received the same or fewer antihypertensive medications. The four patients with nephrotic syndrome were cured of their proteinuria and edema.

CONCLUSIONS

Transarterial renal ablation with alcohol is efficacious for treatment of uncontrolled hypertension and nephrotic syndrome in patients with ESRD. The morbidity and mortality in our series were less than those reported for surgical nephrectomy.

Ablation of tumor and inflammatory tissue with absolute ethanol

Absolute ethanol was used to ablate tumors, inflammatory lesions, and end-stage nephrosclerotic kidneys in 38 patients. Thirty patients had various types of renal tumors, and 3 had chronic end-stage renal failure with malignant hypertension. One patient had a fibrosarcoma of the right leg and one had a metastasis in the humerus from a renal carcinoma. A large adrenal carcinoma was treated with absolute ethanol in a patient who had liver metastases that were ablated one year after the first procedure. An additional patient had metastatic liver disease from a non-functioning adrenal carcinoma. The remaining patient had an extensive hypervascular inflammatory lesion (tuberculosis and aspergilloma) of the right upper pulmonary lobe. In addition to ethanol, coils were introduced in one patient and Gelfoam in another. The amount of ethanol used ranged from 5 to 50 ml. Twenty-two patients suffered from considerable transient pain during ethanol injection, but sedation was necessary in only 3 of them. Skin necrosis appeared in 2 patients requiring plastic reconstruction in one of them. Two patients died within 5 days of the procedure unrelated to the ablation. Two patients presented upper gastrointestinal bleeding within 2 days of the ethanol injection and one of these died in acute renal failure. One patient suffered from left colonic infarction after left renal tumor ablation, but survived for several months. Absolute ethanol was a useful and efficient sclerosing agent causing extensive tumor destruction and marked reduction of the vascularity in tumor and inflammatory lesions, but caused an 18 per cent complication rate.

Alcohol occlusion of segmental renal arteries as alternative to kidney resection

Treatment of postoperative urine leakage after a lower pole resection by embolic occlusions of segmental arteries using pure ethanol in a thirty-four-year-old man is described. There were no postoperative complications, and follow-up examination at two years showed a functioning but small kidney in a patient without symptoms.

Preoperative angioinfarction of localized renal cell carcinoma using absolute ethanol

A total of 25 patients with renal cell carcinoma underwent angioinfarction of the tumor using absolute ethanol. An average of 15 ml. absolute ethanol was injected into the main renal artery through a balloon occlusion catheter. Complete cessation of renal arterial flow could be demonstrated in all cases. The post-embolization syndrome of pain, nausea, vomiting, hypertension and fever was minimal compared to other methods of renal artery occlusion. Of the patients 21 underwent post-infarction transabdominal radical nephrectomy without intraoperative or postoperative complications attributable to the injection of absolute ethanol. No damage to extrarenal tissue was noted at operation. Subsequent surgical dissection was facilitated, particularly in cases of large tumors when control of the renal pedicle often is difficult. Median blood loss was 725 ml. In light of recent reports concerning the benefit of angioinfarction and nephrectomy in metastatic disease a similar approach may be applicable to localized disease. This pilot study shows the safety of preoperative angioinfarction with absolute ethanol and may be used as a reference for future randomized prospective studies comparing angioinfarction and nephrectomy to nephrectomy alone for localized renal cell carcinoma.

Control of hypertension after renal transplantation by embolisation of host kidneys

A percutaneous embolisation technique was used for host kidney ablation in 13 patients with renal allografts and hypertension. Markedly improved blood pressure control was achieved in 9 of them, and morbidity was minimal. All patients have been followed from 12 to 25 months. Embolisation of the host kidneys appears to be a simple, effective, and less hazardous alternative to surgery in the treatment of drug-resistant hypertension after renal transplantation in some patients.

Segmental hepatic arterial occlusion with absolute ethanol in domestic swine

Four to five ml of absolute ethanol was injected into a segmental hepatic artery in eight pigs to study the occlusive effect on the hepatic arterial system. Liver cell damage was indicated by a transient moderate elevation of liver enzymes. Follow-up angiography at various time intervals showed persistent occlusion of intrahepatic arteries at different levels in all pigs and occlusion of the common hepatic artery in four. Reconstitution of the intrahepatic arterial circulation via abundant intrahepatic collaterals was, however, observed. Microscopic examinations demonstrated arterial thrombi and necroses in the vascular walls as well as a great variation in the extent of liver parenchymal damage.