Percutaneous renal ablation in patients with end-stage renal disease: alternative to surgical nephrectomy

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.

Radiologically Guided Renal Artery Embolization with an Amplatzer Vascular Plug as a Rescue Therapy for Refractory Nephrotic Syndrome in AL-Amyloidosis

Nephrotic syndrome is common in immunoglobulin light-chain (AL) amyloidosis and successful therapy may pose a challenge. We report the case of a 63-year-old patient with severe nephrotic syndrome due to primary renal AL-amyloidosis with well-preserved renal function at first presentation. Therapy with high dose steroids, loop diuretics, and ACE-inhibitors did not affect his proteinuria and he was seriously disabled because of symptomatic orthostatic hypotension and anasarca. With the patient's informed consent, medical nephrectomy was tried with nonsteroidal-anti-inflammatory drugs (NSAIDs), cyclosporine, and aminoglycosides, with significant deterioration of his renal function, but without relevant effect on his proteinuria. Despite adequate anticoagulation life threatening thrombotic and bleeding complications occurred. Total renal ablation was finally achieved using an Amplatzer vascular plug Typ IV (AVP 4) with a self-expanding Nitinol mesh design, which was placed in both main renal arteries in the same intervention. The patient became completely anuric, protein loss stopped, and serum albumin slowly rose to normal levels. The patient's clinical condition dramatically improved and he regained his full mobility at the price of a lifelong renal replacement therapy. To our knowledge, this is the first reported usage of such a vascular occluder in the setting of refractory nephrotic syndrome with normal kidney function at the time of first presentation.

Use of angioembolization in urology: a review

This review discusses current and developing indications for angioembolization (AE) techniques in urology cases, including trauma and non-trauma uses for kidney, prostate, and bladder conditions. AE methods, complications and technical and clinical outcomes are outlined for each indication for the purpose of aiding urologists in selecting ideal candidates for this procedure.

Safety and efficacy of transarterial nephrectomy as an alternative to surgical nephrectomy

OBJECTIVE

To evaluate the safety and efficacy of transarterial nephrectomy, i.e., complete renal artery embolization, as an alternative to surgical nephrectomy.

MATERIALS AND METHODS

This retrospective study included 11 patients who underwent transarterial nephrectomy due to a high risk of surgical nephrectomy or their refusal to undergo surgery during the period from April 2002 to February 2013. Medical records and radiographic images were reviewed retrospectively to collect information regarding underlying etiologies, clinical presentations and embolization outcomes.

RESULTS

The underlying etiologies for transarterial nephrectomy included recurrent hematuria (chronic transplant rejection [n = 3], arteriovenous malformation or fistula [n = 3], angiomyolipoma [n = 1], or end-stage renal disease [n = 1]), inoperable renal or ureteral injury (n = 2), and ectopic kidney with urinary incontinence (n = 1). The technical success rate was 100%, while clinical success was achieved in eight patients (72.7%). Subsequent surgical nephrectomy was required for three patients due to an incomplete nephrectomy effect (n = 2) or necrotic pyelonephritis (n = 1). Procedure-related complications were post-infarction syndrome in one patient and necrotic pyelonephritis in another patient. Of four patients with follow-up CT, four showed renal atrophy and two showed partial renal enhancement. No patient developed a procedure-related hypertension.

CONCLUSION

Transarterial nephrectomy may be a safe and effective alternative to surgical nephrectomy in patients with high operative risks.

Renal artery embolization

Renal artery embolization (RAE) is an effective minimally invasive alternative procedure for the treatment of a variety of conditions. Since the 1970s when RAE was first developed, technical advances and growing experience have expanded the indications to not only include treatment of conditions such as symptomatic hematuria and palliation for metastatic renal cancer, but also preoperative infarction of renal tumors, treatment of angiomyolipomas, vascular malformations, medical renal disease, and complications following renal transplantation. With the drastically improved morbidity associated with this technique in part due to the introduction of more precise embolic agents and smaller delivery catheters, RAE continues to gain popularity for various urologic conditions. The indications and techniques for renal artery embolization are reviewed in the following sections.

Renal ablation using bilateral ureteral ligation for nephrotic syndrome due to renal amyloidosis

Nephrotic syndrome is common in immunoglobulin light chain amyloidosis (AL). In patients who do not achieve renal recovery, renal ablation has been reported for intractable proteinuria. We describe a patient with renal-limited AL who failed therapy and developed disabling proteinuria. He underwent laparoscopic ligation of the native ureters. Post-operatively, blood pressure improved. Hemodialysis was initiated. We conclude that bilateral ureteral ligation is a novel and minimally invasive method of renal ablation and may be considered for patients with refractory nephrotic syndrome.

Transcatheter arterial embolization in patients with kidney diseases: an overview of the technical aspects and clinical indications

Therapeutic embolization is defined as the voluntary occlusion of one or several vessels, and this is achieved by inserting material into the lumen to obtain transient or permanent thrombosis in the downstream vascular bed. There are a number of indications for this approach in urological practice, in particular for the patients with parenchymatous or vascular kidney disease. In this review, we present the different embolization techniques and the principally employed occluding agents, and then we present the principal clinical indications and we discuss other pathologies that may benefit from this non-invasive therapy. The complications, side effects and main precautions associated with this approach are also described.

Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children

BACKGROUND

: Angiographic embolization (AE) is used to control hemorrhage in adult blunt liver, spleen, and kidney (ASO) injuries. Pediatric experience with AE for blunt ASO injuries is limited. We reviewed our use of AE to control bleeding pediatric blunt ASO injuries for efficacy and safety.

METHODS

: A 5-year review (trauma registry and charts) of children (age < or = 16 years) who had AE for hemorrhage from blunt ASO injuries. Nonoperative management was attempted in all stable children with blunt ASO injuries. Children with ongoing hemorrhage underwent AE. The success of AE and complications were evaluated. Data were reviewed on injury type and grade, injury severity score, length of intensive care unit stay (LOS-ICU) and length of hospital stay (LOS), and complications.

RESULTS

: One hundred twenty-seven patients with 149 blunt ASO injuries were identified (72 spleen, 51 liver, and 26 renal). Two children had immediate splenectomies. Seven children underwent AE: two spleen (grades IV and V), two liver (grades III and IV), and three grade IV renal injuries. Three children received blood before embolization. Mean age and injury severity score were 12.3 years +/- 3.7 years and 22.4 +/- 10.0,respecyively. Mean intensive care unit stay was 4.8 days +/- 5.5 days with a mean length of hospital stay of 12.8 days +/- 5.5 days. Embolization was successful in all children; there were no procedure-related complications. Four minor complications occurred; two pleural effusions and two patients with transient hypertension. A nephroblastoma was later found in one renal injury requiring nephrectomy.

CONCLUSIONS

: AE is a safe and an effective technique for controlling hemorrhage from blunt ASO injuries in select pediatric patients.

When urine is no longer beneficial: renal artery embolisation in severe nephrotic syndrome secondary to amyloidosis

Renal artery embolisation (RAE) is an interventional radiology procedure which is used to embolise small branches of renal artery. It is mainly used for urologic purposes, i.e., vascular malformations, angiomyolipomas and renal tumours not amenable to surgical resection. Bilateral RAE can be performed via using absolute ethanol, polyvinyl alcohol or microparticles. After RAE, patients may experience post-embolisation syndrome which is usually self-limited. Use of this procedure for refractory nephrotic syndrome has been rarely defined in the literature to date. Here, we describe a patient who had nephrotic syndrome due to secondary systemic amyloidosis. The patient presented with severe proteinuria (33 g per day), hypoalbuminaemia and anasarca oedema. We applied bilateral RAE with microparticles. We did not observe any complications associated with the procedure. Protein excretion, laboratory values and clinical signs returned to normal.

Transcatheter renal artery embolization: clinical applications and techniques

Renal artery embolization is a minimally invasive procedure that is increasingly being used for treatment of a wide range of conditions. The main indications for renal artery embolization include (1) prenephrectomy and preradiofrequency ablation infarction of renal tumors, (2) management of renal angiomyolipomas, (3) palliations of unresectable renal malignancy, (4) renal hemorrhage (life-threatening or chronic debilitating hematuria), (5) arteriovenous fistulas, (6) vascular malformations, (7) renal artery aneurysms and pseudoaneurysms, and other less common indications, such as severe hydronephrosis and hypertension. A variety of embolic materials are available, such as metal coils, sclerosants (glue, Onyx, absolute ethanol, lipiodol), and particulate embolic agents (polyvinyl alcohol particles and embospheres). Selection of the appropriate agent depends on the clinical application, technical and clinical endpoints, as well as the pathology lesion(s) targeted. Renal artery embolization can be performed alone or in combination with remodeling techniques, stent-grafting, and balloon- or stent-assisted coiling in more complicated cases. The procedure is generally regarded as safe and effective for diverse applications and is considered as an evolving area in the field of endoluminal therapy.

[Role of percutaneous arterial embolization in renal pathology]

Therapeutic embolization in renal pathology is used for various conditions in cancerology, traumatology, urology, nephrology and for iatrogenic complications of percutaneous manoeuvers. Any department of vascular radiology may be requested to use this technique, especially in emergent traumatology or palliative cancerology. The authors study the various conditions that may benefit from these procedures and give the highlights of the main indications and the main types of embolic agents used. Complications, side effects and the major precautions are also reviewed.

Renal embolization as an alternative to surgical nephrectomy in children

PURPOSE

Complete renal embolization may be an alternative to surgical nephrectomy. The indications for renal embolization do not differ from those for surgical nephrectomy, but the less invasive nature of the technique is a major advantage. Few case reports are available in the pediatric age group. Our experience showed that complete renal embolization was feasible in pediatric patients with results comparable to those obtained in adults.

MATERIALS AND METHODS

Twelve pediatric patients underwent 14 renal embolizations. The indications for embolization were as follows: (1) severe hypertension in 7 patients with end-stage renal failure; in these cases, a unilateral native nephrectomy was recommended prior to renal transplantation; (2) end-stage hydronephrosis in 3 patients with moderate hypertension or recurrent urinary infection; (3) nephrotic syndrome in 1 patient; or (4) ablation of an irreversibly rejected renal allograft in 1 patient. The embolization was performed under epidural anesthesia in 10 patients and under general anesthesia in 2 patients, by means of a polyvinyl alcohol injection with hemostatic gelatin powder and placement of coils. Postembolization course was followed.

RESULTS

The embolization was successful in all 12 patients. In 1 patient, the procedure had to be repeated as a small accessory artery had revascularized the upper pole. In another patient, the procedure was bilateral in 2 separate sessions. In 10 patients, severe flank pain required narcotic analgesia. Two patients had fever. None had hypertension peaks. Median hospital stay was 4 days. At mean follow-up of 16 months, the results were stable.

CONCLUSION

Renal embolization can avoid surgical nephrectomy also in pediatric patients. The advantages are less morbidity and shorter hospital stay. Our results in the short and medium term were equal to those of surgical removal. The procedure appeared to be safe and minimally invasive.

Renal artery embolization: clinical indications and experience from over 100 cases

OBJECTIVE

To review current indications and techniques for renal artery embolization (RAE) and more specifically to review cases of RAE before nephrectomy for treating patients with a large renal mass.

PATIENTS AND METHODS

All RAEs done at our institution between May 1993 and December 2005 were reviewed. Patients were identified using a database assembled by the Division of Cardiovascular Interventional Radiology. Indications, techniques and RAE-related complications were then obtained from a retrospective review of medical records. Additional data for patients undergoing preoperative infarction were acquired, including estimated blood loss (EBL), transfusion requirement, pathological size, subtype, grade, stage, and level of tumour thrombus if present.

RESULTS

In all, there were 121 RAEs, 69 in males and 52 in females (mean age 57.6 years, range 11-89). Metallic microcoils were the most often used embolization agent, followed by acrylic microspheres (embospheres), polyvinyl alcohol particles, absolute ethanol, and Gelfoam (Pharmacia & Upjohn, USA). The most common indication for RAE was infarction before nephrectomy (54.5%). Other indications included symptomatic angiomyolipomas, palliation of unresectable renal cancer, haemorrhage, perinephric bleeding in end-stage renal disease, vascular lesions, malignant hypertension, and sequelae of end-stage renal disease. RAE-associated complications including coil migration, incomplete embolization, and groin haematoma (in 5.0%). Symptoms of post-infarction syndrome were common, with 74.4% of patients having flank pain, nausea, or vomiting; the vast majority of these symptoms were mild and self-limited. In patients having nephrectomy after RAE the median (range) interval from RAE was 2 (0-78) days. The mean tumour size was 11.2 (3.5-25) cm and 46% of patients had tumour thrombus present in either the renal vein or inferior vena cava (IVC). The mean (median) overall EBL in patients having nephrectomy after RAE was 1048 (725) mL. The mean transfusion requirement over the course of hospitalization was 3.9 units of packed red blood cells.

CONCLUSIONS

RAE is a safe and effective therapeutic tool for many urological, renal and vascular conditions. Its use has increased at our institution due to improved techniques, embolization materials, and our increasing use of RAE as an adjuvant procedure for patients requiring nephrectomy with or without IVC thrombectomy. There are many potential operative advantages for patients having RAE before surgery, with minimal morbidity. It is likely that the lack of prospective randomized trials is the primary reason why it is underutilized in the preoperative setting.

Renal artery embolization with diluted hot contrast medium: an experimental study

PURPOSE

To evaluate the safety and efficacy of diluted hot contrast medium to embolize the renal arteries in a canine model.

MATERIALS AND METHODS

Transcatheter embolization was performed in 15 dogs (five dogs in each phase: I, II, and control). The diluted hot contrast medium was heated to 90 degrees C--100 degrees C and 30--60 mL were injected into a renal artery of each dog in phase I (optimization studies) and II (efficacy studies). In the control group, balloon inflation was performed without injection of diluted hot contrast medium. The temperature measurement was performed on one dog in phase I by temperature probe. Follow-up angiography was performed immediately (n = 15), at 1 week (n = 9), at 1 month (n = 9), and after 3 months (n = 5). All dogs were killed and kidneys were removed for histologic examination.

RESULTS

The procedure was performed successfully in all dogs. Follow-up angiography showed complete obstruction of the injected renal arteries in phases I and II. The microscopic findings showed acute full-thickness necrosis of the renal cortex and renal artery in phase I, and complete coagulative necrosis of the cortex, medulla, and intrarenal blood vessels in phase II. There were no histologic changes of renal veins, inferior vena cava (IVC), and aorta. There were nonspecific findings in the control group.

CONCLUSION

This preliminary experimental study suggests that diluted hot contrast medium may be a safe agent for renal ablation without thrombus formation in the renal vein or IVC.

Transcatheter ethanol renal ablation in 20 patients with persistent urine leaks: an alternative to surgical nephrectomy

PURPOSE

We evaluate the efficacy of transcatheter ethanol renal ablation for destruction of a unilateral, poorly functioning kidney with persistent urinary leaks from fistulas or a nephrostomy tube.

MATERIALS AND METHODS

From January 1992 to January 1999, 19 females and 1 male with a history of pelvic neoplasms, which were responsible for ureteral leaks through the nephrostomy tube in 13 cases or fistulas in 7, were treated with transcatheter ethanol renal ablation. Serum creatinine ranged from 60 to 140 micromol./l. (mean 90), and function of the involved kidney determined by diethylenetetraminepentaacetic acid scintigraphy in 16 patients or by morphological imaging in 4 was low. Drainage of the renal cavities and antibiotic therapy preceded renal ablation. After epidural anesthesia or intravenous sedation renal ablation was performed by catheterization of the renal artery and injection of 1. 5 to 12 ml. (mean 4.6) absolute ethanol, and completed by proximal occlusion with coils and absorbable gelatin sponge.

RESULTS

Arterial flow was interrupted in all cases. Urinary flow ceased in 2 days in 18 of 20 patients, and drains were removed. Two patients had residual urine that was successfully treated with additional embolization. No complications occurred.

CONCLUSIONS

Transcatheter ethanol renal ablation is safe and effective, and permits an in situ nephrectomy that can replace surgical nephrectomy for treatment of urinary leaks.

Transcatheter ethanol renal ablation in 20 patients with persistent urine leaks: an alternative to surgical nephrectomy

PURPOSE

We evaluate the efficacy of transcatheter ethanol renal ablation for destruction of a unilateral, poorly functioning kidney with persistent urinary leaks from fistulas or a nephrostomy tube.

MATERIALS AND METHODS

From January 1992 to January 1999, 19 females and 1 male with a history of pelvic neoplasms, which were responsible for ureteral leaks through the nephrostomy tube in 13 cases or fistulas in 7, were treated with transcatheter ethanol renal ablation. Serum creatinine ranged from 60 to 140 micromol./l. (mean 90), and function of the involved kidney determined by diethylenetetraminepentaacetic acid scintigraphy in 16 patients or by morphological imaging in 4 was low. Drainage of the renal cavities and antibiotic therapy preceded renal ablation. After epidural anesthesia or intravenous sedation renal ablation was performed by catheterization of the renal artery and injection of 1. 5 to 12 ml. (mean 4.6) absolute ethanol, and completed by proximal occlusion with coils and absorbable gelatin sponge.

RESULTS

Arterial flow was interrupted in all cases. Urinary flow ceased in 2 days in 18 of 20 patients, and drains were removed. Two patients had residual urine that was successfully treated with additional embolization. No complications occurred.

CONCLUSIONS

Transcatheter ethanol renal ablation is safe and effective, and permits an in situ nephrectomy that can replace surgical nephrectomy for treatment of urinary leaks.

Urologic management of congenital nephrotic syndrome of the Finnish type

A 7-month-old girl with congenital nephrotic syndrome (CNS) of the Finnish type was referred to our group for surgical evaluation and recommendation of a treatment plan. A Medline literature search was conducted using data bases from 1980 to 1996, on the topics of "congenital nephrotic syndrome" and "surgery." Although there were several articles on CNS in the nephrology and pediatric journals, we found none in the urologic literature. Although a few medical centers advocate a less invasive unilateral nephrectomy or percutaneous renal ablation, most institutions still recommend bilateral nephrectomy to manage patients with CNS in whom aggressive medical management fails. Bilateral nephrectomy followed by dialysis and transplantation should remain the standard of care in 1997 for children with severe CNS.

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.

Case report: transcatheter renal embolization to effect renal ablation in recurrent PUJ obstruction in a patient with haemophilia

We present a case of embolic ablation of a kidney with recurrent infected hydronephrosis in a patient for whom surgical resection was considered undesirable. The hydronephrosis recurred after embolization using gelfoam/steel coils but after a second embolization using lipiodol/absolute alcohol (50/50), the patient has remained asymptomatic. More than one embolization procedure may be necessary to effect renal ablation. Careful evaluation is necessary to determine whether ablation has been achieved. We recommend lipiodol/absolute alcohol as the embolic agent of choice.

Long-term control of hypertension and the predictive value of peripheral plasma renin activity after ablation of end stage kidneys with a new embolic agent

Embolization of end-stage kidneys using our own embolizing agent Vilanol (partially hydrolyzed polyvinyl acetate) was performed in 10 patients with hypertension refractory to conservative therapy. Native kidneys were embolized in 7 patients with chronic renal failure, nonfunctioning renal transplants in 2 patients, and a shrunken kidney in 1 patient. Five of the 10 patients had high (9.96-18.2 ng/ml/h) peripheral renin (PR) levels. The embolization was technically successful in 4 of these 5 patients and was immediately followed by a marked decrease in PR, and simultaneous improvement in blood pressure (BP). The other 5 patients had very low PR levels (0.07-0.65 ng/ml/h), and a reduction in BP was observed in 4 after embolization. One patient died following embolization from cardiac arrest due to hyperkalemia. Six patients (3 in each group) have been on follow-up for 2-5 years with sustained decrease in BP. We conclude that the new agent is effective for renal ablation and control of refractory hypertension.

Enalapril can treat the proteinuria of membranous glomerulonephritis without detriment to systemic or renal hemodynamics

The effect of enalapril on renal hemodynamics and glomerular permselectivity was studied in eight patients with nephrotic syndrome secondary to biopsy-proven membranous glomerulonephritis. The patients received the drug in incremental doses (median, 5 mg) until 24-hour urinary protein excretion had decreased persistently by 30%. Median treatment duration was 6 weeks. Patients were studied three times: (I) after a 4-week run-in period, (II) on the final day of treatment, and (III) after a 4-week wash-out. Median 24-hour urinary protein excretion decreased on treatment from 10.45 g/d to 5.25 g/d and increased to pretreatment levels after the drug was stopped (P less than 0.05 for both changes). Fractional clearance of dextrans greater than 4.1 nm decreased on treatment, indicating both a reduction of macromolecules passing through the shunt pathway of the glomerular basement membrane (GBM) and a possible decrease in ultrafiltration coefficient. There were no significant changes in glomerular filtration rate (GFR), effective renal plasma flow (ERPF), or mean arterial blood pressure (MAP) throughout the study. The effect of enalapril in treating proteinuria appears therefore to be due to a specific intraglomerular action.