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Original Report |
1 Department of Radiology, University Hospitals Gasthuisberg, Herestraat 49,
Leuven B-3000, Belgium.
2 Department of Urology, University Hospitals Gasthuisberg, Leuven,
Belgium.
Received March 23, 2004;
accepted after revision August 10, 2004.
Address correspondence to S. Heye
(sam.heye{at}uz.kuleuven.ac.be).
Abstract
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CONCLUSION. Transcatheter selective embolization is a safe and effective technique for appropriate management of this postoperative vascular complication.
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In the literature, only a few case reports have been presented. Most of these patients have had a pseudoaneurysm and were treated by endovascular embolization [3–6].
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Sonography was performed before angiography in five patients. In four patients, a perirenal hematoma was shown. Two patients were immediately transferred to the angiography suite, without any preceding noninvasive diagnostic examinations (Table 1).
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Postembolization serum creatinine values were analyzed and compared with the level before embolization to evaluate the short-term effect of embolization on renal function and as an additional indication for parenchymal loss of the kidney. Parenchymal loss was initially evaluated by comparing angiograms obtained before embolization with those obtained after embolization. The absence of flow into the site of bleeding on the completion angiogram was considered indicative of a technically successful embolization. Clinical success was defined as the disappearance of the acute symptoms.
Short-term follow-up for bleeding was achieved using clinical and biochemical tests. Follow-up for tumor recurrence was done using CT.
After administration of local anesthetic (lidocaine) at the right groin, vascular access was obtained by placing a 5-French sheath (Radifocus Introducer II, Terumo Europe) in the common femoral artery. First, an abdominal aortogram by means of a 4-French pigtail catheter was obtained to evaluate for the presence of multiple or accessory renal arteries from which the feeding arteries to the bleeding site could originate. Second, selective catheterization and angiography of the renal artery at the site of the partial nephrectomy (4- or 5-French Cobra C2 or Simmons 2 catheter, Terumo Europe) were performed. After the interlobar arteries that were contributing to the bleeding site were identified, superselective catheterization of those feeding arteries was achieved using a 5-French Cobra C2 catheter in one patient. In all other patients, a coaxial microcatheter (Tracker-18 or Renegade, Boston Scientific) was used. The feeding arteries were embolized using coils (0.035-inch stainless steel coils, William Cook Europe) or microcoils (0.018-inch fibered platinum coils, Boston Scientific). In one patient embolization of the feeding arteries was preceded by embolization of the smaller distal branches using polyvinyl alcohol particles (Contour, Boston Scientific) with a diameter varying between 150 and 250 µm.
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The two remaining patients—one with a decrease of hemoglobin and the other with acute flank pain—showed extrarenal extravasation of contrast material on angiography (Figs. 2A and 2B) and a perirenal hematoma on sonography (Table 2).
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Six patients had only one interlobar artery contributing to the bleeding site. In one patient, multiple feeding arteries (three interlobar arteries) were seen. In all seven patients, superselective embolization resulted in a complete cessation of the bleeding and disappearance of either pseudoaneurysm (with or without arteriovenous fistula) (Fig. 1C) or contrast extravasation (Fig. 2C). No complications occurred during the procedure.
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There was no major parenchymal ischemia after the procedure. Parenchymal loss at the end of the embolization procedure was estimated to be 10% or less in all patients. Another criterion for the extent of parenchymal ischemia was renal function, which was evaluated by the serum creatinine level. A temporary increase in the serum creatinine level after embolization was found in one patient (2.88 mg/dL), but this value normalized 1 week later (1.31 mg/dL). This patient had multiple feeding arteries that needed to be occluded, making the embolization procedure longer and more complex. No significant change in the serum creatinine level before and after embolotherapy was seen in the six other patients (difference in serum creatinine level pre- and postembolization: range, –0.03 to 0.29 mg/dL; mean, 0.09 mg/dL).
In all seven patients, immediate clinical success was obtained. During the first week after the embolization procedure, there was no evidence for bleeding recurrence. Long-term follow up (range, 1–89 months; mean, 29.9 months) using CT showed no tumor recurrence.
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In our patients, two distinct clinical presentations of major hemorrhage after partial nephrectomy were seen. Patients presented most frequently with massive hematuria after surgery. In all these patients, a pseudoaneurysm was seen on angiography. This pseudoaneurysm may be associated with an arteriovenous fistula. The other presentation was acute flank pain or a significant decrease in the hemoglobin level (or both). Hemorrhage in the perirenal space can be found in these patients—recognized either by adequately placed suction drains or by noninvasive imaging techniques such as sonography. Angiography enables exact visualization of extravasation of contrast material in the renal fossa.
Percutaneous superselective embolization of the feeding arteries contributing to the bleeding site is preferred to open surgery, which often results in a total nephrectomy [1, 3]. As in cases of renal allografts or traumatic renal artery injuries, percutaneous embolotherapy in cases of hemorrhage after nephron-sparing renal surgery has a high success rate and a low complication (i.e., major parenchymal infarction) rate [7, 8].
Successful embolization can be determined as a total and also permanent occlusion of the vessels contributing to bleeding. It is, however, important to avoid occlusion of the proximal great vessels or the adjacent smaller vessels to keep parenchymal loss to a minimum (10%). Therefore, embolization as distal as possible is mandatory—at least at the level of the interlobar arteries. This can usually be achieved using microcatheters and microcoils as embolic agents [7]. Polyvinyl alcohol particles, as we used in one patient, can be an alternative to coils, but only if the microcatheter is placed in an interlobar artery or even more distally. We preferred occluding the interlobar artery by coils at the end of the procedure for extra safety. Even when more than one feeding artery needs to be occluded (e.g., in case of multiple bleeding sites or pseudoaneurysms or multiple arteries contributing to the bleeding site), minor parenchymal loss after embolization is still possible.
Because no additional significant parenchymal infarction was seen in our patients after embolization, we do not believe control CT scans to evaluate more precisely the extent of the infarct zones are necessary. For this same reason, no antibiotics were administrated before, during, or after the embolization procedure.
No renal function impairment was found in our patients, which is also indicative for the limited loss of renal parenchyma after embolization. The transient elevation of the serum creatinine level in one patient can be attributed to the larger amount of contrast material used during a more complex procedure.
This study contains a small number of patients, but until now only a few case reports, to our knowledge, have appeared on the subject [3–6]. In one case described, the patient underwent open nephrectomy [3], whereas the patients described in the other case reports were treated by percutaneous transcatheter embolization, which was immediately successful in all but one (80%) [4–6]. None of these authors reported deterioration of renal function after selective embolization.
Potential limitations of and difficulties associated with this technique are impaired renal function of the patient, vascular anatomic difficulties, or stenosis of the main renal artery. The problem of impaired renal function can be solved by using mainly CO2 as contrast material and thus minimizing the use of iodinated contrast medium.
Vessel anatomy, such as a tortuous abdominal aorta, can make selective catheterization of the renal artery more difficult, but usually not impossible. In cases of renal artery stenosis, the stenosis can be treated first, before embolization; the only problem here is the higher contrast load of the whole procedure.
Bleeding from a segmental artery is rare; however, when this more proximal artery is occluded, keeping major parenchymal loss to a minimum may cause a problem. If renal function before embolization was not impaired, more extensive parenchymal loss is still preferred over total nephrectomy.
In conclusion, perirenal hemorrhage or intrarenal bleeding with pseudoaneurysm formation or with the occurrence of an arteriocaliceal fistula is a serious complication after nephron-sparing surgery, requiring prompt diagnosis and treatment. Angiography with selective embolization is a safe and efficacious technique for the appropriate management of this postoperative vascular complication.
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