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

Abstract

Renal artery embolization is used for various reasons, and authors from the USA review their experience of using this technique before nephrectomy in patients with large renal masses. They found it to be safe and effective, with minimal morbidity. They note the lack of published prospective randomized trials, and suspect that this contributes to it being underused. 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.

Endovascular management of iatrogenic renal arterial lesions and clinical outcomes

“…PA and AVF are rare complications of partial nephrectomy. Approximately 40 cases of PA after partial nephrectomy have been reported (19)(20)(21)(22)(23)(24). In the literature, PA rate was about 0.43% for open partial nephrectomy (4) and 1.7% for laparoscopic partial nephrectomy (3).…”

“…In case of a renal artery stenosis, embolization may be performed after the recanalization treatment of renal artery. Complications of endovascular embolization such as renal artery dissection, postembolization syndrome (21) and loss of renal function (30) are rare. Renal function can be negatively affected by nephrotoxic iodinated contrast media or devascularization of a part of the renal parenchyma secondary to embolization.…”

Successful management of a giant angiomyolipoma with partial nephrectomy

“…Most studies did not report a significant decrease in tumor size, with recurrence of the tumor and repeat embolization required. [3] Preoperative TAE has been suggested to possibly reduce blood loss intraoperatively, but it must be weighed up with the possible complications following TAE. Reported decrease in size after angioembolization is relatively modest at thirty percent to fifty percent.…”

Treatment of angiomyolipoma at a tertiary care centre: the decision between surgery and angioembolization

“…The agents appear to have similar rates of success, complications and postinfarction syndrome. 22 With new materials, such as acrylic embospheres and hepaspheres continuously, emerging the preferred agents are likely to change over time. 23 The advantage of a surgical approach includes complete resection of the disease and pathologic analysis of the specimen to confirm the diagnosis.…”