Transarterial glue embolization in iatrogenic renovascular injuries

Abstract

Iatrogenic injuries of the intrarenal arterial system include pseudoaneurysms and fistulas. They can cause hematuria and life-threatening hemodynamic instability, and therefore should be treated promptly. Endovascular treatment is recommended for these cases due to its effectiveness. Among the different agents used for embolization, n-butyl-2-cyanoacrylate (glue) has rarely been used. We present 15 patients with pseudoaneurysms and/or arteriovenous or caliceal fistulas who were treated by glue embolization. In our patient group, five had a history of percutaneous nephrolithotomy, six had renal biopsies, three had nephron-sparing surgery, and one had percutaneous nephrostomy. Glue embolizations were performed with the microcatheter technique. All patients were successfully treated, and all but one had excellent follow-ups. One patient suffered from disseminated intravascular coagulation secondary to transfusion and died after the procedure. We think glue embolization is a safe and effective treatment for this group of patients and present our experience along with the technical approach.

Guidelines for the use of NBCA in vascular embolization devised by the Committee of Practice Guidelines of the Japanese Society of Interventional Radiology (CGJSIR), 2012 edition

“…NBCA is also used to induce embolization in cases involving bleeding caused by iatrogenic damage or trauma [25,39,70,75,78,116,117]. In particular, NBCA is a useful embolic material in the following situations: (a) cases in which pseudoaneurysms cannot be embolized via selective catheterization using the isolation technique; (b) embolization involving the preservation of the parent artery [56,134,149,163,167,174,183]; (c) cases in which coil embolization might be unsuitable because of the condition of the target vessels, e.g., those involving markedly tortuous, stenotic, or fine vessels [54,72,87,135,138,165]; (d) cases involving patients in a hypocoagulable state (refer to CQ6).…”

“…Moreover, it is often difficult to control the embolization range during vascular embolization using NBCA, which can cause non-target embolization. In particular, vascular embolization using NBCA can result in the undesirable distal spread of NBCA; NBCA reflux [16,39,99,101,102,105,116,117,136,141,144,145,161]; a small amount of NBCA becoming attached to the catheter tip, causing it to be released into non-target vessels during catheter removal 10; and the induction of vital organ ischemia through collateral channels. Regarding the distal spread of NBCA, venous outflow has been detected in cases involving high-flow AVM/fistulas [18,30,76,82,137].…”

“…The ability of flow-guided catheters to deliver NBCA to more distal locations would seem to be a potential safety advantage [10,53]. (6) Super-selective embolization should be performed after the placement of a microcatheter near to the target lesion, in order to prevent the administration of an excess amount of NBCA [39,103,104]. Injecting small intermittent aliquots of NBCA rather than a single large bolus [71,102] or the combined use of NBCA and other embolic materials is considered to be an effective technique for dose optimization [50,134].…”

“…Organ ischemia or patient-specific factors might be responsible for the pain experienced in some cases. Since the polymerization of NBCA involves an exothermic reaction, it can result in the destruction of the vessel wall and the perivascular tissue [39,64,126]. It also causes pain; however, the mechanism responsible for this is unknown.…”

Transcatheter Arterial Embolization in Patients with Kidney Diseases: an Overview of the Technical Aspects and Clinical Indications

“…The main problem in the post-acute period is persistent hematuria through the creation of an arteriourinary fistula (25, 26). This very frequently occurs following renal biopsy, and it generally closes spontaneously within a few days.…”