Renal Artery Occlusion Research Articles

Technical aspects and 30-day outcomes of the prospective early feasibility study of the GORE EXCLUDER Thoracoabdominal Branched Endoprosthesis (TAMBE) to treat pararenal and extent IV thoracoabdominal aortic aneurysms

ObjectiveThis study reports the technical aspects and 30-day outcomes of the prospective, multicenter early feasibility study designed to evaluate the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz). MethodsThirteen patients with pararenal or extent IV thoracoabdominal aortic aneurysms were prospectively enrolled at five U.S sites and one non-U.S. site from 2014 to 2016. The TAMBE included four portals with either retrograde or antegrade renal portal configuration and used GORE VIABAHN Balloon-Expandable Endoprosthesis (W. L. Gore & Associates) for stenting of the renal and mesenteric arteries. The primary end point was procedural safety at 30 days, defined by absence of major adverse events, including any-cause mortality, myocardial infarction, stroke, paraplegia, bowel ischemia, respiratory failure, severe acute kidney injury (>50% decline in estimated glomerular filtration rate), dialysis, and procedural blood loss >1000 mL. ResultsThere were 11 male and two female patients with a mean age of 69 ± 8 years. Mean aneurysm diameter was 61 ± 13 mm. A total of 52 renal and mesenteric arteries were incorporated (4 vessels/patient). Technical success was achieved in 12 patients (92%). One patient had inadvertent occlusion of a right renal artery due to dissection. There was no mortality, aneurysm rupture, conversion to open repair, dialysis, or spinal cord injury. Mean length of hospital stay was 5 ± 3 days. At 30 days, four patients (31%) had major adverse events, all due to procedural blood loss >1000 mL. One patient had a type I endoleak at the distal renal branch, which was successfully treated by placement of an additional renal stent before dismissal. Computed tomography angiography at 30 days showed patent target vessels and no type I or type III endoleak. ConclusionsThis study confirms the early feasibility of the TAMBE for treatment of pararenal and extent IV thoracoabdominal aortic aneurysms. The high technical success, no mortality, and low morbidity rate support continuation of clinical investigation in a larger population of patients.

Successful endovascular treatment of chronic renal artery occlusion: a preliminary retrospective case series including 15 patients.

To evaluate in a retrospective, single-center, case series if percutaneous transluminal renal angioplasty/stenting of chronic renal artery occlusion is beneficial to renal function and blood pressure control, which remains controversial. Data from 15 consecutive patients with renal artery stump who underwent successful percutaneous transluminal renal angioplasty/stenting only for unilateral chronic renal artery occlusion at our center from January 2007 to February 2018 and completed follow-up were retrospectively evaluated. Of the 15 patients, 14 (93.3%) were treated with stenting and 1 with only balloon angioplasty. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula corrected for Chinese, and changes in blood pressure and need for antihypertensive medications were recorded. At median 1.5-year (interquartile range 0.5-5.0) follow-up, restenosis rate was 20.0%. Renal function improved or remained stable in 26.7% and 53.3% of patients, respectively, and blood pressure normalized or improved in 13.3% and 40.0% of patients, respectively. Young patients with Takayasu's arteritis or fibromuscular dysplasia appeared to benefit the most from revascularization. In this preliminary retrospective series of select patients with renal artery stump, endovascular treatment of chronic renal artery occlusion appeared to preserve renal function and improve blood pressure.

Targeting HIF-1α to Prevent Renal Ischemia-Reperfusion Injury: Does It Work?

Partial nephrectomy (open or minimally invasive) usually requires temporary renal arterial occlusion to limit intraoperative bleeding and improve access to intrarenal structures. This is a time-critical step due to the critical ischemia period of renal tissue. Prolonged renal ischemia may lead to irreversible nephron damage in the remaining tissue and, ultimately, chronic kidney disease. This is potentiated by the incompletely understood ischemia-reperfusion injury (IRI). A key mechanism in IRI prevention appears to be the upregulation of an intracellular transcription protein, Hypoxia-Inducible Factor (HIF). HIF mediates metabolic adaptation, angiogenesis, erythropoiesis, cell growth, survival, and apoptosis. Upregulating HIF-1α via ischemic preconditioning (IPC) or drugs that simulate hypoxia (hypoxia-mimetics) has been investigated as a method to reduce IRI. While many promising chemical agents have been trialed for the prevention of IRI in small animal studies, all have failed in human trials. The aim of this review is to highlight the techniques and drugs that target HIF-1α and ameliorate IRI associated with renal ischemia. Developing a technique or drug that could reduce the risk of acute kidney injury associated with renal IRI would have an immediate worldwide impact on multisystem surgeries that would otherwise risk ischemic tissue injury.

Hydralazine protects against renal ischemia-reperfusion injury in rats

In this study, we investigated whether hydralazine could reduce renal ischemia and reperfusion (I/R) injury in rats. Renal I/R was induced by a 70-min occlusion of the bilateral renal arteries and a 24-h reperfusion, which was confirmed by the increased the mortality, the levels of blood urea nitrogen (BUN), blood creatinine (Cr), renal tissue NO and the visible histological damage of the kidneys. Apoptosis was evaluated by terminal deoxynucleotidyltransferase-mediated dUTP nick-end labeling (TUNEL) staining. Furthermore, the serum levels of malonaldehyde (MDA), tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β) and interleukin-6 (IL-6) were significantly elevated in renal I/R group, while the superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GSH-Px) levels were suppressed. However, intragastric pretreatment with hydralazine at doses of 7.5–30 mg/kg before renal I/R significantly limited the increase in mortality, BUN, Cr, oxidative stress, inflammatory factors, histological damage and apoptosis in the kidneys. In addition, hydralazine also increased p-AKT, Bcl-2 expression and decreased iNOS, Bax, cleaved caspase-3 expression in the kidneys. In conclusion, hydralazine reduced renal I/R injury probably via inhibiting NO production by iNOS/NO pathway, inhibiting oxidative stress, inflammatory response and apoptosis by a mitochondrial-dependent pathway.

Role of chemokine CXC-ligand 16 in renal fibrosis following renal ischemia-reperfusion injury in mice

Objective To evaluate the role of chemokine CXC-ligand 16(CXCL16) in renal fibrosis following renal ischemia-reperfusion(I/R) injury in mice. Methods Twenty-four healthy male C57BL/6 mice, aged 8-10 weeks, weighing 20-30 g, were divided into 4 groups(n=6 each) using a random number table method: sham operation group(group S), sham operation plus anti-CXCL16 antibody group (group S+ A), group I/R, and I/R plus anti-CXCL16 antibody group(group I/R+ A). Renal ischemia was induced by occlusion of the left renal artery for 30 min followed by 72-h reperfusion, and the right kidney was removed on 5th day in anesthetized mice. CXCL16 antibody 5 mg/kg and the equal volume of normal saline were intraperitoneally injected at 72 h after reperfusion twice a week for 2 consecutive weeks in I/R+ A and I/R groups, respectively. Sham operation was performed, and the equal volume of CXCL16 antibody 5 mg/kg and normal saline were intraperitoneally injected at 72 h after reperfusion twice a week for 2 consecutive weeks in S+ A and S groups, respectively. Orbital venous blood samples were collected at day 14 after reperfusion for determination of serum blood urea nitrogen(BUN) and creatinine(Cr) concentrations. Animals were then sacrificed and the left kidney was removed for measurement of the renal fibrosis size(using Sirius red staining), expression of α-smooth muscle actin(α-SMA), fibronectin(FN) and type Ⅰ collagen(Col-Ⅰ) in renal tissues by Western blot. Results Compared with group S, the serum BUN and Cr concentrations and renal fibrosis size were significantly increased, and the expression of α-SMA, FN and Col-Ⅰ was up-regulated in group I/R(P<0.05). Compared with group I/R, the serum BUN and Cr concentrations and renal fibrosis size were significantly decreased, and the expression of α-SMA, FN and Col-Ⅰ was down-regulated in group I/R+ A(P<0.05). Conclusion CXCL16 is involved in the process of renal fibrosis following renal I/R injury in mice. Key words: Chemokines, CXC; Kidney; Reperfusion injury; Fibrosis

A Rare Case of Ascites

Chylous ascites (CA) is a rare form of ascites most frequently caused by lymphatic abnormalities. Diagnosis is established based on clinical presentation, ascitic fluid analysis, and imaging. Here we present a case of CA that occurred as a complication of intra-abdominal aortic surgery. A 56 year-old female with peripheral arterial disease, COPD, anxiety, and peptic ulcer disease presented with abdominal pain/swelling worsening over 1 week. She had been admitted 1 month prior with abdominal pain and was found to have a right renal artery occlusion, SMA occlusion and celiac stenosis. She underwent a supraceliac aorta to celiac and inferior mesenteric artery bypass and had been discharged home 1 week prior to this presentation. Review of systems was notable for only loss of appetite and 30 lbs unintentional weight loss over 3 years. She had no prior liver disease, denied EtOH or illicit drug use, no incarcerations. Her vitals were normal and on exam she was found to have a tense, tender abdomen, with positive fluid wave. Her midline incision was clean, dry, and intact. She had no stigmata of chronic liver disease. Labs were notable for a WBC 15.6, Plt 387, Cr 0.5, Albumin 2.8, T. Bili. 0.5, AST 24, ALT 17, Alk. Phos. 84, and INR 1.0. Ascitic fluid analysis showed cloudy yellow fluid with 5354 RBCs, 1009 WBCs, 90% lymphs, 2% segs, LDH 101, glucose 89, triglycerides (TG) 131 mg/dL, Albumin 1.8 g/dL, protein 3.0 g/dL, and a SAAG of 1.0. Gram stain, culture, and AFB were negative. CT abdomen and pelvis with IV contrast was notable for large volume ascites, normal liver and spleen, and no masses. Lymphangiography (LAG) did not reveal chyle leak. The onset of ascites after aortic surgery raised our suspicion for CA from trauma to the lymphatic system. The diagnosis was supported by the ascitic WBC>500 with lymphocyte predominance, glucose <100, total protein of 3, milky appearance, and TG of 131. LAG is an important technique for the detection of lymphatic leaks with reported detection rates of 64-86%. Combining both LAG and CT imaging modalities facilitated identification of a chyle leak. The management of CA consists of identifying and treating the underlying disease process, dietary modification, and diuretics. Our patient was effectively managed with therapeutic paracentesis and initiation of a high-protein, low-fat parenteral diet with medium chain triglyceride supplementation. Upon follow-up 2 months later, her ascites had completely resolved.2331 Figure 1. Typical Characteristics of Chylous Ascites

Acute renal infarction in Turkey: a review of 121 cases.

Renal infarction is a clinical condition which is caused by renal artery occlusion and leads to permanent renal parenchymal damage. In the literature, there are generally case reports on this subject, and few studies that include a large group of patients. Therefore, we aimed to present the data of a large group of patients who were diagnosed with acute renal infarction in our country in this retrospective study. The data of patients who were diagnosed with acute renal infarction according to clinical and radiological findings in Turkey in the last 3years were examined. For this purpose, we contacted with more than 40 centers in 7 regions and obtained support from clinically responsible persons. Demographic data of patients, laboratory data at the time of diagnosis, tests performed for etiologic evaluation, given medications, and patients' clinical status during follow-up were obtained from databases and statistical analysis was performed. One-hundred and twenty-one patients were included in the study. The mean age was 53 ± 1.4 (19-91) years. Seventy-one (58.7%) patients were male, 18 (14.9%) had diabetes, 53 (43.8%) had hypertension, 36 (30%) had atrial fibrillation (AF), and 6 had a history of lupus + antiphospholipid syndrome (APS). Forty-five patients had right renal infarction, 50 patients had left renal infarction, and 26 (21.5%) patients had bilateral renal infarction. The examinations for the ethiologies revealed that, 36 patients had thromboemboli due to atrial fibrillation, 10 patients had genetic anomalies leading to thrombosis, 9 patients had trauma, 6 patients had lupus + APS, 2 patients had hematologic diseases, and 1 patient had a substance abuse problem. Fifty-seven (57%) patients had unknown. The mean follow-up period was 14 ± 2months. The mean creatinine and glomerular filtration rate (GFR) values at 3months were found to be 1.65 ± 0.16mg/dl and 62 ± 3ml/min, respectively. The final mean creatinine and GFR values were found to be 1.69 ± 0.16mg/dl and 62 ± 3ml/min, respectively. Our study is the second largest series published on renal infarction in the literature. More detailed studies are needed to determine the etiological causes of acute renal infarction occurring in patients.

Comparison of ischaemia-reperfusion-induced acute kidney injury by clamping renal arteries, veins or pedicles in anaesthetized rats.

What is central question of this study What are the differences between a traditional renal pedicle-clamping model of acute kidney injury and models with occluded renal artery or vein alone in rats? What is main finding and its importance? During renal venous occlusion, transmission of high arterial pressure into renal capillaries is likely to have caused the rupture of their walls and the occurrence of haemorrhagic congestion that led to higher kidney tissue damage and dysfunction than with pedicle and artery clamping. Animal models of ischaemic acute kidney injury (AKI) are valuable tools, but their therapeutic outcomes are not usually translated to humans. Ischaemic AKI in murines is mostly induced via renal pedicle clamping, which is different from patients with AKI that is due to renal artery hypoperfusion or vein thrombosis. This study was designed to compare the traditional pedicle-clamping with artery or vein occlusion alone in rat models of bilateral renal ischaemia-reperfusion (BIR). Twenty-eight anaesthetized male Sprague-Dawley rats were divided into four groups, a sham-operation group and groups that underwent 2h reperfusion following 30min clamping of renal arteries (BIR-A group), veins (BIR-V group) or pedicles (BIR-P group). The levels of epithelial injury in proximal tubules and thick ascending limb, intratubular casts and vascular congestion as well as renal malondialdehyde were moderately lower in the BIR-A than BIR-P group, while the BIR-V group showed much higher degrees of these damages than both these groups along with massive haemorrhagic congestion. Accordingly, renal blood flow, glomerular filtration, Na+ reabsorption, K+ and urea excretion, free water reabsorption and urine osmolality were lower in the BIR-V group than in the BIR-A and BIR-P groups, while the BIR-P group had slightly worse renal functional disorders than the BIR-A group. It seems that transmission of high arterial pressure into renal microvessels during venous occlusion causes rupture of capillary walls and haemorrhagic congestion, which leads to intensive kidney injury. In conclusion, the differences in renal disturbances induced by artery, vein and pedicle clamping strongly suggest use of a proper experimental model for each type of human ischaemic AKI.

鈍的腎茎部損傷の治療法の変遷(Transition of treatment for blunt renal pedicle injury: through our 12 cases)

要旨鈍的腎茎部損傷（以下，本症）は，多発外傷を伴うことが多く，迅速な治療の選択を迫られる。しかし治療法が確立しているわけではない。自験例を検討し，本症の治療法を考える。沖縄県立中部病院の33年間と，沖縄県立北部病院の27年間に経験した12例に対して，診療録を後方視的に検討した。男女比は男9例，女3例。年齢中央値は31歳（9–58）。受傷機転は交通外傷10例，木材による圧挫傷1例，転落1例。多発外傷は5例で，他臓器損傷は全例に認めた。治療は腎摘6例，再建4例，未治療2例であった。再建腎の腎機能回復例は，1例のみであった。未治療の1例に高血圧を発症した。血液透析を要する症例はなかった。死亡例は2例で，原因は大量出血による凝固障害と敗血症であった。本症の治療では，救命が最優先であり，そのための腎摘や未治療は，許容される。再建群では不完全閉塞型腎動脈損傷の1例に術後腎機能が回復した。完全閉塞型に対する再建の成功率は非常に低いと考える。

Renoprotective effects of dexmedetomidine against ischemia-reperfusion injury in streptozotocin-induced diabetic rats.

BackgroundDiabetic patients are susceptible to renal ischemia-reperfusion injury, which leads to perioperative complications. Activation of NOD-like receptor protein 3 (NLRP3) inflammasome participates in the development of diabetes, and contributes to renal ischemia-reperfusion injury. Dexmedetomidine (DEX), a highly selective α2-adrenoreceptor agonist, shows renoprotective effects against ischemia-reperfusion injury. We aimed to elucidate the effects, underlying mechanisms, and optimal timing of DEX treatment in diabetic rats.MethodsMale Sprague-Dawley rats (n = 12 per group) were randomly divided into normal-sham, diabetes-sham, diabetes-ischemia-reperfusion-control, diabetes-ischemia-reperfusion-DEX-pre-treatment, and diabetes-ischemia-reperfusion-DEX-post-treatment groups. Renal ischemia-reperfusion injury was induced in diabetic rats by occlusion of both renal arteries for 45 min, followed by reperfusion for 24 h. DEX (10 μg/kg) was administered intraperitoneally 1 h before ischemia (pre-treatment) or upon reperfusion (post-treatment). After reperfusion, renal tissue was biochemically and histopathologically evaluated.ResultsDEX treatment attenuated ischemia reperfusion-induced increase in NLRP3, caspase-1, IL-1β, phospho-AKT, and phospho-ERK signaling. Moreover, oxidative stress injury, inflammatory reactions, apoptosis, and renal tubular damage were favorably modulated by DEX treatment. Furthermore, post-reperfusion treatment with DEX was significantly more effective than pre-treatment in modulating NLRP3 inflammasome, AKT and ERK signaling, and oxidative stress.ConclusionsThis study shows that the protective effects of DEX in renal ischemia-reperfusion injury are preserved in diabetic conditions and may potentially provide a basis for the use of DEX in clinical treatment of renal ischemia-reperfusion injury.

Safety and efficacy of Rapamune\xae (Sirolimus) in kidney transplant recipients: results of a prospective post-marketing surveillance study in Korea

BackgroundFew post-marketing surveillance studies have examined the safety and efficacy of Rapamune® (Sirolimus) in Asian countries. This study aimed to better understand safety and efficacy of Rapamune for kidney transplant recipients in the routine clinical practice setting in Korea.MethodsThis was an open-label, non-comparative, observational, prospective, multi-center, post-marketing surveillance study conducted at 15 Korean transplant centers between 31 August 2009 and 24 September 2015. The subjects were administered Rapamune as part of routine practice. The safety was monitored based on reporting of adverse events (AEs). Efficacy endpoints included acute rejection, graft function, graft survival, and patient survival.ResultsRapamune was most commonly used for late conversion therapy after post-transplant 1 year and was substituted for anti-metabolites (63.6%) or calcineurin inhibitors (28.7%). The median treatment duration of Rapamune was 182 days. Among 209 subjects enrolled, AEs and adverse drug reactions (ADRs) were reported in 54.07% and 43.06% of subjects, respectively, in the safety analysis set. Most of the AEs were expected (96.21%), mild (75.83%), did not result in any action taken with regard to the study drug (72.99%), and resolved by the end of the study (75.36%). The most frequently reported AEs/ADRs were pharyngitis and diarrhea. Most of the serious AEs/ADRs occurred in one or two subjects. Unexpected ADRs of renal artery occlusion and cholangitis were reported by one subject each. The incidence of biopsy-proven acute rejection was 2.87%. At the end of the study, 99.51% of the subjects and their grafts had survived. The mean eGFR was 64.72 ± 19.56 mL/min.ConclusionsRapamune had an acceptable safety profile in prevention of kidney allograft rejection in Korea.

Renal Artery Orientation Influences the Renal Outcome in Endovascular Thoraco-abdominal Aortic Aneurysm Repair

To evaluate the impact of renal artery (RA) anatomy on the renal outcome of fenestrated-branched endografts (FB-EVAR) for thoraco-abdominal aortic aneurysms (TAAA). Between 2010 and 2016, all patients undergoing FB-EVAR for TAAA were prospectively collected. Anatomical, procedural, and post-operative data were retrospectively analysed. RA anatomy was assessed on volume rendering, multi planar and centre line reconstructions by dedicated software (3Mensio). RA diameter, length, ostial stenosis/calcification, orientation and aortic angles of the para-visceral aorta were evaluated. RA orientation was classified in four types: A (horizontal), B (upward), C (downward), D (downward+upward). RA revascularisation by fenestrations or branches was considered. Inability to cannulate and stent RA (RA loss), early RA occlusion (within three months), and composite RA events (one among RA loss, intra-operative RA lesion, RA related re-interventions, RA occlusion) were assessed. Seventy-three patients (male 77%; age 73±6 years) with 39 (53%) type I, II, III and 34 (47%) type IV TAAA, underwent FB-EVAR, for a total of 128 RAs. The mean RA diameter and length were 6±1mm and 43±12mm, respectively. Type A, B, C, and D orientations were 51 (40%), 18 (14%), 48 (36%), and 11 (10%) RAs, respectively. Angulation of para-visceral aorta >45° was present in 14 cases (19%). Ostial stenosis and calcifications were detected in 20 (16%) and 16 (13%) RAs, respectively. Branches and fenestrations were used in 43 (34%) and 85 (66%) RAs, respectively. There were four (3%) intra-operative RA lesions (2 ruptures, 2 dissections). Ten (8%) RAs were lost intra-operatively because of the inability to cannulating and stenting. On univariable analysis, type B RA orientation (p=.001; OR 13.2; 95% CI 3.2-53.6), para-visceral aortic angle>45° (p=.02; OR 4.9; 95% CI 1.3-18.5) and branches (p=.003; OR 9.0; 95% CI 1.9-46.9) were risk factors for intra-operative RA loss; type C RA orientation was a protective factor (p=.02; OR 0.1; 95% CI 0.01-0.9). On multivariable analysis, type B RA orientation (p=.03; OR 5.9; 95% CI 1.1-31.1) and branches (p=.03; OR 7.3; 95% CI 1.1-47.9) were independent risk factors for intra-operative RA loss. Fourteen patients suffered post-operative renal function worsening (> 30% of the baseline). The mean follow up was 19±12 months. Four (3%) early RA occlusions occurred in three patients (2 single kidney patients required permanent haemodialysis). Type D RA orientation (p=.00; RR 17.8; 8.6-37.0) and branches (p=.004; RR 3.2; 2.4-4.1) were risk factors for early RA occlusion on univariable analysis. Five patients (7%) required early RA related re-interventions (recanalisation+relining 3; stent graft extension 1; parenchymal embolisation 1). No late RA occlusion or re-interventions were reported during follow up. Composite RA events occurred in 17 (13%) cases. Type B (p=.05; OR 3.9; 95% CI 1.1-15.7) or D (p=.006; OR 10.9; 95% CI 2.3-50.8) RA orientations and branches (p=.006; OR 5.7; 95% CI 1.6-20.3) were independent predictors of composite RA events on multivariable analysis. Renal artery orientation significantly affects the early RA outcome of FB-EVAR for TAAA. Intra-operative RA loss is predicted by type B RA orientation and branches, while early RA occlusion is predicted by type D orientation and branches. The present data suggest that in TAAA, fenestrations should be the first choice for renal revascularisation in type B and D RA orientations.

WITHDRAWN: Recanalization and stenting of total occlusions of the renal arteries for blood pressure control in resistant to treatment hypertension

ObjectiveTo evaluate whether percutaneous recanalization and stenting of totally occluded renal arteries is feasible and might be justified as effective in reducing the blood pressure (BP) in some patients with preserved collateral renal flow. Patients and methodsSeven consecutive patients (3 women, 4 men) at average age of 42.8 years (range, 15–67 years) with resistant hypertension, high renin activity, renal artery occlusion and preserved subsegmental flow were included. ResultsEndovascular recanalization was successful in 6 of 7 attempted cases. One month after the procedure the 24-h ABPM in the successfully recanalized renal CTO patients showed impressive decrease in the BP average of 138.5/81.7 mm Hg compared to 167.1/95.1 mm Hg before the procedure. Significant decrease in the drug medication was achieved. During the 6-month follow-up, two of the patients had in-stent restenosis- both successfully treated with endovascular reintervention. Secondary patency was 100% for 18 months thereafter and the BP control was excellent without medication increase. ConclusionsThe recanalization of total renal artery occlusions resulted feasible and safe in the described group of patients with resistant hypertension and high plasma rennin activity. The renal artery recanalization had a positive effect on lowering the plasma renin activity and BP control.

Renal Function Salvage After Delayed Endovascular Revascularization of Acute Renal Artery Occlusion in Patients With Fenestrated-Branched Endovascular Aneurysm Repair or Visceral Debranching

Purpose: To analyze the renal function and outcome after delayed (>6 hours) endovascular revascularization of acute renal artery occlusion (RAO) in patients with fenestrated-branched endovascular aneurysm repairs (EVARs) or open visceral debranching. Methods: A single-center retrospective analysis was conducted involving 7 patients (mean age 61 years, range 49–72; 5 women) with 9 RAOs treated with endovascular revascularization between December 2014 and March 2017. Three patients had a solitary kidney with chronic renal insufficiency; 1 patient had bilateral occlusions as the acute event. Initial aortic surgery included 5 branched and 1 fenestrated EVAR as well as 1 open visceral debranching operation. Revascularization of the RAO was performed using aspiration thrombectomy, local lysis therapy, and stent-graft relining. The median time between initial aortic surgery and RAO was 10 months (range 0.5–17). Results: Median renal ischemic time to revascularization was 24 hours (range 7–168). Technical success was 100%, with 1 procedure-related access complication. Temporary dialysis dependency occurred in 4 patients. Mean in-hospital stay was 17 days (range 7–32) with 1 postoperative death at day 10 due to cardiac arrest of unknown cause. Mean follow-up was 10.3 months (range 1.5–27) in 5 of 6 discharged patients. During follow-up, 1 reintervention for recurrent occlusion was performed. At follow-up imaging, all renal arteries were patent. No permanent dialysis dependency occurred. Conclusion: Renal function can be salvaged by delayed revascularization for RAO with prolonged renal ischemia. The endovascular approach with aspiration thrombectomy, local lysis, and stent-graft relining is a feasible technique for revascularization after RAO in patients with fenestrated-branched EVAR or open visceral debranching.

Accuracy of implementing principles of fusion imaging in the follow up and surveillance of complex aneurysm repair.

Fusion imaging is standard for the endovascular treatment of complex aortic aneurysms, but its role in follow up has not been explored. A critical issue is renal function deterioration over time. Renal volume has been used as a marker of renal impairment; however, it is not reproducible and remains a complex and resource-intensive procedure. The aim of this study is to determine the accuracy of a fusion-based software to automatically calculate the renal volume changes during follow up. In this study, computerized tomography (CT) scans of 16 patients who underwent complex aortic endovascular repair were analysed. Preoperative, 1-month and 1-year follow-up CT scans have been analysed using a conventional approach of semi-automatic segmentation, and a second approach with automatic segmentation. For each kidney and at each time point the percentage of change in renal volume was calculated using both techniques. After review, volume assessment was feasible for all CT scans. For the left kidney, the intraclass correlation coefficient (ICC) was 0.794 and 0.877 at 1 month and 1 year, respectively. For the right side, the ICC was 0.817 at 1 month and 0.966 at 1 year. The automated technique reliably detected a decrease in renal volume for the eight patients with occluded renal arteries during follow up. This is the first report of a fusion-based algorithm to detect changes in renal volume during postoperative surveillance using an automated process. Using this technique, the standardized assessment of renal volume could be implemented with greater ease and reproducibility and serve as a warning of potential renal impairment.

PC176. Delayed Renal Artery Revascularization Can Be Associated With Complete Renal Recovery and Freedom From Dialysis

Acute renal ischemia can progress to irreversible loss of renal function if untreated and is considered time sensitive. Increased duration of warm ischemic time is associated with diminished long-term renal recovery. The usefulness of delayed renal artery revascularization (>48 hours) in patients with acute renal failure leading to dialysis dependence is controversial. Clinical case 1 describes a 73-year-old woman with a history of abdominal aortic aneurysm, atrophic left kidney, and right renal artery stent with a baseline creatinine of 2.3 mg/dL had presented with acute on chronic renal failure. She was severely hypertensive and hyperkalemic, with a creatinine of 9 mg/dL. She required urgent hemodialysis. On renal angiography, she was found to have a total occlusion of the right renal artery and deemed end stage renal disease. She presented 2 weeks later with a contained rupture of her abdominal aortic aneurysm. Her computed tomography scan also demonstrated opacification of the mid-right renal artery (Fig 1). She underwent open abdominal aortic aneurysm repair and right renal artery bypass. Upon discharge 12 days later, she was no longer dialysis dependent, making adequate urine, and her creatinine had returned to baseline. Clinical case 2 describes a 48-year-old woman with a history of Takayasus arteritis, prior proximal descending thoracic aorta to infrarenal abdominal aortic bypass and bypass to the left renal artery for mid-aortic syndrome, and atrophic right kidney presented with severe hypertension, fluid overload, and hyperkalemia, and a creatinine of 5.8 mg/dL requiring urgent dialysis. She was anuric and dialysis dependent. Magnetic resonance angiography revealed occlusion of the left renal artery bypass which originated from the aortic bypass graft and collateral filling of the left kidney with differential areas of perfusion (Fig 2). She underwent redo aortic graft to left renal artery bypass 18 days after her initial presentation. Upon discharge, she was no longer dialysis dependent and her creatinine has normalized. Two patients presenting with dialysis dependent acute renal failure underwent delayed renal artery revascularization, greater than 14 days from their presentation. Complete renal recovery with return to baseline renal function was observed in these patients. In select patients, delayed renal artery revascularization (>48 hours of warm ischemic time) is controversial, but can be associated with complete renal recovery and freedom from dialysis.Fig 2Case 2.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

V08-12 BLEEDING DISASTER MANAGEMENT DURING ROBOTIC RENAL SURGERY

You have accessJournal of UrologyProstate & Renal Oncology II1 Apr 2018V08-12 BLEEDING DISASTER MANAGEMENT DURING ROBOTIC RENAL SURGERY Amit Patel and Craig Rogers Amit PatelAmit Patel More articles by this author and Craig RogersCraig Rogers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1978AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Intraoperative complications are reported in approximately 1.8% of robotic partial nephrectomy (RPN) cases. We demonstrate examples of published algorithms for management of bleeding during robotic kidney surgery using real-life scenarios in video format. METHODS We present 8 robotic renal surgery cases (5 partial, 3 radical nephrectomy) demonstrating management of escalating vascular injuries, bleeding during renorraphy and excision of mass during RPN, management of a misfired endovasular stapler and bleeding during radical nephrectomy (missed upper pole vessel and torn parasitic vessel), one requiring open conversion. RESULTS Steps to manage vascular injuries included compression, cautery, increased pneumoperitoneum and utilization of a pre-prepared rescue suture. Techniques to avoid bleeding during excision and renorraphy included early unclamping to help visualize vessels, utilization of clips/sutures to visible vessels, additional tightening of renorraphy sutures and clamping maneuvers to avoid venous congestion while improving renal artery occlusion. Steps to manage bleeding during nephrectomy included removal of remaining attachments to control a missed vessel and a controlled conversion to open procedure. 7 cases were managed with EBL<400ml, no transfusions, and hospital stay<3 days. One patient converted to open had an EBL of 800ml with 2 units transfused and a 5 day hospital stay. CONCLUSIONS Intraoperative bleeding during robotic renal surgery, although rare, can be disasterous if not managed appropriately. Familiarity of algorithms to manage intraoperative bleeding, and preparation for these scenarios, may help prevent unnecessary patient morbity. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e823 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Amit Patel More articles by this author Craig Rogers More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The efficiency of zero ischemia index in predicting complexity and outcomes of off-clamp nephron-sparing surgery

Objective To evaluate the efficacy of zero ischemia index (ZII) in predicting the complexity and perioperative outcomes of off-clamp nephron-sparing surgery (NSS). Methods The patients between June 2016 and June 2017 in our institution who underwent off-clamp NSS were prospectively evaluated. ZII was defined as the product of the tumor diameter and depth within renal parenchyma. The ZII>6 defined as higher risk while ZII≤6 defined as low risk. The operating time, estimated blood loss, hospital stay, drainage, and complication rate were analyzed. Results There were 35 males and 10 females with average age of 42 y(range 23-76y). Mean tumor size was 2.4 cm (range 0.8-4.2 cm). Mini-flank approach open NSS was performed in 33 cases and laparoscopic NSS was performed in 12 cases. Off-clamp NSS was successfully performed in 44 patients except for renal artery occlusion in 1 case. Mean operative time was (95.0±17.5) min (range 50-150 min); The average estimated blood loss was (152.4±134.2) ml (range 20-600 ml); Mean postoperative drainage was (97.3±59.7)ml (range 50-300 ml); Mean postoperative hospital stay was (6.1±1.3) d (range 5-8 d). Not severe post operative complication was observed. There were 37 patients in low risk group and 8 patients in high risk group. Operating time was significantly longer in high risk group [(118.8±14.6 min) vs. (89.9±13.4) min, P<0.01]. EBL [(375.0±158.1) ml vs. (104.3±61.4) ml, P<0.01] and drainage [(161.2±91.3)ml vs. (83.5±40.4)ml, P<0.01] were also significantly higher in high risk group. But there was no significant difference in hospital stay between two groups. The postoperative pathology indicated that 35 cases of clear cell carcinomas, 2 cases of chromophobe renal cell carcinomas, one case of papillary carcinoma and seven cases of angiomyolipomas. Conclusions The ZII is a novel and effective measurable criterion which can help predict the risk of perioperative outcomes of off-clamp NSS. ZII=6 is established as a preliminary threshold for patient selection of off-clamp NSS. Key words: Nephron sparing surgery; Zero ischemic; Renal neoplasm

Retroperitoneal laparoscopic adrenalectomy with transient renal artery occlusion for large adrenal tumors (≥8 cm).

To analyze our experience in retroperitoneal laparoscopic adrenalectomy (RLA) with transient renal artery occlusion for large adrenal tumors (≥8 cm) and to explore the safety and feasibility of this surgical procedure. A retrospective cohort study was conducted with a surgical data review of 18 patients with large adrenal tumors who underwent RLA with transient renal artery occlusion in our hospital. Eighteen patients were treated by RLA with transient occlusion of the renal artery, and none were converted to open adrenalectomy. The renal artery occlusion time, operative time, estimated blood loss, perirenal drainage time, postoperative hospital stay, and postoperative drainage were 7.6 ± 1.0 min, 176.3 ± 49.7 min, 247.2 ± 274.1 mL, 4.1 ± 1.02 days, 6.3 ± 1.4 days, and 73.6 ± 47.9 mL, respectively. No severe complications occurred, with the exception of hemodynamic instability in one patient with a pheochromocytoma and one transfusion during the operation. Only one case of adrenal crisis occurred postoperatively. Pathological examination revealed 9 cases of pheochromocytoma, 6 cases of adrenal myelolipoma, 1 case of adrenal ganglioneuroma, 1 case of hygromata, and 1 case of adrenal teratoma. No recurrence or evidence of metastasis was observed during the 7-to-30-month follow-up period. RLA with transient renal artery occlusion is a feasible, effective, and safe treatment for large adrenal tumors (≥8 cm).

Total Renal Artery Occlusion: Recovery of Function After Revascularization

Current trends in managing atherosclerotic renal artery stenosis favor medical therapy, on account of negative results from prospective trials of revascularization, such as CORAL and ASTRAL. One result of this trend has been encountering occasional patients with progressive disease, sometimes leading to total arterial occlusion. We illustrate a case of accelerated hypertension with complete renal artery occlusion in which the patient recovered function after surgical bypass and we review the clinical approach used and the advanced imaging modalities available to us. A high index of suspicion and careful radiologic imaging play important roles in selecting patients who may have residual function and may benefit from revascularization. This case illustrates an example whereby restoring renal artery perfusion for carefully selected patients can be life changing, with recovery of kidney function and improved blood pressure, pill burden, and overall quality of life.