Selective Renal Arteriography Research Articles

Transcatheter embolisation of iatrogenic renal vascular injuries

The aim of our study was to review our experience and long-term follow-up in the treatment of iatrogenic renal vascular injuries using transcatheter embolisation. Our retrospective analysis of cases collected in two interventional centres consists of a total of 21 patients who underwent renal arterial embolisation (RAE) for iatrogenic arterial kidney bleeding. Biopsy (n = 4), percutaneous nephrolithotomy (n = 4), nephron-sparing surgery (n = 4), guidewire-induced arterial perforation during coronary angiography or renal stenting (n = 3), percutaneous nephrostomy (n = 3), renal endopyelotomy/pyeloplasty (n = 2) and surgical nephrectomy were the iatrogenic causes. Seven patients presented with haemodynamic instability requiring blood transfusion (33.3%), the remaining were haemodynamically stable (66.7%). Diagnostic renal angiography revealed 9 actively bleeding vessels, 6 pseudoaneurysms, 4 arteriovenous fistulas and 1 arterio-calyceal fistula. In one patient selective renal arteriography was negative probably because the bleeding observed at CT angiography was self-limited. Twenty-one embolisation procedures were performed in 20 patients; one patient required a second embolisation 3 h after the first one. Embolisation was performed with microcoils, polyvinyl alcohol particles, embospheres, spongostan emulsion and vascular plug. The technical success rate was 100%. The overall clinical success rate was 95%. Apart from a patient who died due to disseminated intravascular coagulation, no major complications requiring intensive care treatment were encountered during or after the procedures. No patient required emergency surgery or subsequent surgical treatment. No statistically significant differences in eGFR or renal function stage appeared after RAE. Percutaneous treatment can be proposed as a first-line treatment in iatrogenic renal arterial injuries, resulting in a safe and effective procedure.

Comparison of diagnostic accuracy of Doppler USG and contrast-enhanced magnetic resonance angiography and selective renal arteriography in patients with atherosclerotic renal artery stenosis

BackgroundThere are many systemic complications of conventional selective renal arteriography (SRA), such as contrast-mediated nephropathy. Contrast-enhanced magnetic resonance angiography (CE-MRA) and renal artery Doppler ultrasonography (DUSG) have been used increasingly for renal artery stenosis (RAS). The aim of this study was to evaluate the accuracy of CE-MRA and DUSG as used for diagnosis of RAS.Material/MethodsWe divided 130 consecutive patients investigated for resistant hypertension into 2 groups based on age: group 1 was patients <60 years old and group 2 was patients >60 year. DUSG, CE-MRA, and SRA were performed in group 1 and group 2 patients.ResultsSeventy-two patients (24 males [M], 48 females [F]) in group 1, and 58 patients (26 M, 32 F) in group 2 were included in the study. In the evaluation of clinically significant renal artery stenosis with DUSG, in group 1 the overall sensitivity was 83.33% and overall specificity was 81.82%, and in group 2 they were 69.23% and 0%, respectively, when compared with SRA. In the evaluation of clinically significant renal artery stenosis with CE-MRA, the overall sensitivity and specificity were 92.31% and 36.36%, respectively, in group 1 and 100.00% and 73.33%, respectively in group 2, when compared with SRA.ConclusionsCE-MRA is an accurate, non-invasive method for the diagnosis of RAS in patients above 60 years of age and DUSG may be the choice of diagnostic method for RAS in patients under 60 years of age.

Imaging in renal trauma

Renal injuries are classified, based on the American Association for the Surgery of Trauma classification, in to five grades of injury. Several imaging modalities have been available for assessing the grade of renal injury, each with their usefulness and limitations. Currently, plain radiographs and intravenous urography have no role in the evaluation of patients with suspected renal injury. Ultrasonography (USG) has a limited role in evaluating patients with suspected retroperitoneal injury; however, it plays an important role during follow up in patients with urinoma formation. USG helps to monitor the size of a urinoma and also for the drainage procedure. The role of selective renal arteriography is mainly limited to an interventional purpose rather than for diagnostic utility. Retrograde pyelography is useful in assessing ureteral and renal pelvis integrity in suspected ureteropelvic junction injury and for an interventional purpose, like placing a stent across the site of ureteric injury. Magnetic resonance imaging has no role in acute renal injuries. Multidetector computed tomography is the modality of choice in the evaluation of renal injuries. It is also useful in evaluating traumatic injuries to kidneys with preexisting abnormalities and can help to define the extent of penetrating injuries in patients with stab wounds in the flank region. The combination of imaging findings along with clinical information is important in the management of the individual patient. This article will describe a spectrum of renal injuries encountered in a trauma setting.

Cause and management of delayed hemorrhage after minimally invasive percutaneous nephrolithotomy

Objective To discuss the cause and management of delayed hemorrhage after minimally invasive percutaneous nephrolithotomy (PCNL). Methods From 2004 to 2009,there were 13 cases (10 men and 3 women, mean age 47 years) developed severe bleeding following PCNL. The cause of hemorrhage and treatments were retrospectively analyzed and summarized. Results The time of hemorrhage was 5-40 d. In 7 of 13 cases, the bleeding were was controlled by complete bed rest,hemostatic,balloon compression and clamped nephrostomy tube. Six of 13 underwent selective renal arteriography after ineffective with conservative treatment. The DSA showed 4 were false aneurysm and 2 were arteriovenous fistula. All the 6 cases were treated by the super-selective arteriolar embolization. The hematuria was disappeared 1- 3 d later. The intravenous pyelogram revealed the renal function kept well during follow-up visit. Conclusions Delayed hemorrhage is one of the severe complications, which may be caused when the renal puncture passage established as forming false aneurysm and arteriovenous fistula. The renal arteriography and super-selective arteriolar embolization could be a safe and effective treatment for the severe hemorrhage after PCNL. Key words: Percutaneous nephrolithotomy; Postoperative hemorrhage; Universal precaution

Frequency and predictors of renal artery stenosis in patients with coronary artery disease

Renal artery stenosis (RAS) remains underdiagnosed because of nonspecific clinical manifestations, including in patients with coronary artery disease (CAD). To estimate the prevalence and identify predictors of RAS in patients with CAD undergoing coronary angiography. University-based medical centre. We enrolled 650 consecutive patients (mean age=67+/-10 years, 80% men) with confirmed CAD. All patients underwent selective renal arteriography in the same procedure. We estimated the prevalence of RAS, defined as a >50% lesion. Multiple variable analysis of factors associated with presence of RAS was carried out using a logistic regression model. Variables that emerged as predictors by single-variable analysis were included in the model, along with variables that were tentatively associated with RAS, based on a literature review. RAS was detected in 94 patients (14.5%, 95% CI: 11.8-17.2%), including 20 (3.1%) with bilateral lesions. By single-variable analysis and presence and number of coronary artery stenoses (P<.001), hypertension (P=.001), and creatinine clearance <90 ml/min (P<.001) were associated with an increased risk of RAS. By multiple variable analysis, male sex (P<.05), presence and number of coronary artery lesions (P<.01), hypertension (P=.001), and renal insufficiency (P<.001) predicted the presence of RAS. The main clinical predictors of RAS in patients with CAD were hypertension, renal insufficiency, and multivessel CAD. These observations might help defining a high-risk subgroup of patients in need of meticulous investigations of both CAD and RAS.

Pseudocysts of the pancreas presenting as renal mass lesions.

SUMMARY AND CONCLUSIONS Two cases of pseudocyst of the pancreas are presented, both of which were misinterpreted pre-operatively as intrarenal lesions. Although selective renal arteriography may serve to differentiate vascular from avascular lesions of the kidney, and extrinsic from intrinsic mass lesions in most cases, a small number of extrinsic lesions causing gross deformity of the kidney can be confused with masses of intrinsic origin despite adequate arteriographic studies. In these cases surgical exploration reveals the true nature of the lesion. Should a thick-walled cystic mass be encountered which is filled with liquid decomposed blood, an emergency amylase determination should be done on the fluid, and if it is high indicating that the cyst is of pancreatic origin, either resection of the involved pancreas should be performed, or provision made for adequate and prolonged drainage of the consequent pancreatic fistula.

Congenital intrarenal arteriovenous malformation presenting with gross hematuria after endoscopic intervention: a case report

IntroductionAlthough diagnostic ureterorenoscopy is a minimally invasive and effective diagnostic procedure, it has the potential for significant postoperative complications. We report the first case in the literature of intrarenal arteriovenous fistulas causing hemodynamic effective anemia 4 days after ureterorenoscopic biopsy.Case presentationA 63-year-old Caucasian woman presented with hemodynamic effective macrohematuria (hemoglobin 70 g/liter) 4 days after ureterorenoscopy and biopsy of the upper pole collecting system due to recurrent microhematuria. Duplex-sonography and computed tomography angiography revealed multiple arteriovenous fistulas and erosions into the calyceal system. Intra-arterial digital subtraction angiography confirmed this condition. After superselective embolization of the arteriovenous fistulas, the patient had no further episodes of bleeding or microhematuria.ConclusionIf malignancies, urolithiasis or urinary tract infections are ruled out by common diagnostic procedures as the cause of recurrent minor or gross hematuria, the possibility of arteriovenous fistulas should be included in the differential diagnosis and Duplex-Sonography or the more invasive selective renal arteriography should be performed as this is the most definitive method for diagnosing arteriovenous fistula.

Hypertension and segmental renal infarction in children: apropos of two cases

Segmental renal infarction (SRI) is a rare condition that causes renovascular hypertension (RVH), which accounts for 8-10% of all causes of pediatric hypertension. We report the clinical course of two children with idiopathic SRI who suffered severe arterial hypertension associated with hyponatremia. Hypertension was diagnosed during the study of hematuria in the first case and due to a hypertensive emergency in the second case. The etiology was found to be renovascular in both patients, involving the occlusion of small renal arteries and causing SRI. Our first patient was treated with partial nephrectomy, and the second patient was treated with antihypertensive medication given the impossibility of removing the infarcted renal area. The occlusion of small renal arteries is a rare disease of unknown origin in which the gold standard for diagnosis is selective renal arteriography. The definitive treatment is surgical segmentectomy. If segmentectomy is not feasible because of the localization of the infarcted area, as in our second patient, medical treatment is required. In view of the importance of RVH in children and the rareness of the particular etiology here reported (SRI), a review of the literature was done.

Renal artery aneurysm treatment with coil embolization

Renal artery aneurysm is a rare condition, but its incidence has increased through discovery because of improved imaging techniques. However, a therapeutic approach for renal artery aneurysm has not been established. We report the case of a 58-year-old female who had developed hypertension at 52 years of age and was under oral medication for this condition. In a medical check-up, a right renal artery aneurysm of 10 mm in diameter was detected by computed tomography (CT). Renal function was normal and there were no abnormalities in urinalysis; therefore, the patient was observed as an outpatient. Abdominal CT performed 9 months later revealed a saccular renal artery aneurysm of 15 mm in diameter with partial wall calcification and mild mural thrombus. Selective right renal arteriography detected a tumor with calcification, but no renal arterial stenosis or renal arteriovenous fistula. Since the aneurysm had enlarged, catheter treatment was selected to reduce the risk of rupture. A 6-Fr guide catheter was inserted into the right renal artery and the tip of a microcoil catheter was advanced into the aneurysm, which was then embolized with 12 microcoils. The absence of the aneurysm was confirmed using right renal arteriography. No complications occurred during or after embolization, and selective right renal arteriography performed 3 months later showed no change in the coil position or blood flow in the aneurysm, suggesting a good postoperative course. Our results suggest that this approach may generally be applicable for renal artery aneurysms, depending on the shape, size, and location of the aneurysm.

Prevalence and Risk Factors of Atherosclerotic Renal Artery Stenosis in 1,200 Chinese Patients Undergoing Coronary Angiography

Aims: Atherosclerotic renal artery stenosis (ARAS) is a common and potentially reversible cause of end-stage renal failure. Our study aimed to determine the prevalence and predictors of ARAS in Chinese patients undergoing coronary angiography for suspected coronary heart disease (CAD), or for acute or chronic myocardial infarction. Methods: Selective renal arteriography was performed immediately after coronary angiography in 1,200 consecutive patients. Medical history and laboratory data were obtained before the procedure. Significant renal artery stenosis was defined as ≧50% narrowing of the luminal diameter. Uni- and multivariate logistic regression analyses were made to explore the association of the clinical and laboratory variables, including some items which had never or rarely been studied, with ARAS or CAD. Results: Of the 1,200 patients, 840 were male and 360 female. Their mean age was 62 ± 10 years. Low-grade (<50%) and significant coronary artery stenosis was found in 108 (9%) and 610 (51%) patients respectively. By multivariate logistic regression analysis, risk factors associated with the presence of coronary artery stenosis included male, older age, smoking, high serum concentration of low density lipoprotein, lipoprotein (a), and fast blood glucose ≧7.0 mmol/l. Significant ARAS was present in 116 (9.7%) patients, of which 20 (1.7%) were bilateral. The incidence of ARAS was similar in patients with suspected CAD or myocardial infarction. Multivariate logistic regression analysis showed the association of the clinical variables with ARAS included: older age, hypercholesterolemia, a more than 10-year history of hypertension, proteinuria and S_Cr ≧133 µmol/l. The severity of ARAS is significantly related to the severity of coronary artery disease. Conclusion: ARAS is a frequent finding in Chinese patients undergoing coronary angiography, especially in patients with significant coronary artery stenosis and risk factors for ARAS. Renal arteriography can be a helpful examination in these patients.

Surgical correction of intrarenal arteriovenous fistula with preservation of the kidney.

Abstract A patient with a calcified arteriovenous fistula of the left kidney was correctly diagnosed by selective renal arteriography. At surgery it was possible to identify the single vessel supplying the arteriovenous fistula and to ligate it with correction of the vascular abnormality. The end-artery characteristics of the renal arterial distribution make this surgical approach feasible and, in addition, permits the salvage of the involved kidney. Although renal arteriovenous fistula is not a common condition, with the increasing number of people having needle biopsies of the kidney as well as experiencing major abdominal injuries, its existence should be kept in mind whenever such patients develop abdominal pain, bruit, cardiomegaly, congestive heart failure, and diastolic hypertension. Early surgery is indicated, with the primary aim being the eradication of the vascular abnormality and salvage of the kidney if at all possible.

Reduction in Renal Function After Renal Arteriography and After Renal Artery Angioplasty

Objective: to investigate the incidence and risk factors for renal function deterioration after renal angiography and angioplasty or stenting.Methods: a retrospective study of 85 consecutive patients undergoing selective renal artery arteriography (n=53) or renal artery angioplasty % (PTRA) stenting (n=32) for renal artery stenosis. Multivariate logistic regression analysis was used to determine independent predictors of deterioration of renal function, defined as an increase of serum creatinine by at least one third within 24h.Results: deterioration of renal function occurred in 13 patients (15%), [8/53 (15%) after angiography and 5/32 (16%) after PTRA/stenting]. Only pre-existing renal impairment (se-creatinine≥177μmol/l) (Odds ratio: 40; 95% confidence interval 1.2–72, p=0.02) and administered dosage of contrast agent (more than 225ml) (OR 67; 95% CI1 1.8–100, p=0.02) were independently associated with renal function deterioration.Conclusion: transient renal dysfunction after renal artery angiography or PTRA/stenting occurs in about 15% of patients, but persistent renal failure is uncommon. Pre-existing renal impairment and amount of contrast agent are independent risk factors. Endovascular treatment of renal artery stenosis is not associated with a higher risk of renal deterioration compared to selective renal angiography.

Experimental Evaluation of a New Transcatheter Vascular Embolization Device in the Swine Model

To evaluate a new transcatheter device suitable for arterial embolization in an animal model. A new prototype self-expanding braided embolic device (Embolizor), consisting of nitinol wire strands fixed at either end with platinum-iridium bands and covered with a film of polyethylene, was deployed through 5-F diagnostic catheters into renal artery branches in five swine. Standard stainless-steel spring coils were deployed in other renal branches and served as controls. The animals underwent follow-up selective renal arteriography to determine presence or absence of vessel recanalization or device migration 15-23 days after device deployment. Histopathologic evaluation of target vessels and peripheral renal parenchyma was also performed. Ten Embolizors and 10 stainless-steel coils were deployed in arteries ranging in size from 1.8 to 3.0 mm in diameter. The Embolizor was easily and precisely deployed. Angiographic evidence of vascular occlusion in the Embolizor group was noted within 30 seconds in eight device deployments and within 5 minutes in two. No early or delayed device migration was noted on follow-up arteriography. In the control group, seven of 10 previously occluded arteries were recanalized. No recanalization was noted in the Embolizor group. Light microscopy revealed evidence of infarction in all specimens examined. Whereas three specimens in the Embolizor group contained occasional giant cells, there were numerous multinucleated giant cells present within the interstices of all control spring coils. The Embolizor was easily, precisely, and successfully deployed through standard selective diagnostic angiographic catheters. Short-term follow-up demonstrated no recanalization or migration of the device. The Embolizor was shown on histopathologic analysis to have no significant foreign body reaction.

Imaging of renal trauma: a comprehensive review.

Computed tomography (CT) is the modality of choice in the evaluation of blunt renal injury. Intravenous urography is used primarily for gross assessment of renal function in hemodynamically unstable patients. Selective renal arteriography or venography can provide detailed information regarding vascular injury. Retrograde pyelography is valuable in assessing ureteral and renal pelvic integrity in suspected ureteropelvic junction injury. Ultrasonography is useful in detecting hemoperitoneum in patients with suspected intraperitoneal injury but has limited value in evaluating those with suspected extraperitoneal injury. Occasionally, radionuclide renal scintigraphy or magnetic resonance imaging may prove helpful. Renal injuries can be classified into four large categories based on imaging findings. Category I renal injuries include minor cortical contusion, subcapsular hematoma, minor laceration with limited perinephric hematoma, and small cortical infarct. Category II lesions include major renal lacerations extending to the medulla with or without involvement of the collecting system and segmental renal infarct. Category III lesions are catastrophic renal injuries and include multiple renal lacerations and vascular injury involving the renal pedicle. Category IV injuries are ureteropelvic junction injuries. CT is particularly useful in evaluating traumatic injuries to kidneys with preexisting abnormalities and can help assess the extent of penetrating injuries in selected patients with limited posterior stab wounds. Integration of the imaging findings in renal injury with clinical information is critical in developing a treatment plan.

Utility of CT angiography for evaluation of living kidney donors.

We reviewed our initial experience with helical computed tomography (CT) angiography in the evaluation of living kidney donors which, until now, has necessitated arteriography. Nineteen donors (12 women, 7 men) have had their renal anatomy evaluated solely by CT angiography preoperatively. All scans demonstrated normal collecting systems and single ureters. Five donors (26%) had supernumerary renal arteries. Fourteen donors had single, 4 donors had two, and 1 donor had three renal arteries. Helical CT demonstrated small polar vessels in several donors. Two donors (10%) had supernumerary renal veins. Accuracy of vascular anatomy defined on CT was 90% when confirmed at operation. Anatomically all CT findings were consistent with operative findings except in 1 donor who was found to have a 0.8 cm lesion near the renal hilum. At our institution, the total charges for selective renal arteriography are $3845 and for helical CT with three-dimensional (3-D) reconstruction are $1546. The amount of contrast dye (approximately 100 mL) is equivalent. Patients uniformly reported that the CT scan was a convenient and painless procedure. The accuracy of helical CT angiography is equivalent to arteriography in assessing renal vascular anatomy (with the additional benefit of imaging venous and parenchymal anatomy). Charges for helical CT are 59% less. There is greater patient acceptance and potentially less morbidity associated with the non-invasive nature of helical CT. We believe that CT angiography is the radiologic procedure of choice for the assessment of renal anatomy in potential living kidney donors.

Renin Secreting Tumors: Diagnosis, Conservative Surgical Approach and Long-Term Results

During the last 15 years 8 patients were diagnosed with renin secreting juxtaglomerular cell tumors among 30,000 hypertensive patients. Clinical characteristics included severe hypertension poorly medically controlled in young patients (mean age 22.3 years) and severe hypokalemia (mean 2.83 mmol./l.). Secondary hyperaldosteronism was present in all cases with a constant elevation of renin activity. Renal vein sampling was only positive in 64 percent of cases. Selective renal arteriography demonstrated an avascular area in 43 percent of the patients. Computerized tomography showed the tumor in all cases. Mean tumor size was 24 mm. (range 10 to 50). Conservative surgery was feasible in all patients. Perioperative ultrasonography was used for 3 intraparenchymal tumors. Hypertension and hypokalemia resolved within 1 week after surgery. At a mean followup of 98 months (range 24 to 204) no tumor recurrence was documented.

Mixed renal tumor with carcinomatous and fibroleiomyomatous components, associated with angiomyolipoma in the same kidney

A 54-year-old woman, without the stigmas of tuberous sclerosis, underwent radical nephrectomy for simultaneous occurrence of an Angiomyolipoma (AML) and a carcinomatous and fibroleiomyomatous mixed tumor in the same kidney, diagnosed by computerized tomography, selective renal arteriography and anatomopathological examination. The peculiar findings of the mixed neoplasia, characterized by a mixture of carcinomatous and fibroleiomuscular components are stressed. The latter component is considered to be a proliferative element interacting with the carcinomatous one. After review of the pertinent literature, this is the first example of an association of AML and renal cell carcinoma (RCC) in which the RCC is constituted by a mixture of carcinomatous and fibroleiomyomatous cells.

Iatrogenic renal vascular lesions: treatment by arterial catheter embolisation

Five patients, four male and one female aged 17–65 years (mean 41 years), with iatrogenic renal vascular lesions were treated by percutaneous artenial embolisation. Vascular trauma was caused by percutaneous biopsy (two cases), percutaneous nephrolithotomy (one case), partial nephrectomy (one case) and total nephrectomy (one case). Recurrent macroscopic haematuria was present in four cases and congestive cardiac failure due to reno-caval shunt in one case. Selective renal arteriography revealed false aneurysm in all cases, associated with arteriovenous fistula in four cases. Treatment was performed by selective embolisation of the injured artery. Coils and n-butyl-2-cyanoacrylate mixed with iodised oil or tantalum powder were used as embolic agents. Two patients required two embolisation procedures for definitive treatment. No complication was observed.

Spectrum of renal vascular malformation

In summary, renal AVMs are rare. The possibility of these lesions should be raised in cases of hematuria of unknown etiology, prolonged hematuria following trauma or needle biopsy, unexplained congestive heart failure or abdominal/flank bruit, or hypertension after renal trauma. Selective renal arteriography is the study of choice for establishing the diagnosis, the hallmark being demonstration of an abnormal arterial communication with a vein. The goal of management should be maximum preservation of renal parenchyma. Observation with follow-up is indicated for asymptomatic AVMs.

Splenosis Presenting as a Left Renal Mass Indistinguishable from Renal Cell Carcinoma

Splenosis following splenic trauma is a common but underdiagnosed entity before surgical exploration. In all previously reported cases the ectopic splenic tissue was distinctly separate from the kidney. To our knowledge we report the first known case in which the splenic tissue was located in direct apposition with the kidney. Using conventional imaging techniques, including renal ultrasonography, abdominal computerized tomography and selective renal arteriography, this ectopic splenic tissue appeared to be part of the left kidney and was indistinguishable from renal cell carcinoma. The pathophysiology, clinical presentation and diagnostic studies of splenosis are reviewed.