TRANSCATHETER
EMBOLIZATION
RENAL ARTERIOVENOUS MARTIN L. GOLDMAN, SUSAN K. FELLNER, THOMAS
OF
FISTULA
M.D.
M.D.
S. PARROT-T, M.D.
From the Departments of Radiology and Medicine, Divisions of Nephrology and Surgery, and Urology, Emory University School of Medicine, Atlanta, Georgia
ABSTRACT - A patient with malignant hypertension and acute renalfailure underwent percutaneous renal biopsy which resulted in the creation of an arteriovenousjistula that communicated with the renal pelvis. Successful segmental embolization with gelatin sponge (Gelfoam) was achieved via a transcatheter approach.
The diagnosis of renal arteriovenous fistula is best made by angiography. In cases in which the fistula results in renovascular hypertension, high output cardiac failure, or bleeding, the classic therapeutic approach has been surgical.‘,2 Because of intrarenal location of many arteriovenous fistulas, total or partial nephrectomy has been necessary. Recently, selective arterial occlusion has been utilized as an alternative to surgery.3-5 We report a case of postbiopsy renal arteriovenous fistula managed successfully with transcatheter embolization with gelatin sponge (Gelfoam). Case Report A thirty-one-year-old black man with a strong family history of hypertension had poorly controlled hypertension for two years. Over a period of several weeks accelerated hypertension, congestive heart failure, grade IV retinopathy, and renal failure with a creatinine clearance of 1 cc. per minute developed. Peripheral venous renin was 9.2 ng. per milliliter per hour (normal: < 1 ng.). Renal angiography showed small kidneys with absence of nephrogram bilaterally. The interlobar arteries had a “pruned tree” appearance, and the arcuate and interlobular arteries failed to fill. After peritoneal dialysis and control of hypertension the patient underwent a percutaneous
386
right renal biopsy with a Vim-Silverman needle. The biopsy showed characteristic changes of malignant nephrosclerosis. Immediately following biopsy he began to pass bright red blood from the bladder, subsequently requiring transfusion with 2 units of blood. No bruit was heard over the right flank or abdomen. Over the next seventytwo hours he had intermittent gross hematuria, occasionally with clots. A second renal angiogram was performed utilizing the Seldinger technique with a 6.7 F polyethylene catheter. The right main renal artery was visualized and the catheter was advanced into a distal branch of the dorsal renal artery. Angiography demonstrated an arteriovenous fistula with extravasation of contrast material into the calyces, and additionally outlined clots within the upper collecting system. Multiple fragments of gelatin sponge cut into 2-mm. squares were injected into the interlobar artery supplying the arteriovenous fistula. Immediate follow-up renal angiography showed complete closure of the fistula (Fig. 1). Following gelatin sponge embolization, the patient required no further transfusion. Hematuria gradually subsided over the next two days. A peripheral venous renin at this time was 30 ng. per millilter per hour. The patient is presently
UROLOGY
/ SEPTEMBER1975
/ VOLUMEVI,
NUMBER3
FIGURE 1. Occlusion of traumatic arteriovenous fistula. (A) Angiogram prior to biopsy demonstrates nonspecific arterial changes of chronic renal disease. (B) Angiogram three days following closed renal biopsy demonstrates an aneurysm (arrow) in the lower pole of the right kidney. (C) Angiogram with catheter advanced into an interlobar branch of the dorsal renal artery demonstrates arteriovenousfistula with early filling of veins (arrows), and extravasation of contrast material into collecting system, outlining blood clot. (D) Following embolization with gelatin sponge, a right renal artery angiogram demonstrates thrombosis of interlobar artery (arrow) to arteriovenous fistula.
maintained motensive monoxidil.
on regular hemodialysis and is noron therapy with propranolol and Comment
With greater clinical suspicion, and with increased availability of angiography, the diagnosis of arteriovenous fistula is being made more fre-
UROLOGY
/ SEITEMBER
1975 / VOLUME
VI, NUMBER 3
quently. Almost one half of all reported arteriovenous fistulas have been described within the past three years. Over 70 per cent of renal arteriovenous fistulas result from trauma, and more than 40 per cent of acquired arteriovenous fistulas are secondary to renal biopsy.’ Fistulas develop with a frequency of up to 18 per cent following biopsy; most, however, are small and
387
insignificant. A small percentage may have gross hematuria and/or subcapsular hematoma may develop requiring corrective surgical management. Complications of renal biopsy occur more frequently when associated with hypertension and central puncture of the kidney.1,6 The angiogram can precisely localize the lesion, thereby facilitating the performance of procedures that will not sacrifice renal parenchyma. However, in more than one half of the patients with symptomatic arteriovenous fistulas reported by O’Brien et al. l and McAlhany et al. ,2 surgical intervention resulted in nephrectomy. Recently the cardiovascular radiologist has been actively involved in designing methods for controlling life-threatening hemorrhage. Selective angiography permits placement of the catheter in close proximity to the lesion. Various substances such as gelatin sponge, blood clots, thrombin, Ivalon, tissue adhesive, faP5 can then be injected directly to occlude the lesion. Tissue adhesives, such as isobutyl cyanoacrylate, provide instantaneous and permanent clotting of the injected blood vessel. ‘~9~These agents, however, do not presently have approval for clinical use from the Federal Drug Administration. Gelatin sponge is readily available, inexpensive, and produces a clot of more than twenty-four hours’ durationg In contrast, injected blood clots are usually lysed within several hours. Renal infarction with resulting hypertension is a potential complication. However, selective angiography and embolization minimizes this complication .
388
We propose that in selected patients with symptomatic arteriovenous fistula, angiography with selective embolization may be the treatment of choice. Department of Radiology 69 3utler Street, Southeast Atlanta, Georgia 30303 (DR. GOLDMAN) References 1. O’BRIEN, D. P., PARROTT,T. S., WALTON, K. N., and LEWIS, E. L.: Renal arteriovenous fistulas, Surg. Gynecol. Obstet. 139:739 (1974). 2. MCALHANY,J. C., BLACK, H. C., HANBACK,L. D., and YARBROUGH,D. R.: Renal arteriovenous fistula as a cause of hypertension, Am. J. Surg. 122: 117 (1971). 3. BOOKSTEIN,J. J., and GOLDSTEIN, H. M.: Successful management of post biopsy arteriovenous fistula with selective arterial embolization, Radiology 109: 535 (1973). 4. RIZK, G. K., ATALLAH, N. K., and BRIDI, G. I.: Renal arteriovenous fistula treated by catheter embolization, Br. J. Radial. 46: 222 (1973). 5. DOTTER,C. T., GOLDMAN, M. L., and R&cH, J.: Instant selective arterial occlusion with isobutyl Z-cyanoacrylate, Radiology 114:227 (1975). 6. KGHLER, R., and EDGREN, J.: Angiographic abnormalities following percutaneous needle biopsy of the kidney, Acta Radiol. 15: 515 (1974). R~SCH, J., GOLDMAN,M. L., and DOTTER, C. T.: Percutaneous occlusion of the gastric coronary vein. Presented at the 22nd annual meeting of the Association of University Radiologists, New York, May 8, 1974. KERBER, C. : Experimental arteriovenous fistula. Creation and percutaneous catheter obstruction with cyanoacrylate, Invest. Radiol. 10: IO (1975). CHUANG,V. P., and REUTER, S. R.: Selective arterial embohzation for the control of traumatic splenic bleeding, ibid. 10: 18 (1975).
UROLOGY I SEmEMBER 1975 /
VOLUME VI, NUMBER 3
EMBOLIZATION
RENAL ARTERIOVENOUS MARTIN L. GOLDMAN, SUSAN K. FELLNER, THOMAS
OF
FISTULA
M.D.
M.D.
S. PARROT-T, M.D.
From the Departments of Radiology and Medicine, Divisions of Nephrology and Surgery, and Urology, Emory University School of Medicine, Atlanta, Georgia
ABSTRACT - A patient with malignant hypertension and acute renalfailure underwent percutaneous renal biopsy which resulted in the creation of an arteriovenousjistula that communicated with the renal pelvis. Successful segmental embolization with gelatin sponge (Gelfoam) was achieved via a transcatheter approach.
The diagnosis of renal arteriovenous fistula is best made by angiography. In cases in which the fistula results in renovascular hypertension, high output cardiac failure, or bleeding, the classic therapeutic approach has been surgical.‘,2 Because of intrarenal location of many arteriovenous fistulas, total or partial nephrectomy has been necessary. Recently, selective arterial occlusion has been utilized as an alternative to surgery.3-5 We report a case of postbiopsy renal arteriovenous fistula managed successfully with transcatheter embolization with gelatin sponge (Gelfoam). Case Report A thirty-one-year-old black man with a strong family history of hypertension had poorly controlled hypertension for two years. Over a period of several weeks accelerated hypertension, congestive heart failure, grade IV retinopathy, and renal failure with a creatinine clearance of 1 cc. per minute developed. Peripheral venous renin was 9.2 ng. per milliliter per hour (normal: < 1 ng.). Renal angiography showed small kidneys with absence of nephrogram bilaterally. The interlobar arteries had a “pruned tree” appearance, and the arcuate and interlobular arteries failed to fill. After peritoneal dialysis and control of hypertension the patient underwent a percutaneous
386
right renal biopsy with a Vim-Silverman needle. The biopsy showed characteristic changes of malignant nephrosclerosis. Immediately following biopsy he began to pass bright red blood from the bladder, subsequently requiring transfusion with 2 units of blood. No bruit was heard over the right flank or abdomen. Over the next seventytwo hours he had intermittent gross hematuria, occasionally with clots. A second renal angiogram was performed utilizing the Seldinger technique with a 6.7 F polyethylene catheter. The right main renal artery was visualized and the catheter was advanced into a distal branch of the dorsal renal artery. Angiography demonstrated an arteriovenous fistula with extravasation of contrast material into the calyces, and additionally outlined clots within the upper collecting system. Multiple fragments of gelatin sponge cut into 2-mm. squares were injected into the interlobar artery supplying the arteriovenous fistula. Immediate follow-up renal angiography showed complete closure of the fistula (Fig. 1). Following gelatin sponge embolization, the patient required no further transfusion. Hematuria gradually subsided over the next two days. A peripheral venous renin at this time was 30 ng. per millilter per hour. The patient is presently
UROLOGY
/ SEPTEMBER1975
/ VOLUMEVI,
NUMBER3
FIGURE 1. Occlusion of traumatic arteriovenous fistula. (A) Angiogram prior to biopsy demonstrates nonspecific arterial changes of chronic renal disease. (B) Angiogram three days following closed renal biopsy demonstrates an aneurysm (arrow) in the lower pole of the right kidney. (C) Angiogram with catheter advanced into an interlobar branch of the dorsal renal artery demonstrates arteriovenousfistula with early filling of veins (arrows), and extravasation of contrast material into collecting system, outlining blood clot. (D) Following embolization with gelatin sponge, a right renal artery angiogram demonstrates thrombosis of interlobar artery (arrow) to arteriovenous fistula.
maintained motensive monoxidil.
on regular hemodialysis and is noron therapy with propranolol and Comment
With greater clinical suspicion, and with increased availability of angiography, the diagnosis of arteriovenous fistula is being made more fre-
UROLOGY
/ SEITEMBER
1975 / VOLUME
VI, NUMBER 3
quently. Almost one half of all reported arteriovenous fistulas have been described within the past three years. Over 70 per cent of renal arteriovenous fistulas result from trauma, and more than 40 per cent of acquired arteriovenous fistulas are secondary to renal biopsy.’ Fistulas develop with a frequency of up to 18 per cent following biopsy; most, however, are small and
387
insignificant. A small percentage may have gross hematuria and/or subcapsular hematoma may develop requiring corrective surgical management. Complications of renal biopsy occur more frequently when associated with hypertension and central puncture of the kidney.1,6 The angiogram can precisely localize the lesion, thereby facilitating the performance of procedures that will not sacrifice renal parenchyma. However, in more than one half of the patients with symptomatic arteriovenous fistulas reported by O’Brien et al. l and McAlhany et al. ,2 surgical intervention resulted in nephrectomy. Recently the cardiovascular radiologist has been actively involved in designing methods for controlling life-threatening hemorrhage. Selective angiography permits placement of the catheter in close proximity to the lesion. Various substances such as gelatin sponge, blood clots, thrombin, Ivalon, tissue adhesive, faP5 can then be injected directly to occlude the lesion. Tissue adhesives, such as isobutyl cyanoacrylate, provide instantaneous and permanent clotting of the injected blood vessel. ‘~9~These agents, however, do not presently have approval for clinical use from the Federal Drug Administration. Gelatin sponge is readily available, inexpensive, and produces a clot of more than twenty-four hours’ durationg In contrast, injected blood clots are usually lysed within several hours. Renal infarction with resulting hypertension is a potential complication. However, selective angiography and embolization minimizes this complication .
388
We propose that in selected patients with symptomatic arteriovenous fistula, angiography with selective embolization may be the treatment of choice. Department of Radiology 69 3utler Street, Southeast Atlanta, Georgia 30303 (DR. GOLDMAN) References 1. O’BRIEN, D. P., PARROTT,T. S., WALTON, K. N., and LEWIS, E. L.: Renal arteriovenous fistulas, Surg. Gynecol. Obstet. 139:739 (1974). 2. MCALHANY,J. C., BLACK, H. C., HANBACK,L. D., and YARBROUGH,D. R.: Renal arteriovenous fistula as a cause of hypertension, Am. J. Surg. 122: 117 (1971). 3. BOOKSTEIN,J. J., and GOLDSTEIN, H. M.: Successful management of post biopsy arteriovenous fistula with selective arterial embolization, Radiology 109: 535 (1973). 4. RIZK, G. K., ATALLAH, N. K., and BRIDI, G. I.: Renal arteriovenous fistula treated by catheter embolization, Br. J. Radial. 46: 222 (1973). 5. DOTTER,C. T., GOLDMAN, M. L., and R&cH, J.: Instant selective arterial occlusion with isobutyl Z-cyanoacrylate, Radiology 114:227 (1975). 6. KGHLER, R., and EDGREN, J.: Angiographic abnormalities following percutaneous needle biopsy of the kidney, Acta Radiol. 15: 515 (1974). R~SCH, J., GOLDMAN,M. L., and DOTTER, C. T.: Percutaneous occlusion of the gastric coronary vein. Presented at the 22nd annual meeting of the Association of University Radiologists, New York, May 8, 1974. KERBER, C. : Experimental arteriovenous fistula. Creation and percutaneous catheter obstruction with cyanoacrylate, Invest. Radiol. 10: IO (1975). CHUANG,V. P., and REUTER, S. R.: Selective arterial embohzation for the control of traumatic splenic bleeding, ibid. 10: 18 (1975).
UROLOGY I SEmEMBER 1975 /
VOLUME VI, NUMBER 3
