Urol. Radiol. 1, 175-177 (1980)
Urologic Radiology
Transcatheter Embolization of Traumatic Renal Arteriovenous Fistula J a i m e T i s n a d o , M i c h a e l C. Beachley, a n d M a r c o A. A m e n d o l a Department of Radiology, Virginia Commonwealth University/Medical College of Virginia, Richmond, Virginia, USA
Abstract. A n i a t r o g e n i c r e n a l a r t e r i o v e n o u s fistula was t r e a t e d b y t r a n s c a t h e t e r e m b o l i z a t i o n with p a r t i cles o f a b s o r b a b l e g e l a t i n sponge. R e c u r r e n t m a s s i v e h e m a t u r i a was successfully c o n t r o l l e d . T h e p r o c e d u r e was easily a c c o m p l i s h e d with m i n i m a l loss o f r e n a l parenchyma. Surgery, which usually requires partial or t o t a l n e p h r e c t o m y , was avoided. Key words: R e n a l a r t e r i o v e n o u s fistula -- R e n a l biopsy - Interventionalangiography - Embolization.
dure was completed uneventfully. Histologic examination established the diagnosis of glomerulonephritis secondary to heroin nephropathy. The following day, gross hematuria developed, with the passage of large amounts of blood and large clots. The patient continued to have repeated episodes of gross hematuria, necessitating the transfusion of several units of blood during the following days. Cystoscopies were performed twice for removal of blood clots. A repeat IVP revealed a faint nephrogram on the left side, but no pyelogram, even in delayed films up to 3 h. Large clots were present in the bladder. The hematocrit dropped to 26% de-
R e n a l a r t e r i o v e n o u s (A-V) fistulas are a f r e q u e n t c o m p l i c a t i o n o f p e r c u t a n e o u s n e e d l e biopsy. T h e m a j o r i t y o f the fistulas are a s y m p t o m a t i c a n d close s p o n t a n e o u s l y [1]. O n o c c a s i o n , however, c o n t i n u e d h e m o r r h a g e m a y r e q u i r e surgical i n t e r v e n t i o n , u s u a l l y r e s u l t i n g in p a r t i a l or t o t a l n e p h r e c t o m y for the c o n trol o f b l e e d i n g [1]. W i t h the w i d e s p r e a d use o f i n t e r v e n t i o n a l a n g i o g raphy, transcatheter embolization of traumatic renal A - V fistulas is b e i n g a c c o m p l i s h e d with success a n d ease [2-8]. Successful t r a n s c a t h e t e r e m b o l i z a t i o n o f a n i a t r o g e n i c r e n a l A - V fistula was p e r f o r m e d o n one of our patients.
Case Report A 33-year-old black male presented with a long-standing history of heroin abuse and asymptomatic proteinuria of 3-5 g/24 h. The physical examination was essentially normal. The only significant laboratory finding was a proteinuria of 4.7 g/1000 cc urine. An intravenous pyelogram (IVP) was normal. The patient underwent percutaneous needle biopsy of the lower pole of the left kidney under fluoroscopic guidance. Two passes were made. The proceAddress reprint requests to." Jaime Tisnado, M.D., Medical College of Virginia, MCV Station, Box 615, Richmond, Virginia 23298, USA
Fig. 1. Selective left renal arteriogram. There is marked enlargement of one of the interlobar arteries to the lower pole. A pseudoaneurysm is well demonstrated (arrow). There is early opacification of interlobar and arcuate veins and the main renal vein (arrowheads). A lobar branch to the mid portion of the kidney is also dilated
0171-1091/80/0001-0175 $01.00 © 1980 S p r i n g e r - V e r l a g N e w Y o r k , Inc.
176
J. Tisnado et al.: Embolization of Renal A-V Fistula spite repeated blood transfusions. The blood pressure, which was normal on admission, had risen to 150/100 mm Hg. Emergency selective left renal arteriography using a No. 7. French polyethylene catheter revealed a pseudoaneurysm arising from one of the interlobar branches supplying the inferior pole of the kidney, and also early and dense opacification of lobar and arcuate veins and the main renal vein (Fig. 1). It was then elected to embolize the offending artery. The catheter was advanced and superselectively placed into the artery supplying the lesion. A repeat arteriogram using 3 cc of contrast material confirmed the adequate position of the catheter (Fig. 2). Then several small pieces of absorbable gelatin sponge (Gelfoam a) soaked in a mixture of saline and contrast material were injected through the catheter into the artery feeding the fistula, with immediate cessation of the A-V shunting. The patient experienced no untoward symptoms. A control arteriogram revealed complete occlusion of the A-V fistula, although a tiny pseudoaneurysm remained at the interlobar artery (Fig. 3). The bleeding stopped immediately and did not recur. The patient made an uneventful recovery and was discharged 2 days later. He was seen in follow-up 3 months later. He remained normotensive and hematuria did not recur. A repeat IVP was normal.
Fig. 2. Superselective arteriogram. The catheter has been advanced well into the branch feeding the arteriovenous fistula. There is rapid opacification of draining veins and the main renal vein. The pseudoaneurysm is well demonstrated
Fig. 3. Superselective postembolization arteriogram. The draining veins are no longer opacified. Contrast material has refluxed into branches to the mid and upper portions of the kidney, showing generalized arterial spasm
Discussion
Iatrogenic A-V fistulas are a frequent occurrence after percutaneous renal needle biopsy. It is estimated that about 40% of acquired A-V fistulas are secondary to renal biopsy [1]. The majority of the fistulas close spontaneously without sequelae. However, massive hematuria may sometimes develop that cannot be controlled with conservative therapy. Surgical intervention in those cases will require the sacrifice of a significant amount of renal tissue because heminephrectomy or total nephrectomy is usually necessary [1]. Since most of these patients already have severe renal disease, prompting the biopsy in the first place, the loss of renal parenchyma can be of grave clinical significance. A logical extension of the use of interventional angiography is transcatheter embolization of traumatic A-V fistulas. Embolic materials used are autologous clot; clot modified with aminocaproic acid (Amicar 2); muscle, and subcutaneous fat; stainless steel coils with Dacron strands; detachable silicone balloons; isobutyl-2-cyanoacrylate; polyvinyl alcohol foam3; and absorbable gelatin sponge [2-8]. Transcatheter electrocoagulation and also occlusion of fistulas by wedging the catheter into the feeding arteries have been reported [9, 10]. We prefer the use of absorbable gelatin sponge since it is readily available, is easily injected, and does not seem to occlude the vessel permanently. The occlusion of the fistula was immediate, and the patient was spared a surgical 1 2 3
The Upjohn Co. Kalamazoo, Michigan, USA Lederle Laboratories, Pearl River, New York, USA Unipoint Industries, High Point, North Carolina, USA
177
J. Tisnado et al. : Embolization of Renal A-V Fistula
procedure that undoubtedly may have caused considerable morbidity. The procedure was accomplished with minimal loss of renal tissue. Transcatheter embolization is an attractive alternate method for controlling renal hemorrhage. Hypertension, which rarely may result from ischemia secondary to A-V fistula, can be easily controlled [1]. Our patient became normotensive immediately after occlusion of the fistula. In any interventional embolic procedure, the perfect placement of the catheter into the artery to be embolized is of great importance for the successful result. Otherwise, peripheral embolization of other arteries may occur. If the fistula is too large, there is a potential danger of pulmonary embolization of the injected particles. In such cases, stainless steel coils are probably a safer embolic material [8]. The insertion of a balloon into the renal vein prior to the intraarterial injection of the embolic particles has been advocated to avoid this potentially serious complication. This has not been necessary in our experience. Finally, if transcatheter embolization is unsuccessful in controlling the hemorrhage, the patient can still undergo surgery although it may necessitate the sacrifice of a large amount of renal tissue. Acknowledgement. We would like to thank Mr. Everett Tompkins for his secretarial assistance.
References 1. Messing E, Kessler R, Kavaney PB: Renal arteriovenous fistulas. Urology 8:101 107, 1976 2. Silber SJ, Collins E, Clark R: Treatment of hemorrhage from renal trauma by angiographic injection of clot. J Urol 116:15-19, 1976 3. Barbaric Z, Cutcliff WB: Control of renal arterial bleeding after percutaneous biopsy. Urology 8." 108-111, 1976 4. Rizk GK, Atalla NK, Bridi GI: Renal arteriovenous fistula treated by catheter embolization. Br J Radio146:222-224, 1973 5. Kerber CW, Freeny PC, Cromwell L. Margolies MT, Correa RI: Cyanoacrylate occlusion of a renal arteriovenous fistula. Am J Roentgenol 128:663-665, 1977 6. White RI, Kaufman SL, Barth KH, De Caprio V, Strandbert ID : Embolotherapy with detachable silicone balloons. Radiology 131:619-627, 1979 7. Pontes JE, Parekh N, McGuckin JT, Banks MD, Pierce IM: Percutaneous transfemoral embolization of arterioinfundibularvenous fistula. J Urol 116:98 99, 1976 8. Wallace S, Gianturco C, Anderson JH, Goldstein HM, Davis LI Bree RL: Therapeutic vascular occlusion utilizing steel coil technique: clinical applications. Am J Roentgenol 127:381-387, 1976 9. McAlister DS, Johnsrude I, Miller MM, Clapp I, Thompson WM: Occlusion of acquired renal arteriovenous fistula with transcatheter electrocoagulation. Am J Roentgenol 132:9981000, 1979 10. Maxwell DD, Frankel RS: Wedged catheter management of a bleeding renal pseudoaneurysm. J Urol 116:96-97, t976
Urologic Radiology
Transcatheter Embolization of Traumatic Renal Arteriovenous Fistula J a i m e T i s n a d o , M i c h a e l C. Beachley, a n d M a r c o A. A m e n d o l a Department of Radiology, Virginia Commonwealth University/Medical College of Virginia, Richmond, Virginia, USA
Abstract. A n i a t r o g e n i c r e n a l a r t e r i o v e n o u s fistula was t r e a t e d b y t r a n s c a t h e t e r e m b o l i z a t i o n with p a r t i cles o f a b s o r b a b l e g e l a t i n sponge. R e c u r r e n t m a s s i v e h e m a t u r i a was successfully c o n t r o l l e d . T h e p r o c e d u r e was easily a c c o m p l i s h e d with m i n i m a l loss o f r e n a l parenchyma. Surgery, which usually requires partial or t o t a l n e p h r e c t o m y , was avoided. Key words: R e n a l a r t e r i o v e n o u s fistula -- R e n a l biopsy - Interventionalangiography - Embolization.
dure was completed uneventfully. Histologic examination established the diagnosis of glomerulonephritis secondary to heroin nephropathy. The following day, gross hematuria developed, with the passage of large amounts of blood and large clots. The patient continued to have repeated episodes of gross hematuria, necessitating the transfusion of several units of blood during the following days. Cystoscopies were performed twice for removal of blood clots. A repeat IVP revealed a faint nephrogram on the left side, but no pyelogram, even in delayed films up to 3 h. Large clots were present in the bladder. The hematocrit dropped to 26% de-
R e n a l a r t e r i o v e n o u s (A-V) fistulas are a f r e q u e n t c o m p l i c a t i o n o f p e r c u t a n e o u s n e e d l e biopsy. T h e m a j o r i t y o f the fistulas are a s y m p t o m a t i c a n d close s p o n t a n e o u s l y [1]. O n o c c a s i o n , however, c o n t i n u e d h e m o r r h a g e m a y r e q u i r e surgical i n t e r v e n t i o n , u s u a l l y r e s u l t i n g in p a r t i a l or t o t a l n e p h r e c t o m y for the c o n trol o f b l e e d i n g [1]. W i t h the w i d e s p r e a d use o f i n t e r v e n t i o n a l a n g i o g raphy, transcatheter embolization of traumatic renal A - V fistulas is b e i n g a c c o m p l i s h e d with success a n d ease [2-8]. Successful t r a n s c a t h e t e r e m b o l i z a t i o n o f a n i a t r o g e n i c r e n a l A - V fistula was p e r f o r m e d o n one of our patients.
Case Report A 33-year-old black male presented with a long-standing history of heroin abuse and asymptomatic proteinuria of 3-5 g/24 h. The physical examination was essentially normal. The only significant laboratory finding was a proteinuria of 4.7 g/1000 cc urine. An intravenous pyelogram (IVP) was normal. The patient underwent percutaneous needle biopsy of the lower pole of the left kidney under fluoroscopic guidance. Two passes were made. The proceAddress reprint requests to." Jaime Tisnado, M.D., Medical College of Virginia, MCV Station, Box 615, Richmond, Virginia 23298, USA
Fig. 1. Selective left renal arteriogram. There is marked enlargement of one of the interlobar arteries to the lower pole. A pseudoaneurysm is well demonstrated (arrow). There is early opacification of interlobar and arcuate veins and the main renal vein (arrowheads). A lobar branch to the mid portion of the kidney is also dilated
0171-1091/80/0001-0175 $01.00 © 1980 S p r i n g e r - V e r l a g N e w Y o r k , Inc.
176
J. Tisnado et al.: Embolization of Renal A-V Fistula spite repeated blood transfusions. The blood pressure, which was normal on admission, had risen to 150/100 mm Hg. Emergency selective left renal arteriography using a No. 7. French polyethylene catheter revealed a pseudoaneurysm arising from one of the interlobar branches supplying the inferior pole of the kidney, and also early and dense opacification of lobar and arcuate veins and the main renal vein (Fig. 1). It was then elected to embolize the offending artery. The catheter was advanced and superselectively placed into the artery supplying the lesion. A repeat arteriogram using 3 cc of contrast material confirmed the adequate position of the catheter (Fig. 2). Then several small pieces of absorbable gelatin sponge (Gelfoam a) soaked in a mixture of saline and contrast material were injected through the catheter into the artery feeding the fistula, with immediate cessation of the A-V shunting. The patient experienced no untoward symptoms. A control arteriogram revealed complete occlusion of the A-V fistula, although a tiny pseudoaneurysm remained at the interlobar artery (Fig. 3). The bleeding stopped immediately and did not recur. The patient made an uneventful recovery and was discharged 2 days later. He was seen in follow-up 3 months later. He remained normotensive and hematuria did not recur. A repeat IVP was normal.
Fig. 2. Superselective arteriogram. The catheter has been advanced well into the branch feeding the arteriovenous fistula. There is rapid opacification of draining veins and the main renal vein. The pseudoaneurysm is well demonstrated
Fig. 3. Superselective postembolization arteriogram. The draining veins are no longer opacified. Contrast material has refluxed into branches to the mid and upper portions of the kidney, showing generalized arterial spasm
Discussion
Iatrogenic A-V fistulas are a frequent occurrence after percutaneous renal needle biopsy. It is estimated that about 40% of acquired A-V fistulas are secondary to renal biopsy [1]. The majority of the fistulas close spontaneously without sequelae. However, massive hematuria may sometimes develop that cannot be controlled with conservative therapy. Surgical intervention in those cases will require the sacrifice of a significant amount of renal tissue because heminephrectomy or total nephrectomy is usually necessary [1]. Since most of these patients already have severe renal disease, prompting the biopsy in the first place, the loss of renal parenchyma can be of grave clinical significance. A logical extension of the use of interventional angiography is transcatheter embolization of traumatic A-V fistulas. Embolic materials used are autologous clot; clot modified with aminocaproic acid (Amicar 2); muscle, and subcutaneous fat; stainless steel coils with Dacron strands; detachable silicone balloons; isobutyl-2-cyanoacrylate; polyvinyl alcohol foam3; and absorbable gelatin sponge [2-8]. Transcatheter electrocoagulation and also occlusion of fistulas by wedging the catheter into the feeding arteries have been reported [9, 10]. We prefer the use of absorbable gelatin sponge since it is readily available, is easily injected, and does not seem to occlude the vessel permanently. The occlusion of the fistula was immediate, and the patient was spared a surgical 1 2 3
The Upjohn Co. Kalamazoo, Michigan, USA Lederle Laboratories, Pearl River, New York, USA Unipoint Industries, High Point, North Carolina, USA
177
J. Tisnado et al. : Embolization of Renal A-V Fistula
procedure that undoubtedly may have caused considerable morbidity. The procedure was accomplished with minimal loss of renal tissue. Transcatheter embolization is an attractive alternate method for controlling renal hemorrhage. Hypertension, which rarely may result from ischemia secondary to A-V fistula, can be easily controlled [1]. Our patient became normotensive immediately after occlusion of the fistula. In any interventional embolic procedure, the perfect placement of the catheter into the artery to be embolized is of great importance for the successful result. Otherwise, peripheral embolization of other arteries may occur. If the fistula is too large, there is a potential danger of pulmonary embolization of the injected particles. In such cases, stainless steel coils are probably a safer embolic material [8]. The insertion of a balloon into the renal vein prior to the intraarterial injection of the embolic particles has been advocated to avoid this potentially serious complication. This has not been necessary in our experience. Finally, if transcatheter embolization is unsuccessful in controlling the hemorrhage, the patient can still undergo surgery although it may necessitate the sacrifice of a large amount of renal tissue. Acknowledgement. We would like to thank Mr. Everett Tompkins for his secretarial assistance.
References 1. Messing E, Kessler R, Kavaney PB: Renal arteriovenous fistulas. Urology 8:101 107, 1976 2. Silber SJ, Collins E, Clark R: Treatment of hemorrhage from renal trauma by angiographic injection of clot. J Urol 116:15-19, 1976 3. Barbaric Z, Cutcliff WB: Control of renal arterial bleeding after percutaneous biopsy. Urology 8." 108-111, 1976 4. Rizk GK, Atalla NK, Bridi GI: Renal arteriovenous fistula treated by catheter embolization. Br J Radio146:222-224, 1973 5. Kerber CW, Freeny PC, Cromwell L. Margolies MT, Correa RI: Cyanoacrylate occlusion of a renal arteriovenous fistula. Am J Roentgenol 128:663-665, 1977 6. White RI, Kaufman SL, Barth KH, De Caprio V, Strandbert ID : Embolotherapy with detachable silicone balloons. Radiology 131:619-627, 1979 7. Pontes JE, Parekh N, McGuckin JT, Banks MD, Pierce IM: Percutaneous transfemoral embolization of arterioinfundibularvenous fistula. J Urol 116:98 99, 1976 8. Wallace S, Gianturco C, Anderson JH, Goldstein HM, Davis LI Bree RL: Therapeutic vascular occlusion utilizing steel coil technique: clinical applications. Am J Roentgenol 127:381-387, 1976 9. McAlister DS, Johnsrude I, Miller MM, Clapp I, Thompson WM: Occlusion of acquired renal arteriovenous fistula with transcatheter electrocoagulation. Am J Roentgenol 132:9981000, 1979 10. Maxwell DD, Frankel RS: Wedged catheter management of a bleeding renal pseudoaneurysm. J Urol 116:96-97, t976
