Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 241-244

The role of angioembolization in the management of hemorrhagic urovascular emergencies: Retrospective Cohort Study


1 Department of Urology, IKDRC-ITS, Ahmedabad, Gujarat, India
2 Department of Urology, JIPMER, Puducherry, India
3 Department of Cardiology, JIPMER, Puducherry, India

Date of Submission20-Nov-2019
Date of Acceptance10-Dec-2019
Date of Web Publication12-Sep-2020

Correspondence Address:
Lalgudi Narayan Dorairajan
Department of Urology, JIPMER, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_96_19

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  Abstract 


Introduction: Transarterial embolization is an effective method in the management of hemorrhagic vascular emergencies irrespective of its etiology. The aim of this study is to evaluate the role of angioembolization in the management of urovascular bleed and to evaluate the morphological and functional impact in the embolized organ in the medium-term follow-up. Materials and Methods: The hospital records of 11 patients with 12 renal units and two patients with hematuria of bladder origin who underwent angioembolization from the period of October 2012 to October 2015 were retrospectively reviewed. Data on clinical indication, technique, site, and type of bleeding were recorded. The outcome measures such as success rate, preprocedural requirement of blood transfusion, and periprocedural complications were analyzed. Results: Indications for angioembolization included blunt renal trauma (2), metastatic renal cell carcinoma (1), postpercutaneous nephrolithotomy (3), postpercutaneous nephrostomy (1), angiomyolipoma (2), renal biopsy (2), postpartial nephrectomy (1), cervical cancer with intractable radiation cystitis (1), and postradical cystectomy with internal iliac artery pseudoaneurysm (1). Out of these, two patients had secondary bleed and required a second session of angioembolization. The meantime between the first presentation and embolization was 34.46 h (4–96 h). Mean preprocedural blood transfusion requirement was 4.9 units (3–8 units). None of these patients required postprocedural blood transfusion. There was no serious postprocedural complication. There was no incidence of hypertension or renal impairment in the medium-term follow-up. Conclusion: The procedure carries low morbidity and a high rate of preservation of organ function. Hence, it should always be considered in the management of postoperative bleeding before embarking on surgical exploration.

Keywords: Angioembolization, coils, Gelfoam, urovascular emergencies


How to cite this article:
Mishra AK, Dorairajan LN, Manikandan R, Pillai AA. The role of angioembolization in the management of hemorrhagic urovascular emergencies: Retrospective Cohort Study. Indian J Vasc Endovasc Surg 2020;7:241-4

How to cite this URL:
Mishra AK, Dorairajan LN, Manikandan R, Pillai AA. The role of angioembolization in the management of hemorrhagic urovascular emergencies: Retrospective Cohort Study. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Oct 22];7:241-4. Available from: https://www.indjvascsurg.org/text.asp?2020/7/3/241/294927




  Introduction Top


Transarterial embolization (TAE) is an effective method in the management of hemorrhagic vascular emergencies irrespective of its etiology. A sea-change improvement and recent innovations in catheters and embolic agents have added leaps and bounds to the accuracy, precision, and high success rate of this technique. However, there are many unresolved issues such as the timing of embolization, its impact on the blood transfusion requirement, complications, long-term morphological, and functional follow-up of embolized organs.

The aim of this study is to evaluate the role of angioembolization therapy in the management of urovascular bleed and to evaluate the morphological and functional impact in the embolized organ in the medium-term follow-up.


  Materials and Methods Top


The hospital records of 11 patients with 12 renal units and two patients with hematuria of bladder origin who underwent TAE for massive urovascular bleed from the period of October 2012 to October 2015 at a single center were retrospectively reviewed. All procedures were performed on an emergency (requiring immediate intervention) basis by experienced cardiologists in close collaboration with consultant urological surgeons. Variables recorded for each patient included age, sex, clinical indication, technique of embolization, site and type of bleeding, underlying pathology, timing of embolization since their first presentation, and embolization agents were recorded. The outcome measures such as success rate, pre- and post-procedural requirement of blood transfusion, periprocedural complications, hospital stay, and long-term outcomes such as appearances of kidneys on imaging and blood pressure were analyzed. The success of the procedure was defined as complete occlusion of blood flow on postembolization angiography.


  Results Top


A total of 13 patients underwent angioembolization, of which 5 were female and 8 were male. The mean age of the patients was 46.9 years ranging from 21 to 70 years. Indications for angioembolization included blunt renal trauma (2), metastatic renal cell carcinoma (RCC) (1), post-percutaneous nephrolithotomy (PCNL) (3), postpercutaneous nephrostomy (1), angiomyolipoma (AML) (2), renal biopsy (2), postpartial nephrectomy (1), cervical cancer with intractable hemorrhagic radiation cystitis (1), and postradical cystectomy with internal iliac artery pseudoaneurysm (1) [Table 1]. The characteristic angiographic appearances are shown in [Figure 1]a and [Figure 1]b [Figure 3]a and [Figure 3]b. All patients underwent selective angioembolization procedure. Out of these, two patients one with metastatic RCC and another patient with internal iliac artery pseudoaneurysm communicating with neobladder had secondary bleed and required a second session of angioembolization [Figure 2]. One patient of bilateral AML underwent angioembolization for the left side lesion, and subsequently, partial nephrectomy after 6 weeks, but in the immediate postoperative period, she developed spontaneous hemorrhage on the contralateral side and needed angioembolization for the right lesion also. The meantime between the first presentation and embolization was 34.46 h (4–96 h). Mean preprocedural blood transfusion requirement was 4.9 units (3–8 units). None of these patients required postprocedural blood transfusion. The embolization agents included only coils (n = 5) polyvinyl alcohol (PVA) particles (n = 1), Gelfoam (n = 1), coil along with Gelfoam (n = 2), and coil along with PVA particles (n = 2) patients. Technical success was achieved in all cases, but clinical success was achieved in 93% cases as one patient with hemorrhagic radiation cystitis rebled after 1 month and ultimately landed up in cystectomy. There was no serious postprocedural complication in our series. Minor complications in the form of postembolization syndrome (PES) were seen in three patients, including fever, flank pain, nausea, and vomiting. All these were managed conservatively using analgesics, antipyretics, and antiemetics. All patients except one with metastatic RCC are in follow-up till date with functional imaging in the form of a renogram. There were no morphological changes seen on follow-up imaging in any of our patients. There had been no incidence of hypertension or renal impairment in the medium-term follow-up till date.
Table 1: Clinical details, indications, angiography findings, complications, and outcome of angioembolization among study subjects

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Figure 1:(a) Left metastatic renal cell carcinoma with hematuria showing large arteriovenous malformation. (b) A significant decrease in size of the lesion postpolyvinyl alcohol particle embolization

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Figure 2:(a) Postradical cystectomy with orthotopic neobladder showing right internal iliac artery pseudoaneurysm. (b) Postcoil and polyvinyl alcohol particle embolization showing no extravasation of contrast from the artery

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Figure 3:(a) Postpartial nephrectomy patient showing right midpolar artery pseudoaneurysm. (b) Postcoil and polyvinyl alcohol particle embolization and no extravasation of contrast from the artery

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  Discussion Top


Since the past four decades, TAE has established its role in successfully managing a myriad of benign as well as malignant hemorrhagic urovascular emergencies as a procedure that not only salvages the organ but also life itself.

Injury to the renal artery or its branches following trauma or during PCNL can be diagnosed precisely using angiography and managed by TAE techniques. Sangthong et al.[1] analyzed the outcome of 517 patients of blunt trauma abdomen, resulting in renal artery injury and found that detaining endovascular interventions may lead to delayed hemorrhage, pseudoaneurysm, hematuria, infection, and urinoma formation. It plays a tremendous role in the management of persistent hypotension with hematuria, resulting from posttraumatic renal artery laceration and arteriovenous (AV) fistula or pseudoaneurysm. It is also helpful in preoperative assessment.

Morita et al.[2] studied 17 patients with Grade 4 renal injuries managed with angioembolization and reported complete success with the preservation of kidney function.

Kessaris et al.[3] in a large series of postpercutaneous renal procedure patients presenting with hematuria established that angioembolization averted the need of any surgical procedure.

Takebayashi et al.[4] published the role of angioembolization in bleeding renal AV malformations and found long-term outcomes to be astounding. Most of these patients had preserved renal function on follow-up.

Kothari et al.[5] in a series of 30 AML patients mentioned the increased risk of recurrent bleeding in those with associated tuberous sclerosis. Oesterling et al.[6] reported the data of 82 AML patients with size more than 4 cm who were symptomatic and 9% of these presented with hemorrhagic shock thus highlighting the role of angioembolization in AML.

Loffroy et al.[7] studied the management of postbiopsy renal allograft AV fistula with selective arterial embolization (SAE) for about 7 years and found 100% success rate with no significant postprocedure renal infarction or functional deterioration and established that the long-term survival of the renal allograft was not afflicted by angioembolization.

Almgård et al.,[8] in 1973, first performed embolization for advanced metastatic renal carcinoma. Schwartz et al. also mentioned the effectiveness of the intervention in reducing the incidence and intensity of hematuria and improving the hematocrit level. Superselective embolization is best for the management of small tumors as it reduces the area of iatrogenic necrosis and preserves normal parenchyma, and hence, in patients with advanced-stage renal carcinoma, angioembolization is mainly applied as a cytoreductive and palliative procedure thus alleviating the symptoms of hematuria and pain.

In spite of PCNL being safe and efficient in the surgical treatment of renal calculus disease, there are occasions when due to massive hemorrhage or persistent hematuria SAE is indicated. el-Nahas et al.[9] reported post-PCNL severe bleeding managed with TAE in a series of 36 patients, with successful cessation after the first session in 26 (72%) patients and after 2 sessions in 10 (28%) patients. Huber et al. reported clinical success in 63% of patients using initial TAE.

El-Nahas et al.[10] stated that upper-pole calyceal puncture was associated with the highest incidence of vascular injury presumably due to long oblique tract and more parenchymal injury. Richstone et al.[11] reported pseudoaneurysm as the most common finding (53% of patients), rest being lacerated renal vessel and AV malformations. Jain et al.[12] proposed that large stone bulk along with multiple punctures was a predictor of failure of angioembolization. These findings were in concurrence with Zeng et al.[13]

Pisco et al.[14] reported a complete control of bleeding in 69% of cases with pelvic malignancies by embolizing the anterior division of the internal iliac artery.

Intractable hematuria as a result of bladder tumor was successfully treated by angioembolization of the anterior division of the internal iliac artery, as reported by Nabi et al.[15] Perioperative intractable hematuria associated with transurethral resection of bladder tumor can be effectively controlled with TAE as established by Gujral et al.[16]

The anterior division of the internal iliac artery should be embolized bilaterally irrespective of whether the bleeding point is detectable on angiography or not, as it prevents bleeding from collaterals. It has been found that TAE not only effectively controls hematuria but also decreases the requirement of blood transfusion and improves hematocrit.

PES described as severe flank pain, nausea, vomiting, and increasing total leukocyte count was noted in 50% of patients by Samoni et al. and 63% of patients by Jain et al.

Coil dislodgment or migration to anatomical or extraanatomical site has also been reported in the literature.[17]

Interpretation of the current case series reestablishes the fact that TAE is a highly effective method, especially in emergency situations. In all our cases, bleeding was intractable and would have required open surgical intervention to control hemorrhage if embolization facilities were not available or failed. Extravasation of contrast on a preembolization angiography was seen in all the cases, suggesting ongoing bleeding. There was a remarkable reduction in the requirement of blood transfusion following the procedure leading us to conclude that this procedure should be recommended much early in the course of the management. Minor and easily manageable complications profile reemphasizes the safety of this procedure.


  Conclusion Top


Selective angioembolization is an important adjunct to the management of bleeding complications following urological procedures. It is a highly effective and minimally invasive technique for the management of urovascular bleed of various etiologies. The procedure carries low morbidity and a high rate of preservation of function in the organ whose vessel is embolized. Hence, angioembolization should always be considered in the management of postoperative bleeding before embarking on surgical exploration. Ours is a small retrospective case series with a short follow-up period of 4 years, so prospective studies with longer follow-up duration preferably randomized controlled studies are essentially needed to address the issues of morphological and functional impact on the embolized organs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sangthong B, Demetriades D, Martin M, Salim A, Brown C, Inaba K, et al. Management and hospital outcomes of blunt renal artery injuries: Analysis of 517 patients from the National Trauma Data Bank. J Am Coll Surg 2006;203:612-7.  Back to cited text no. 1
    
2.
Morita S, Inokuchi S, Tsuji T, Fukushima T, Higami S, Yamagiwa T, et al. Arterial embolization in patients with grade-4 blunt renal trauma: Evaluation of the glomerular filtration rates by dynamic scintigraphy with 99mtechnetium-diethylene triamine pentacetic acid. Scand J Trauma Resusc Emerg Med 2010;18:11.  Back to cited text no. 2
    
3.
Kessaris DN, Bellman GC, Pardalidis NP, Smith AG. Management of hemorrhage after percutaneous renal surgery. J Urol 1995;153:604-8.  Back to cited text no. 3
    
4.
Takebayashi S, Hosaka M, Kubota Y, Ishizuka E, Iwasaki A, Matsubara S. Transarterial embolization and ablation of renal arteriovenous malformations: Efficacy and damages in 30 patients with long-term followup. J Urol 1998;159:696-701.  Back to cited text no. 4
    
5.
Kothary N, Soulen MC, Clark TW, Wein AJ, Shlansky-Goldberg RD, Crino PB, et al. Renal angiomyolipoma: Long-term results after arterial embolization. J Vasc Interv Radiol 2005;16:45-50.  Back to cited text no. 5
    
6.
Oesterling JE, Fishman EK, Goldman SM, Marshall FF. The management of renal angiomyolipoma. J Urol 1986;135:1121-4.  Back to cited text no. 6
    
7.
Loffroy R, Guiu B, Lambert A, Mousson C, Tanter Y, Martin L, et al. Management of post-biopsy renal allograft arteriovenous fistulas with selective arterial embolization: Immediate and long-term outcomes. Clin Radiol 2008;63:657-65.  Back to cited text no. 7
    
8.
Almgård LE, Fernström I, Haverling M, Ljungqvist A. Treatment of renal adenocarcinoma by embolic occlusion of the renal circulation. Br J Urol 1973;45:474-9.  Back to cited text no. 8
    
9.
el-Nahas AR, Shokeir AA, Mohsen T, Gad H, el-Assmy AM, el-Diasty T, et al. Functional and morphological effects of postpercutaneous nephrolithotomy superselective renal angiographic embolization. Urology 2008;71:408-12.  Back to cited text no. 9
    
10.
El-Nahas AR, Shokeir AA, El-Assmy AM, Mohsen T, Shoma AM, Eraky I, et al. Post-percutaneous nephrolithotomy extensive hemorrhage: A study of risk factors. J Urol 2007;177:576-9.  Back to cited text no. 10
    
11.
Richstone L, Reggio E, Ost MC, Seideman C, Fossett LK, Okeke Z, et al. First prize (tie): Hemorrhage following percutaneous renal surgery: Characterization of angiographic findings. J Endourol 2008;22:1129-35.  Back to cited text no. 11
    
12.
Jain V, Ganpule A, Vyas J, Muthu V, Sabnis RB, Rajapurkar MM, et al. Management of non-neoplastic renal hemorrhage by transarterial embolization. Urology 2009;74:522-6.  Back to cited text no. 12
    
13.
Zeng G, Zhao Z, Wan S, Khadgi S, Long Y, Zhang Y, et al. Failure of initial renal arterial embolization for severe post-percutaneous nephrolithotomy hemorrhage: A multicenter study of risk factors. J Urol 2013;190:2133-8.  Back to cited text no. 13
    
14.
Pisco JM, Martins JM, Correia MG. Internal iliac artery: Embolization to control hemorrhage from pelvic neoplasms. Radiology 1989;172:337-9.  Back to cited text no. 14
    
15.
Nabi G, Sheikh N, Greene D, Marsh R. Therapeutic transcatheter arterial embolization in the management of intractable haemorrhage from pelvic urological malignancies: Preliminary experience and long-term follow-up. BJU Int 2003;92:245-7.  Back to cited text no. 15
    
16.
Gujral S, Bell R, Kabala J, Persad R. Internal iliac artery embolisation for intractable bladder haemorrhage in the peri-operative phase. Postgrad Med J 1999;75:167-8.  Back to cited text no. 16
    
17.
Bhageria A, Seth A, Bora GS. Migrated embolization coil: A rare cause of urinary tract obstruction. Indian J Urol 2012;28:437-8.  Back to cited text no. 17
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