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VASCULAR IMAGING Table of Contents   
Year : 2004  |  Volume : 14  |  Issue : 3  |  Page : 303-307
Pictorial essay - transarterial embolization of latrogenic renal vascular injury

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Keywords: Renal Vascular Injury, Embolization

How to cite this article:
Rao A. Pictorial essay - transarterial embolization of latrogenic renal vascular injury. Indian J Radiol Imaging 2004;14:303-7

How to cite this URL:
Rao A. Pictorial essay - transarterial embolization of latrogenic renal vascular injury. Indian J Radiol Imaging [serial online] 2004 [cited 2020 Aug 10];14:303-7. Available from:
Percutaneous selective embolization is a safe and effective means for treating iatrogenic renal vascular injuries. This pictorial essay demonstrates and describes the imaging findings and the technique, in detail, involved in the process of embolization.

Traumatic injury to the renal vasculature is a well-recognized and most worrisome complication of percutaneous renal procedures such as renal biopsy, percutaneous nephrostomy (PCN) and percutaneous nephrolithotomy (PCNL).

The most common causes of haemorrhage post percutaneous renal procedures are pseudoaneurysms and arterio-venous fistulas[1]. The treatment of choice for traumatic renal arterial injury that does not resolve spontaneously is transarterial embolization [2],[3],[4]. Angiography is the definitive test to diagnose arterial injury resulting from renal biopsy. Angiography is superior to surgical exploration both as a diagnostic and as a therapeutic modality[5].

   Indications Top

The criteria for embolization are post procedure persistent hematuria and/or dropping hematocrit or the demonstrated presence of a large intrarenal or perinephric haematoma by CT[6].

   Technique Top

Angiography is usually performed via the right femoral approach. A 7F sheath is used as an introducer in an adult with normal femoral artery. This sheath provides access to a wide range of catheters, which might be needed for embolization. Initial flush aortography is performed through a 5F multiple holes pigtail catheter, which shows the main renal arteries on either side or accessory ones if present [Figure - 1]. Sometimes the site of bleeding can be seen on the initial flush aortogram[2].

The selective renal angiogram can show pseudoaneurysm [Figure - 2]A, arterio-venous fistula (AVF) [Figure - 3]A, arterio-caliceal fistula or frank extravasation of contrast[2]. The catheter is advanced further subselectively into the branch of the renal artery feeding the lesion. Additional lateral or oblique and magnification views are helpful in delineating the exact location of the arterial injury [Figure - 2]B and [Figure - 4]C. If the lesion is accessed by 5F visceral catheter then steel coils (Occluding spring emboli, Wiliam Cook, Europe) are deployed through this catheter. If the lesion is peripherally located and follows a tortuous course, coaxial micro catheter system is used to reach the site after exchanging the visceral catheter with a 7F renal guiding catheter. Some micro catheters, such as Tracker 18 (Target Therapeutics, Fremont, CA) and compatible guide wire, can be introduced through 5F visceral catheter; its manipulation into a tortuous artery is better achieved by pushing it through 7F renal catheter. The microcatheter tip is placed as close as possible to the injured renal artery branch. Roadmapping is useful to catheterize small and peripheral branches. Check angiography is performed to ensure right catheter position before any intervention is carried out [Figure - 4]B. Complex helical fibered platinum coils (Target therapeutics, Fremont, CA) are then deployed depending on the size of the vessel to be occluded, which are permanent embolic material. The size and number of coils is dependent on the size of the vessel to be embolized. The size should be slightly bigger than the vessel to achieve total embolization. Intermittent check angiography is done with hand injections after deployment of each coil to look for the degree of occlusion and any inadvertent non-target embolization. It also checks the catheter position for the subsequent coiling. This may be combined with injection of gelatin sponge (Gelfoam, Upjohn Co, Kalamazoo, MI) if satisfactory occlusion is not achieved. 1 mm 3 gelfoam particles are mixed with contrast and saline and injected slowly by hand so that there is no reflux into the adjacent normal vessels. Check angiography is again performed at this stage to look for the degree of occlusion. After ensuring adequate occlusion the microcatheter system, if used, is taken out and the visceral catheter is placed in the main renal artery.

Post embolization angiogram shows occlusion of the feeding vessel with non-visualization of lesion and a small avascular segment distal to the occluded branch. It also demonstrates the patency of the rest of the vessels. [Figure - 2]D.

   Complications Top

Patients may experience post embolization syndrome (transient fever, pain and leucocytosis), which is usually self-limiting and treated symptomatically. Post embolization hypertension, if any, is transient. Rebleeding is a rare occurrence and is presumed to be due to gelfoam recanalization or embolization of the wrong artery. Non-target embolization can occur if catheter is not placed correctly and as close as possible to the lesion. Though the bleeding ceases immediately, the urine takes some time to clear completely due to previous clots and hemorrhage.

   Discussion Top

In most cases selective renal angiogram shows the renal vascular injury. But sometimes it may only be seen on sub selective injections[2]. A thorough search is made to identify the bleeder if initial angiograms fail to show any lesion. Renal capsular artery injury or other extra renal arterial injuries such as lumbar artery or internal iliac artery branches must be considered as possible sources of bleeding after percutaneous renal procedures if no intrarenal vascular injury is found[5], [7]. The embolization is performed once the feeding branch is identified and catheterized sub selectively as close to the lesion as possible. The aim is to achieve occlusion of the vessel with minimal loss of renal tissue due to distal infarction, which is inevitable as the renal artery branches are end arteries. Renal tissue loss is considered small to moderate (less than 30%) and large (30-50%) [2]. Coils are preferred embolic agents in larger vessel injuries or fast-flowing AVFs [6]. The size of the coil is determined after measuring the vessel diameter and should be slightly bigger than it. A smaller coil will not cause complete occlusion, while a larger coil straightens out and may extend beyond the site of embolization.

The use of coaxial microcatheter system allows for precise embolization of peripheral vessels with microcoils or gelfoam 6. Tracker-18 catheter and platinum microcoils can be used when previous attempts at superselective catheterization have failed and can be used coaxially with the standard angiographic catheters [8]. Gel foam was used most commonly earlier because of its utility and absorbability [6]. It was the preferred substance because of its potential for a more peripheral occlusion and concomitant minimal tissue loss with a theoretical potential for ultimate post-healing recanalization [2].

Flow directed embolization with gelfoam particles or coils could be done when subselective catheterization is not possible[2]. Haemorrhage usually stops immediately with no need for surgical exploration.

   Conclusion Top

Percutaneous intra-arterial embolization is the treatment of choice, which not only is life saving but ultimately a kidney sparing procedure in the management of hemorrhage after percutaneous renal intervention. Embolization of the peripheral vessel is preferable to frank exploration and is the preferred modality, even in a transplanted kidney.[9], [10].

   References Top

1.Kessaris DN, Bellman GC, Pardalidis NP, Smith AG. Management of hemorrhage after percutaneous renal surgery. J Urol.1995; 153: 604-608.   Back to cited text no. 1    
2.Fisher RG, Ben-Menachem Y, Whigham C. Stab wounds of the renal artery branches: 3. Angiographic diagnosis and treatment by embolization. AJR 1989; 152: 1231-1235.  Back to cited text no. 2    
3.Heyns CF, VanVollenhoven P. Increasing role of angiography and segmental artery embolization in the management of renal stab wounds. J Urol.1992; 147: 1231-1234.  Back to cited text no. 3    
4.Kantor A, Scalafani SJA, Scalea T, Duncan AO, Atweh N, Glanz S. The role of interventional radiology in the management of genitourinary trauma. Urol Clin North Am 1989; 16: 255-265.  Back to cited text no. 4    
5.Silberzweig JE, Tey S, Winston JA, Mitty HA. Percutaneous renal biopsy complicated by renal capsular artery pseudoaneurysms. Am J Kid Dis.1998; 31(3): 533-535.  Back to cited text no. 5    
6.Fisher BG, Ben-MenachemY. Angiography and embolization in renal trauma. In: Stanley Baum (ed) Abrams' Angiography (Vol II). Little, Brown and Company, 1997; 1230-1243  Back to cited text no. 6    
7.7. Jain R, Kumar S, Phadke R, Baijal SS, Gujral RB. Intra-arterial embolization of lumbar artery pseudoaneurysms following percutaneous nephrolithotomy. Australas Radiol.2001; 75: 383-386.  Back to cited text no. 7    
8.Kaufman SL, Martin LG, Zuckerman AM, Koch SR, Silverstein MI, Barton JW. Peripheral transcatheter embolization with platinum microcoils. Radiology.1992; 184: 369-372.  Back to cited text no. 8    
9.Patterson DE, Segura JW, Leroy AJ, Benson RC Jr, May G. The etiology and treatment of delayed bleeding following percutaneous lithotripsy. J Urol. 1985; 133: 447-451.  Back to cited text no. 9    
10.Orons PD, Zajko AB. Angiography and interventional aspects of renal transplantation. Radiol Clin North Am. 1995; 33: 461-471.  Back to cited text no. 10    

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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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