Embolotherapy for salvaging renal allografts with post biopsy complications

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1 Embolotherapy for salvaging renal allografts with post biopsy complications Poster No.: C-2634 Congress: ECR 2013 Type: Scientific Exhibit Authors: S. Gaharwar, R. V. PHADKE ; Lucknow/IN, LUCKNOW, UTTAR PRADESH/IN Keywords: Interventional vascular, Kidney, Catheter arteriography, Embolisation, Arteriovenous malformations DOI: /ecr2013/C Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 37

2 Purpose Renal Transplantation is the modality of choice treatment for ESRD patients among: 1) Hemodialysis 2) Peritoneal dialysis 3) Transplantation Among these, transplantation is the modality of choice (Fig. 1) as it not only improves patients quality of life but significantly prolongs their survial as compared to patients who are on dialysis. However, even there are advancements in management of graft, there is approx. 50% loss of graft survival (Fig. 2), with common causes of graft survival being rejection and chronic allograft nephropathy(fig. 3). Here comes the need of "CORE BIOPSY"- it is gold standard test for diagnosis of renal allograft rejection as helps in establishment of exact diagnosis, an aid to determine nature of recommended therapy and to correctly ascertain degree of active or chronic changes. Also rest of imaging modalities lack good sensitivity and specificity so as to early prognosticate the situation (Fig. 4). However, few complications ( %) do arise during or after allograft biopsy which are: 1) Hemorrhage (microscopic/gross) 2) Arterial injuries a) AV fistulae (5-10%) b) Pseudoaneurysm c) Arteriocalyceal fistulae d) Arterial thrombosis (rare) Miost of the complications (70%) resolve within a year or two, with remaining 30% requiring interventional management (Fig 6), as they can lead to further complications (Fig 5). Page 2 of 37

3 These complications may require correction, and coaxial catherisation with effective embolisation is known to be most effective and non-invasive method of treatment with minimal renal parenchymal damage. We evaluated the incidence of post biopsy vascular complications in renal transplants and assessed the use of super-selective embolisation for treatment. Page 3 of 37

4 Images for this section: Fig. 1: comparison of patients on dialysis with those who underwent transplantation. Page 4 of 37

5 Fig. 2: Graft survival rate Page 5 of 37

6 Fig. 3: Causes of graft failure Page 6 of 37

7 Fig. 4: Modalities for assessment of graft. Page 7 of 37

8 Fig. 5: sequelae of post biopsy vascular complications Fig. 6: management of post biopsy vascular complications Page 8 of 37

9 Methods and Materials A total of 353 biopsies in renal transplants were performed in our institute during the period from January 2010 to October 2012 under real time ultrasonographic guidance. Of these patients 4- all males, developed serious renal vascular complications, and required angiographic evaluation and transarterial embolisation. All four patients had persistent hematuria and/or deteriorating renal function because of perinephric hematoma. Interventions: An angiographic study combined with endovascular treatment of the intrarenal AVF and pseudo aneurysms was performed in all four patients. Embolisation was performed with coils, gel foam or NBCA as and when required. After successful embolisation, all patients became asymptomatic. Page 9 of 37

10 Results The incidence of major post biopsy renal vascular complications in our series was 1.14 % (04/353), which is comparable to published literature ( %)[ Nyman et al, 1997]. CASE I: 42 yr male underwent renal transplanation in April, On 26th Nov. underwent allograft biopsy so as to evaluate for proteinuria. Histological examination of the specimen was unremarkable except for slight increase in mesangial matrix. 20 days post biopsy he presented with rising serum creatinine. Bed side USG revealed a pulsatile hypoechoic mass in allograft parenchyma s/o pseudoaneurysm with large perinephric hematoma. Hence the patient was posted for angiography. Selective transplant renal arteriography was done which showed three segemental arteries supplying upper and mid pole (Fig.7), whereas lower pole was supplied by accessory artery anastomosed to right external iliac artery (Fig. 8). Focal contrast pooling s/o pseudoaneurysms was seen in upper pole of transplant kidney (Fig. 8) which persisted in delayed phase (Fig. 9), with feeder from distal lobar branch of upper segmental artery. Selective angiogram of distal lobar branch of upper segmental artery shows pseudoaneurysm being fed by proximal interlobar artery (Fig 10). Three HILAL MR compatible( 2mm X 2cm) coils were used to embolise the pseudoaneurysm and feeding interlobar artery using anchorage technique (Fig. 11). Panoramic view of transplant renal angiogram [POST- PROCEDURE] shows no contrast pooling as compared to INITIAL ANGIOGRAM (Fig. 12) with non opacification of pseudoaneurysm and feeding interlobar branch. Later, patient was discharged under stable conditions on 31st December, 2011). CASE II 32 yr male with end stage renal failure underwent living related kidney transplantation in april, He underwent graft biopsy on 6th May, for increasing creatinine and fever, which was reported to be histologically normal. Hence was discharged under stable conditions. However, he was again admitted on 22nd August for decreased urine output. USG showed large perinephric hematoma (Fig. 13), and hence was referred to our Department for Emergency DSA +/- EMBOLOTHERAPY. Page 10 of 37

11 Selective transplant renal artery angiography showed an abnormal area of contrast extravasation and pooling in the region of upper pole of left kidney with contrast extravastion from upper segmental and upper lobar branch of middle segmental artery (Fig. 14). Super selective catherisation of middle segmental artery was done followed by deployment of coils. Final angiogram of transplant renal artery obtained after proximal embolisation of upper interlobar branch from lower lobar branch of upper segmental artery, still showed some contrast extravasation (Fig. 15). Two more coils were used to embolise another feeding branch which was a proximal interlobular artery from middle segmental artery, however check angiograms still shows contrast extravastion (Fig. 16). Two more coils were used to embolise the distal upper interlobar branch of middle segmental artery, followed by selective check angiograms, which showed reduced contrast extravasation in the area (Fig. 17). this was followed by coiling of feeders from upper segmental artery (Fig. 18). Final check angio (Fig. 19) showed no obvious contrast extravasation as compared to initial angiogram. Later, patient was discharged under stable conditions. CASE III 34 yr male underwent renal transplanation in Aug On day 5 underwent allograft biopsy because of oliguria. On 6th day drainage catheter showed fresh blood. Hence patient was reffered to our department for embolisation of feeding artery and pseudoaneurysms. Selective angiogram of right external iliac artery showed focal area of contrast extravasation in the region of upper pole of transplant kidney, which persisted in delayed phase (Fig. 20). A streak of contrast was seen extending from pseudoaneurysm in perinephric region (Fig. 21). Super selective angiogram of lower lobar branch of upper segmental artery shows pseudoaneurysm with streak of contrast extravasation extending in perinephric region, this feeding artery was selectively embolised (Fig. 22). However still focal abnormality with contrast extravastion was seen from upper lobar branch of upper segmental artery in a different region, which was embolised using two (2mm X 2cm) coils, however super-selective check angiogram still showed contrast extravasation in the area (Fig. 23). Hence gel foam (1-1.5 ml) was used as adjunctive embolic agent, followed by selective angiograms, which showed complete embolisation, with no e/o contrast extravasation (Fig. 24). Patient was further discharged under stable conditions. CASE IV Page 11 of 37

12 Images for this section: Fig. 7: Initial check angiogram showing shows end to end anastamosis of transplant kidney main renal artery to internal iliac artery, with three segmental arteries supplying upper and mid pole of transplant kidney. Page 12 of 37

13 Fig. 8: Lower pole supplied by accessory artery which is end to side anastomosed to external iliac artery. Page 13 of 37

14 Fig. 9: Delayed phase showing contrast pooling in pseudoaneurysm. Page 14 of 37

15 Fig. 10: Selective angiogram of distal lobar branch (white arrows) of upper segmental artery shows pseudoaneurysm (red asterisk) being fed by proximal interlobar artery (blue arrow). Page 15 of 37

16 Fig. 11: Three HILAL MR compatible(red arrows- 2mm X 2cm) coils were used to embolise the pseudoaneurysm and feeding interlobar artery using anchorage technique. Page 16 of 37

17 Fig. 12: Panoramic view of transplant renal angiogram [POST-PROCEDURE] shows no contrast pooling (red circles)as compared to INITIAL ANGIOGRAM. Page 17 of 37

18 Fig. 13: Large intraparenchymal and perinephric hematoma on bed side sonography. Page 18 of 37

19 Fig. 14: Three segmental arteries (arrows) with contrast extravasation from upper segmental and upper lobar branch of middle segmental artery. An abnormal area of contrast extravasation & pooling in the region of upper pole of kidney (red asterisk). Page 19 of 37

20 Fig. 15: Selective angiogram of transplant renal artery obtained after proximal embolisation (arrow) of upper interlobar branch from lower lobar branch of upper segmental artery, using 2 mm X 3 cm coil. This artery was predominant feeder of distal extravasation site. However, even then contrast extravasation seen. Page 20 of 37

21 Fig. 16: Selective angiogram of middle segmental artery (left image) showed upper lobar branch feeding the contrast extravasation site.two coils (arrows) were used to embolise the feeding branch (right image) which is a proximal interlobular artery from middle segmental artery, however check angiograms still shows contrast extravastion. Page 21 of 37

22 Fig. 17: Selective check angiograms (post coiling), showed reduced contrast extravasation in the area. Page 22 of 37

23 Fig. 18: left image showing selective angiograms of upper lobar branch of upper segmental artery with contrast extravasation (red circles). Right image post coiling (arrows) in feeder artery with no obvious contrast extravasation seen. Page 23 of 37

24 Fig. 19: Panoramic view of transplant renal angiogram [POST-PROCEDURE] showed no obvious contrast extravasation. Page 24 of 37

25 Fig. 20: Left image showing focal area of contrast extravasation in the region of upper pole of transplant kidney (red circle), which persisted in delayed phase (right image). Page 25 of 37

26 Fig. 21: Focal pseudoaneurysm (red arrows) with streak of contrast extravasation seen from upper polar interlobar arteries, which is communicating with perinephric region (white arrow). An ill defined indentation (black arrows) seen over upper polar renal parenchyma s/o perinephric hematoma. Page 26 of 37

27 Fig. 22: Left image : Super-selective angiogram of lower lobar branch of upper segmental artery shows focal contrast pooling (pseudoaneurysm- red arrows), with streak of contrast extravasation extending in perinephric region. Right image: Post coiling superselective angiogram of lower lobar branch of upper segmental artery reveals successful embolisation with no e/o contrast pooling or extravasation. Page 27 of 37

28 Fig. 23: Left image: Post coiling (red arrow) selective angiogram of renal artery shows focal abnormality with contrast extravasation (red circle) from upper lobar branch of upper segmental artery. Right image: Upper interlobar branch of upper lobar branch was embolised using two (2mm X 2cm) coils (red arrows), however super-selective check angiogram showed contrast extravasation in the area. Page 28 of 37

29 Fig. 24: Selective angiograms (post gel foam), which showed complete embolisation, with no e/o contrast extravasation. Page 29 of 37

30 Fig. 25: Longitudinal view of upper pole of transplanted kidney obtained with a 3.5 MHz transducer demonstrates an area of intense and mixed red and blue color ( color aliasing), suggesting high velocity and disturbed flow involving lobular artery at cortico-medullary junction of upper pole. Spectral doppler of area of disturbed flow (involving intralobar artery in papillary region) shows region of low RI. Page 30 of 37

31 Fig. 26: Findings were confirmed on superselective catheterisation of upper polar branch from middle branch with microferret. Two areas of AVF were seen with early visualisation of draining veins. Fig. 27: This was followed by deployment of 2 mm X 2 cm pushable coil. Few minutes post coiling check angios with microferret as well as RDC revealed occlusion of territorial artery and non visualization of previously visualized draining veins. Page 31 of 37

32 Fig. 28: DSA was repeated on 9/8/12, with check angio on superselective catheterisation, revealed reopening of the fistulous communication sites. Page 32 of 37

33 Fig. 29: Hence NBCA glue FIG 5 (a), (b), (c) was used in a ratio of 1:4 for reocclusion of territorial artery. Check angios showed non visualization of early draining veins s/o successful embolisation. Page 33 of 37

34 Fig. 30: Doppler study of transplanted kidney was done using linear 5MHz transducers with careful assessment of upper pole. It revealed echogenic clot in upper pole calyces with small spurts of echogenic blood in calyx from papilla on grey scale imaging. Power and color doppler showed small spurts which can be traced to a small arterial branch suggesting arterio-calyceal fistula. Different views were checked and best view was LAO and RAO at approx Patient was then posted for DSA. Page 34 of 37

35 Fig. 31: Left image: This was followed by advancement of in upper polar branch supplying collateral territory of previous coiled artery. Check angios with showed 2 early draining veins suggesting AVF, with focal area of contrast extravastion with pooling just microcatheterposterior to previously coiled artery. Best view to assess this was found to be RAO 530. Right image shows The small branch of lower branch of Main RA was selectively embolised using 1:3 NBCA (0.2ml). Check angios showed complete glue cast of branch with small distance obliteration of draining veins with stoppage of early venous drainage. No e/o AVF or contrast extravasation was seen. Page 35 of 37

36 Conclusion Renal allograft biopsy is an essential tool for follow up evaluation of transplant recipients, though can result in inadvertent vascular injuries resulting in perinephric hematoma, vascular injuries or hematuria. Conservative management in conjunction with ultrasound is recommended in most patients. Persistent vascular injuries or hematuria can be effectively treated by transcatheter embolisation. The decision to perform embolisation and timing of embolisation depend on the degree and type of symptoms that the patient displays as well as the institutional experience with transcatheter embolisation. Page 36 of 37

37 References Benoit G, Charpentier B, Roche A, Bellamy J, Mohamedi D, Fries D.Arteriocalyceal fistula after grafted kidney biopsy: successful management by selective catheter embolization. Urology 1984; 24: Nyman R, Cappelen-Smith J, Al Suhaibani H, Alfurayh O, Shakweer W, Akhtar M. Yield and complications in percutaneous renal biopsy. A comparison between ultrasound-guided gun-biopsy and manual techniques in native and transplant kidneys. Acta Radiol. 1997;38: Naraghi R M, Jordan M L. In: Shapiro R, Simmons RL, Starzl TE, editor. Renal Transplantation.Stamford, CT: Appleton & Lange; Surgical complications. pp Page 37 of 37