Beograd, 14.10.2012 Urinary tract embolization asist. Peter Popovič, MD, MSc Head of abdominal radiology department, Institute of Radiology, UMC Ljubljana
Embolization Who and when procedure: local/general anaesthesia Rtg ( C arm) with DSA catheter, microcatheter.. embolic materials
Embolization: Possible indications Renal cell carcinoma (RCC) Angiomyolipoma (AML) Aneurysm AVFs Trauma Discuss indications and contraindications of transcatheter embolization Understand the role of transcatheter embolization
Renal cell carcinoma (RCC) Embolization: Possible indications Advanced disease (T3) Embolic materials: ethanol - Prenephrectomy to reduce technical difficulties of surgery - Palliative embolization (survival, quality of life, solving symptoms)
56 yr., M, RCC T3 slika oclusion balloon xylocain ethanol
Renal cell carcinoma (RCC) Embolization: Possible indications Disease localized to the kidney (T1) Embolic material:pva,tam+lipiodol - Embolization prior to RFA - Embolization prior to partial nepherectomy - After ablation or partial nepherectomy (complications)
Renal cell carcinoma-bone metastases microcatheter Embolic material:pva,tam
Renal cell carcinoma-bone metastases 25% metastases at presentation, 40% will develop osseous metastases management of painful bone metastases Conventional Therapy: Radiation Therapy Chemotherapy Hormonal Therapy Systemic Radioisotope Therapy Bisphosphonates Image-guided Intervention: Embolization Radiofrequency Ablation (RFA) Embolization and RFA RFA and Cementoplasty
Renal cell carcinoma-bone metastases preoperative embolization reduce blood loss, effect proven in case series preablative embolization potentially increase efficacy of subsequent RFA, currently no trials palliative embolization pain control, increased mobility, good results in single-arm studies
Kidney metastases
Angiomyolipoma (AML) Approximately 80% of AMLs manifest as sporadic lesions The remainder manifest as part of tuberous sclerosis 80% of AMLs larger than 4 cm will become symptomatic Rupture and haemorrhage are seen in 50% of renal angiomyolipomas that measure 4 cm. in diameter Shen-Yang Lee et all.cardiovasc Intervent Radiol (2009)
AML When do we have to treat? If Symptomatic, whatever the size (Flank pain, Haematuria, Retroperitoneal bleeding) If Asymptomatic Above 4 cm: treatment How do we have to treat? Selective embolization? Nephron-sparing surgery? Radiofrequency ablation? Shen-Yang Lee et all.cardiovasc Intervent Radiol (2009)
54 y,, F, abdominal discomfort, AML, 4,7 cm ethanol microcatheter
AML How do we have to treat? Embolizationis considered the first line treatment for asymptomatic AML larger than 4 cm. Embolizationis considered the first line of treatment in ruptured AML Incomplete embolization results in a high incidence of recurrent symptoms Shen-Yang Lee et all.cardiovasc Intervent Radiol (2009) Rimon U, AJR 2006
AML Embolization It s safe: No arteriovenous shunting was found in any tumor (18 AML) Most investigators use absolute ethanol 1. mixed with iodized oil easily administered, diffuses through the entire tumor vasculature, permanently occludes the arteries at the capillary level, induces tumor infarction and necrosis 2.Mixed with calibrated particules (45-150)- particles would increase the effect of ethanol Shen-Yang Lee et all.cardiovasc Intervent Radiol (2009) Rimon U, AJR 2006
, 55 yr., Neurofibromatoza, bleeding
Kidney aneurysm include both (a) true aneurysms (b) pseudoaneurysms degenerative,atherosclerosis, fibromuscular dysplasia, and collagen disorders trauma, inflammation, infection, or vasculitis asymptomatic and symptomatic
Kidney aneurysm -etiology Extra parenhimal Intra parenhimal Fibromuscular dysplasia Trauma Polyarteritis nodosa Tuberkuloza Neurofibromatoza Mikotična Ehlers-Danlos syndrome Trauma
Kidney aneurysm FMD Extra parenhimal?
Extra parenhimal Kidney aneurysm FMD
Aneurysm When do we have to treat? women of childbearing age, with lesions greater than 10 mm in diameter any patients with lesions larger than 20 mm in diameter patients with progressively enlarging lesions symptomatic patients with a lesion of any size
, 28 yr., biopsy left kidney
Results of embolization for post renal biopsy bleeding Overal hemmorrhagic complications after renal biopsy 3.2%-7.5% Embolization required 0.3-0.9% autor years pts Control of bleeding Renal function decrease Perini 1998 21 100% 0% Makeux 2003 13 100% 23% 8% Puppas 2006 6 100% 0% Loffray 2008 12 100% 25% 0% complicati ons
, 43 yr., biopsy Tx kidney, Hematuria, decrease renal function AVF
Natural history of post Bx AVFs Complications: Hematuria, hypertension, decrease renal function, congestive heart failure, retroperitoneal hematoma, abdominal pain 70% close spontaneously between 2 weeks and 18 months Indications to treat - renal hemorrhage persisting for more than 72 h after biopsy - progressive deterioration of renal function Ko JS et al. J Vasc Interv Radiol. 2009
, 30 yr.,knife accident, after 4 week- bleeding
, 30 yr.,knife accident, after 4 week- bleeding
25 ys., M, polytrauma, stable, Gr III-IV?
25 ys., M, polytrauma, stable, Gr III-IV conservative
25 ys., M, polytrauma, stable, Gr III-IV, peristent clinical signs of bleeding? Peristent bleeding reguire surgical treatment
25 ys., M, polytrauma, stable, Gr III-IV openbook injury
37 ys., M, polytrauma, unstable, Gr V-schathered kidney
Kidney trauma-grading Grade 1: Hematuria with normal imaging studies, contusions, nonexpanding subcapsular hematomas Grade 2: Nonexpanding perinephric hematomas confined to the retroperitoneum, superficial cortical lacerations less than 1 cm in depth without collecting system injury Grade 3: Renal lacerations greater than 1 cm in depth that do not involve the collecting system Grade 4: Renal lacerations extending through the kidney into the collecting system, injuries involving the main renal artery or vein with contained hemorrhage, segmental infarctions without associated lacerations, expanding subcapsular hematomas compressing the kidney Grade 5: Shattered or devascularized kidney, ureteropelvic avulsions, complete laceration or thrombus of the main renal artery or vein American Association for the Surgery of Trauma (AAST)
37 ys., polytrauma, unstable Gr V or unstable kidney to the surgeon Stabilized Gr V trauma could be managed - Multiple selective embolization - Truncal renal artery embolization Surgery 77-89 % total nephrectomy (41% complications) Buckley J Trauma 2011, Sarani, JVIR 2011
Gr V kidney trauma 10 unstable pts. Renal embolization -total 7, selective 3 Initial clinical success 10 pts 6 month follow-up: no complications Brewer E. J Urology 2009, Stewart A, J Trauma 2010
Trauma blunt or penetrating trauma the most commonly injured organs are the spleen, liver, retroperitoneum, small bowel, kidneys, bladder, colorectum, diaphragm, and pancreas CT - highly sensitive, specific, and accurate in detecting the presence and extent of injury to the abdomen in acutely traumatized patients non-operative management in 60-90% of blunt hepatic, splenic or renal injures Bessoud B et al. AJR 2007
Embolization - Complications Post-embolizationsyndrome - 80% Nausea and vomiting,low-grade fever, flank pain and headache Conservative management Renal abscess Non targeted embolization Other related angiography complications < 1% Bessoud B et al. AJR 2007
Conclusions Therapeutic embolization to treat urinal tract is indicated in very different disorders, such as cancer, trauma, iatrogenic complications, arteriovenous fistulas and aneurysm. Any vascular radiology department may be called upon to perform such treatments in elective and in an emergency setting