Clinical application of superselective renal artery embolization in renal damage hemorrhage ————– International Journal of Urology, 2015, 35 He Overview; Li Qiang, Zhuo Hui Reviewer (Department of Urology, The Second Clinical College of Chongqing Medical University-Chengdu Third People’s Hospital, Chengdu, 610031, China) [Keywords] Renal artery; embolization; Hemorrhage; Therapeutic [中图分類号] R692 [文文标志码] A Department of Urology, Chengdu Third People’s Hospital, Chengdu, China HE Superselective renal artery embolization in the treatment of renal damage hemorrhage HE Ben, LI Qiang. ZHUO Hui (Department of Urology, the Second affiliated Hospital of Chengdu Chongqing Medical University-the Third Peoples Hospital of Abstract】Renal damage hemorrhage is a common urological emergency, which used to be treated by conservative internal medicine or surgery. With the maturation of interventional technology, SRAE has shown obvious advantages in the diagnosis and treatment of renal injury bleeding, and has been widely used in clinical practice. This article focuses on the clinical application of SRAE in renal injury hemorrhage. Author Biography: He (1986-), male, Wenchuan County, Sichuan, China, resident, master, specializing in urological stones and tumors. E-mail: [email protected]; Tel: 15184337228. Corresponding author: Qiang Li, Professor, Chief Physician. E-mail: [email protected] Renal injury and bleeding is an emergency in urology, which is often difficult to treat, mainly because of the poor efficacy of conservative medical treatment and the difficulty of surgical treatment to preserve the kidney. It is difficult to preserve the kidney with surgical treatment. The causes of renal injury bleeding may be medical injuries such as percutaneous nephrolithotripsy (PCNL), trauma, ruptured renal tumor aneurysm and renal arteriovenous malformation. In recent years, the development of interventional radiology technology, superselective renal artery embolization (SRAE) can not only accurately locate the diagnosis, but also effectively control bleeding and maximize the protection of renal function, which opens up an effective minimally invasive treatment method for renal injury bleeding. In 1973, Bookstein et al [1] first reported the use of renal artery embolization to control renal hemorrhage, and soon Chuang et al [2] performed renal artery embolization in seven patients with renal hemorrhage, of which six were successful and five avoided nephrectomy as a result. In 1979, Tisnado et al [3] successfully treated a medically induced renal arteriovenous fistula using transcatheter vascular embolization with absorbable gelatin sponge pellets, avoiding the excessive parenchymal loss associated with surgical treatment. In 1984, Uflacker et al [4] reported the results of 17 cases of renal injury bleeding treated with SRAE. 16 cases of active bleeding ceased after transcatheter vascular embolization and 1 case of delayed cessation of bleeding; 4 of these cases In 1995, Kessaris et al [5] completed 2200 cases of percutaneous renal surgery, 17 of which underwent SRAE for hemorrhage, of which only 2 required further open surgery to stop the bleeding. At present, SRAE plays an increasingly important role in the diagnosis and treatment of bleeding kidney injury with its advantages of exact hemostasis, minimal trauma and rapid recovery. Compared with traditional open surgery, SRAE can rapidly control bleeding and maximize the preservation of kidney function. 2. Current status and progress of SRAE in renal injury bleeding 2.1 SRAE for postoperative hemorrhage in PCNL PCNL is currently the main treatment for upper urinary tract stones, with the advantages of minimally invasive and rapid recovery, and has been accepted by the majority of urologists and patients. Postoperative haemorrhage is one of the serious complications of PCNL, and Dore et al [6] reported an incidence of 0.5% to 2.0%, while large domestic samples reported [7, 8] 0.5% (9/1963) and 1.78% (46/2589).SRAE has become an ideal treatment for severe postoperative bleeding in PCNL because of its exact effect compared with medical treatment and less invasive compared with open surgery. The 2012 EAU guidelines recommend SRAE as the first choice in both diagnosis and treatment of severe bleeding after PCNL [9], and the 2014 version of the domestic guidelines recommend that SRAE should be performed immediately if the conservative results are unsatisfactory for those belonging to renal segmental and interlobular vascular injuries [10]. Wu Wenqi et al [11] reported that SRAE treated 46 cases of severe bleeding after PCNL, among which 36 cases were successfully embolized once and 5 cases twice and the bleeding stopped, 4 cases were cured after haemostatic drug infusion with negative renal arteriogram, and 1 case died suddenly on the second day after the bleeding stopped after embolization, and they concluded that severe bleeding after PCNL was mainly related to surgical injury to small arteries such as renal segment, interlobular and arch arteries, and SRAE Wang et al [12] reported 25 cases of severe bleeding after PCNL treated with SRAE, and 5 cases underwent SRAE twice due to new bleeding and absorption of embolic material, and the authors strongly recommended SRAE as the preferred modality for the treatment of renal bleeding, and pointed out that even if the initial treatment failed, embolization could still be repeated several times to avoid removal of the kidney.Zeng et al [13] reported a multicenter retrospective clinical study that included 117 patients who underwent SRAE for post-PCNL hemorrhage in 6 medical institutions, including 8 cases with 2 and 3 successful embolizations and 1 nephrectomy, which analyzed the risk factors for failure of initial SRAE treatment in these 12 cases and identified 3 risk factors: establishment of multiple percutaneous renal channels, renal arteriography showing more than 2 bleeding sites and Jinga et al [14] completed 2095 cases of PCNL and summarized the clinical data of 22 cases treated with SRAE in 226 cases of post-PCNL bleeding. renal arteriogram showed causes of bleeding including 15 cases of pseudoaneurysm, 5 cases of arteriovenous fistula, and 2 cases of arterial tear, and the results of univariate analysis showed significant risk for severe hematuria requiring SRAE The significant risk factors for SRAE were multiple antler-shaped renal stones, transcatheter calyx puncture, and a history of pyelonephritis. 2.2 SRAE for bleeding due to renal arteriovenous malformation Renal arteriovenous malformation (RAVM) consists of thickened blood supply arteries, malformed vascular masses, and tortuous and dilated draining veins, and has a low clinical incidence (0.04%) [15] and is one of the most important causes of painless sarcoid hematuria. RAVM is classified as congenital or acquired, and the former is subdivided into varicose veins and aneurysmal types, which often develop after the age of 30 years. In varicose veins, the malformed vessels are mostly located in the submucosal lamina propria of the renal pelvis, and the lesioned vessels often lack elastic fibers and dilate in a bead-like pattern, which can easily break into the collecting system and cause hematuria; in aneurysmal type, several abnormal vessels are connected between the arteries and veins in the kidney, and the shunt flow is larger. The acquired type is often caused by renal inflammation, tumor, trauma, and surgery, and is often associated with a single arteriovenous fistula with an inconspicuous mass of malformed vessels. Since the application of interventions for the treatment of RAVM bleeding, SRAE has become the method of choice for the treatment of this type of disease [16]. Murata et al [17] successfully performed SRAE in 12 patients with sarcoid hematuria due to RAVM, renal arteriography showed 10 cases of varicose veins and 2 cases of aneurysmal type, using gelatin sponges, metal coils and liquid embolization materials, 2 of them relapsed (with coils alone) and underwent SRAE again, with no renal function abnormalities at a mean follow-up of 2 years, they concluded that SRAE treatment was definitive and effective Zhang et al [18] summarized the clinical data of 6 cases of SRAE for RAVM bleeding, 2 cases used steel coils and 4 cases chose isobutyl cyanoacrylate as embolization material, with an average follow-up of 22 months and no recurrence of bleeding or complications. Recently, a scholar [19] reported that n-Butyl-2 cyanoacrylate was chosen as embolization material for 6 cases of RAVM bleeding (4 cases of variceal type and 2 cases of aneurysmal type), of which 5 cases were successfully embolized once and 1 case twice, and 1 case recurred and was embolized again (alcohol with iodine oil) at 41 months postoperative follow-up. 2.3 SRAE for renal bleeding due to trauma and other causes Among urinary tract injuries, renal injury is more common second only to urethral injury [20]. Interventional treatment of traumatic renal hemorrhage aims to control bleeding, reduce the risk of surgical exploration, and maximize preservation of renal function.Heyns et al [21] reported 28 cases of renal hemorrhage caused by non-medical trauma treated with SRAE, of which 24 (86%) were successful and 2 (8%) had complications, suggesting that SRAE should also be preferred for severe hematuria caused by non-medical trauma. Also, SRAE has been used to successfully manage interlobular renal pseudoaneurysms caused by closed trauma [22, 23]. In addition, SRAE has also been applied to renal hemorrhage due to other causes.Stoica et al [24], through a retrospective analysis of 11 cases of spontaneous ruptured hemorrhage from renal malformation tumors treated with SRAE from 1999 to 2009 (2 cases of hemorrhagic shock), concluded that SRAE was accurate and effective in managing acute ruptured tumor hemorrhage with embolization, hemostasis, and few complications. Recently, Zeng et al [25] used SRAE to successfully treat 9 cases of hemorrhage after renal biopsy (7 cases of sarcohematuria and 2 cases of perirenal hematoma), and chose steel spring coils or microsteel spring coils as embolization agents for 5 cases of severe renal injury and renal artery rupture, and used polyvinyl alcohol pellets for embolization of 4 cases of pseudoaneurysm and potential renal artery injury risk. Xue et al [26] also confirmed that SRAE is safe and effective in the treatment of traumatic renal artery pseudoaneurysms that occur after pediatric renal biopsy. In a large-scale multicenter clinical study with 20-month follow-up reported by Hyams et al [27], an American scholar, retrospectively analyzed 998 cases of minimally invasive partial nephrectomy with 20 cases of vascular injury (17 cases of pseudoaneurysm and 3 cases of arteriovenous fistula), and SRAE was successfully performed in 16 cases with good clinical results. 3. Conclusion Since the introduction of SRAE into urology for the treatment of renal injury bleeding, it has become the method of choice for the treatment of renal injury bleeding because of its obvious advantages of localization and characterization, exact hemostatic effect, and effective protection of renal function. 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