Renal Artery Embolization Case Study

Nephron Sparing Transcatheter Renal Artery Embolization in Trauma Patient

Introduction: Acute renal hemorrhage is a common medical emergency, which can lead to hemorrhagic shock and eventual death. Complete nephrectomy is used in emergency surgery and is associated with significant postoperative complications. Employing nephron sparing super-selective Transcatheter renal artery embolization techniques can be used to treat acute renal bleeding disorders eliminating need for exploratory laparotomy and nephrectomy.

Case:
Thirty-three-year-old patient arrived as level one trauma, with multiple gun-shot wounds to right flank and left femur. Patient was hemodynamically stable after received multiple liters of intravenous fluids. CT scan at
that time revealed large laceration through lower pole of right kidney with active arterial bleeding and significant perinephric and extraperitoneal hematoma.
Patient was immediately transported to interventional artery suit to selective artery embolization. Using fluoroscope guidance, the patient’s renal arteries was visualized which demonstrated active arterial bleeding from several subsegmental fourth order branches off of the right renal artery. Four intravascular coils were deployed and follow arteriograms were performed after each coil demonstrating successful coil embolization of fourth order branches of the right renal artery supplying the lower pole of the right kidney. Orthopedic surgeons also left knee spanning external fixation.
Three days after the procedure, the patient was transferred out of the ICU. He continued to demonstrate hemodynamic stability. Furthermore, his Foley catheter was removed and patient continued to void spontaneously, which his creatinine down trended to normal limits.

Discussion: Acute renal hemorrhage is a common medical emergency, and can lead to hemorrhagic shock.
In 1973, Bookstein and Ernst were the first to employ renal artery embolization in management of acute renal hemorrhage. There are several factors when considering which agents to use for any given clinical scenario, including, the diameter of vessel to be embolized – vessels smaller than the resolution of digital subtraction angiography are considered small – the length of embolization and viability of tissue after embolization. For large vessel, metal coils and gelfoam can be employed. For smaller vessels particular embolic agents such as polyvinyl alcohol particles and embospches, sclerosants (glue, onyx, ethiodol) can be
employed. In our patient, renal artery was angiographically visualized with extravasation of contrast media demonstrating acute renal hemorrhage.
Since permanent occlusion of these abnormalities was required for treatment metal coils were deployed. This technique allows for partial renal artery embolization, which eventually lead to segmental infracts of the treated kidney. Furthermore, not only selective embolization provides controlled occlusion of minuscule renal artery branches, it is also not associated with clinically significant reduction in renal function. Studies conducted by Somani and Nabi demonstrated a technical success rate of 93% in emergent renal artery embolization. Even though considered a safe and effective procedure, main complication includes coil migration, which could potentially lead to pulmonary embolization and hypotension, can be corrected using snare procedures. Other complications include incomplete embolizations, and groin hematomas. These complications were reported in less than 2% of cases.

Conclusion: Renal artery embolization is a safe, effective and minimally invasive procedure which can be use in treatment of renal hemorrhage. Emergency embolization should be performed as soon as diagnosis is established to prevent further complications. Furthermore, selective embolization techniques should be employed, and special attention should be placed on using embolic agents of proper size. By employing transcather renal artery embolization techniques, renal
function can be preserved, and eliminate need for exploratory laparotomy.