Transarterial embolisation of renal arteriovenous malformation: safety and efficacy in 24 patients with follow-up

doi:10.1016/j.crad.2015.06.079

Clinical Radiology

Volume 70, Issue 11, November 2015, Pages 1177-1184

https://doi.org/10.1016/j.crad.2015.06.079 Get rights and content

Highlights

•
The efficacy and safety of renal artery embolization for renal arteriovenous malformation as well as its long-term outcome are evaluated.
•
Renal artery embolization is safe and effective for the treatment of renal arteriovenous malformation.
•
Multiple sessions of embolization may lead to successful treatment of incompletely treated or recurrent renal arteriovenous malformation.

Aim

To evaluate the efficacy and safety of renal artery embolisation (RAE) for renal arteriovenous malformation (AVM) as well as its outcomes.

Materials and methods

The technical and clinical success rates, radiological and laboratory findings, and complications of RAE for 31 renal AVMs in 24 patients (M:F=9:15, mean age 46 years) at two separate medical institutions were retrospectively evaluated. Technical success was defined as complete occlusion of feeding arteries with no residual nidus seen on post-treatment angiography. Clinical failure was defined as recurrence of haematuria, presence of AVM on follow-up ultrasound or computed tomography, repeated RAE or surgery for the control of haematuria. Overall clinical success was defined as resolution haematuria or disappearance of AVM on follow-up imaging after single or multiple sessions of RAE.

Results

Types of renal AVM were AVM, arterio-venous fistula (AVF) with intranidal aneurysm, and acquired AVF in 19, 1, and 4 patients, respectively. 18 patients (75%) underwent a single session of RAE, while 6 patients (25%) had two or more sessions of RAE. The level of embolisation was feeder, segmental artery, and main renal artery in 28 (90%), 2 (6%), and 1 (4%) procedures, respectively. Coil, n-butyl 2-cyanoacrylate, and polyvinyl alcohol were the most frequently chosen embolic materials and were used in 19, 14, and 8 procedures, respectively. The clinical success rate after initial RAE was 67% (16/24). Overall clinical success rate, including multisession RAE, was 88% (21/24). The technical success rate of 31 procedures was 65% (20/31). Among 11 technical failures in 10 patients, 4 achieved clinical success without additional RAE, 3 underwent second session RAE to achieve clinical success, and 3 patients underwent nephrectomy due to recurrence.

Conclusion

RAE is a safe and effective treatment for renal AVM. Technical failure of RAE does not always lead to clinical failure and multiple embolisation sessions may be effective for recurrent renal AVM.

Introduction

Renal arteriovenous malformation (AVM) is a pathological communication between the arterial and venous circulation that bypasses capillary bed. AVM could be either congenital or acquired.¹ Acquired AVM, arterio-venous fistula (AVF), tend to manifest as a single linear connecting vessel, comprise 70–80% of renal arteriovenous abnormalities and usually result from trauma, biopsy, surgery, malignancy, or inflammation.² Two types of congenital renal AVM, cirsoid and cavernous type, are described. Cirsoid AVM should fulfil certain criteria, which includes no prior history of renal injury or disease and typical angiographic findings with tortuous vascular channels between segmental or interlobar renal arteries and veins.³ Cavernous AVM shows a single dilated vessels and is less common.⁴

Patients with renal AVM usually present with gross haematuria or flank pain with occasional accompanying hypertension or heart failure.3, 5, 6 Renal angiography is used to confirm the presence of renal AVM and in planning treatment. To date, renal AVM has been treated by surgery, such as nephrectomy. Endovascular approaches for treating AVM are gaining popularity.⁷ The introduction of smaller delivery catheters and more precise delivery of embolic materials have drastically reduced the morbidity associated with this technique.1, 8, 9, 10, 11, 12 Therefore, currently, this treatment modality is becoming popular as it provides maximal preservation of functioning renal parenchyma as well as treating the disease and symptoms.

Several case reports and case series of renal artery embolisation (RAE) and ablation of renal AVM have reported successful results1, 13, 14, 15; however, there are few studies regarding the comprehensive analysis of clinical and radiological outcomes and effectiveness of multiple RAE sessions based on long-term follow-up data. The present study was undertaken to evaluate the efficacy and safety of RAE for renal AVM as well as its long-term outcomes.

Section snippets

Patients

From January 2001 to December 2014, 31 RAE procedures were performed for 24 renal AVMs in 24 patients at two, separate medical institutions. A total of 24 patients, i.e., 9 men (age range, 16–71 years; mean age 43 years) and 15 women (age range, 30–69 years; mean age 47 years) were included in this study.

Clinical medical records were retrospectively reviewed for symptoms and signs of renal AVM, underlying medical status and baseline renal function, i.e., blood urea nitrogen/creatinine (BUN/Cr).

Patient characteristics

Clinical characteristics and outcomes of the 24 patients and 31 procedures are summarised in Table 1. 18 patients (75%) underwent a single session of RAE, whereas 6 patients (25%) had two or more sessions of RAE. Therefore, a total of 31 RAE procedures were performed in 24 patients. 17 patients (71%) had haematuria or flank pain, and 7 (29%) were asymptomatic. One patient had a single kidney with a past medical history of nephrectomy for renal cell carcinoma.

All patients underwent CT or

Discussion

Renal AVM is an uncommon cause of haematuria and is a diagnostic and therapeutic challenge in clinical practice. The present study revealed that single or multiple RAE sessions could be an effective and safe treatment strategy for patients with renal AVM.

The technical success rate of 65% and the overall clinical success rate of 88% seem to be comparable to those reported in previous studies.¹ Primary and secondary success rates were 73.7 and 94.7%, respectively, based on a review of 19 patients

Acknowledgments

This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and future Planning (2014R1A2A2A01005857).

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A Case of Right Renal Arteriovenous Malformation Mimicking the Symptoms of Urinary Tract Infection in the Emergency Department
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Renal arteriovenous malformation (AVM) is a rare cause of massive hematuria, and patients with renal AVM may present with symptoms like urinary tract infections in the emergency department.
A 37-year-old woman presented to the emergency department with symptoms of hematuria, urinary hesitancy, and severe suprapubic pain that had been present for a few hours. A urine examination revealed no pyuria, but urine occult blood for 3+ and a red blood cell count of >100 per high-power field. Bedside echocardiography revealed right kidney hydronephrosis and a distended bladder with a blood clot. A 3-way Foley catheter was inserted and drained 800 mL of bloody urine. A contrast-enhanced computed tomography scan was ordered that showed a 1.1-cm hypervascular tumor in the lower pole of right kidney, with active bleeding and rupture into the adjacent collecting system. Active renal tumor bleeding or renal AVM was suspected. The patient was transferred to a tertiary medical center where right renal artery angiography was arranged and disclosed an AVM with aneurysm formation at the right renal lower pole. Transarterial embolization was performed immediately to embolize the 3 feeders of the AVM.
Renal AVM is a rare but potentially life-threatening cause of massive hematuria. Delayed or missed diagnosis is possible because renal AVM may present with symptoms like urinary tract infection, especially in young females. Renal artery angiography is the diagnosis of choice, and emergent transarterial embolization is now the standard of treatment.
Long-Term Outcomes of Selective Renal Artery Embolization for Renal Arteriovenous Fistulae with Dilated Venous Sac
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To retrospectively evaluate the role of selective renal artery embolization for renal arteriovenous fistulae (AVFs) with dilated venous sac.
Between 2002 and 2015, 14 patients (7 men and 7 women; mean age, 60 years) with a single renal AVF with dilated venous sac underwent selective renal artery embolization. Three patients presented with gross hematuria, 4 presented with occult blood in urine, and 1 presented with chronic heart failure. Five patients had a history of renal biopsy or partial nephrectomy. Embolic agents used included pushable fibered coils, detachable microcoils, hydrogel coils, N-butyl 2-cyanoactylate, and/or absolute ethanol. Technical success was defined as complete angiographic occlusion of the renal AVF without visualization of the venous sac. Clinical success was defined as the disappearance of the AVF on ultrasound and contrast-enhanced computed tomography, without any symptoms.
Fifteen sessions of selective renal artery embolization were performed. Technical success was achieved in 13 sessions (86.7%). Clinical success was achieved in 13 patients (92.9%) after a mean follow-up of 48 months (range, 6-155 months). Two major complications occurred—renal vein thrombosis (n = 1) and renovascular hypertension (n = 1)—and were successfully managed with warfarin and an angiotensin-II receptor blocker, respectively. The former patient required re-embolization because of recanalization. No significant changes were observed in the mean serum creatinine level (.86 mg/dL vs .85 mg/dL; P = .67) and the mean estimated glomerular filtration rate (66.0 mL/min/1.73m² vs 67.4 mL/min/1.73m²; P = .4) after 6 months.
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Renal atriovenous malformation (AVM) is an abnormal communication between the renal blood vessels in which the arterial and venous circulation communicate with each other bypassing capillary bed.1
Transarterial embolisation for congenital renal arteriovenous malformations improves clinical condition even with partial obliteration
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The complete obliteration rate was 56.3%, and the clinical success rate was 87.5% over a median follow-up period of 398.5 days. PubMed was searched for relevant English-language publications that appeared between 1998 and 2017; seven case series describing the use of TAE to treat CRAVM were identified (Table 2).6–12 Although it is difficult to compare studies because the definitions of clinical success varied, the results seem comparable to those reported previously.6–12
To evaluate the efficacy and safety of transarterial embolisation (TAE), used to treat congenital renal arteriovenous malformations (CRAVMs).
The medical records were searched retrospectively to identify patients who underwent TAE to treat CRAVM from January 2003 to August 2015. Patient demographics, clinical presentations, and imaging findings were reviewed. TAE outcomes, including complete or partial obliteration, clinical success, complications, renal function changes, and relapse of symptoms or signs after the final TAE, were assessed.
Over the 12-year period, 16 patients (nine male, seven female; median age, 47 years) who underwent 21 TAE procedures to treat 16 CRAVMs were enrolled in the study. The most common clinical presentation was haematuria (81.3%). Thirteen patients (81.3%) had cirsoid and three (18.7%) had aneurysmal CRAVMs. Of the 16 CRAVMs, 11 (68.8%) were peripheral, four (25%) were central, and one (6.3%) was both peripheral and central. The complete obliteration rate was 56.3%. The clinical success rate was 87.5% over a median follow-up period of 398.5 days. Two (9.5%) major complications and 14 (66.7%) minor complications were encountered. No statistically significant change in renal function was evident after TAE.
TAE was safe and effective when used to treat CRAVM; the complication profile was acceptable and renal function was preserved. TAE improved the clinical condition of CRAVM patients even when obliteration was only partial.
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To evaluate effectiveness and safety of embolization of congenital renal arteriovenous malformations (AVMs) using ethanol and/or coil according to angiographic type.
Between August 2010 and October 2015, 11 patients (13 sessions; 10 women and 1 man; mean age, 50.8 y) with congenital renal AVMs were treated using ethanol and/or coils via 2 approaches (transarterial access or direct puncture). Demographics, clinical findings, diagnostic modalities, angiographic types, technical and clinical success rates, and complications were reviewed. Renal AVMs were classified into 3 angiographic types, and treatment was based on this classification.
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Embolization of congenital renal AVMs via transarterial or direct percutaneous approaches using ethanol and/or coils based on a simple angiographic classification was safe and effective and elicited good outcomes. Most of the patients with congenital renal AVMs were women.

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Transarterial embolisation of renal arteriovenous malformation: safety and efficacy in 24 patients with follow-up

Highlights

Aim

Materials and methods

Results

Conclusion

Introduction

Section snippets

Patients

Patient characteristics

Discussion

Acknowledgments

J Urol

J Urol

J Urol

Urology

J Vasc Interv Radiol

J Urol

J Urol

J Vasc Interv Radiol

J Vasc Interv Radiol

The role of transarterial embolization in the management of hematuria secondary to congenital renal arteriovenous malformations

Urol Int