The Tangential Extraperitoneal Retrorenal Approach in Kidney Transplant Biopsy: An Observational Study to Assess Complication and Adequacy Rates

Introduction: Ultrasound-guided percutaneous kidney allograft biopsy is the gold-standard for pathology work-up. Recent studies postulate better safety and efficacy for tangential approaches, however, there is no recommendation regarding biopsy needle path. In this context, we previously described the unified tangential extraperitoneal retrorenal (TER) approach for standard allograft biopsy.Methods: A single-center retrospective observational study evaluated safety and efficacy of the TER biopsy approach among 250 patients that underwent 330 ultrasound-guided kidney transplant biopsies between January 2011 and May 2020.Results: The overall major complication rate was 0.56% per biopsy attempt (1.21% per biopsy) including blood transfusion, arterial embolization and bladder catheterization for gross hematuria in 0.28, 0.14 and 0.14% of biopsy attempts, respectively (0.61, 0.30 and 0.30% of biopsies, respectively). Minor complications included subcapsular and/or perinephric hematoma, superficial bleeding, arteriovenous fistula and gross hematuria in 12.6, 3.0, 2.5 and 1.4% of biopsy attempts, respectively (27.0, 6.4, 5.5 and 3.0% of biopsies, respectively). Sample adequacy rate was 86.7%, ranging from 82.2 to 94.1% if one or ≥two cores were analyzed, respectively. Residents and consultants yielded similar complication and adequacy rates.Conclusion: According to current literature, ultrasound-guided TER kidney transplant biopsy is a safe and efficient approach eligible for nephrology training.

Extradural thoracic nerve root hemangioblastoma approached by a combined posterior thoracic spine and video-assisted thoracoscopic surgery: A case report

Background: Hemangioblastomas commonly occur in the posterior fossa and are typically attributed to sporadic or familial Von Hippel–Lindau disease. Spinal hemangioblastomas, found in 7–10% of patients, are usually located within the cord (i.e., intramedullary). Here, a 58-year-old male presented with a purely extradural hemangioblastoma involving a spinal root that was surgically excised. Case Description: A 58-year-old male was admitted with a progressive paraparesis and incomplete sensory deficit. The magnetic resonance imaging documented a solid dumbbell-shaped lesion that extended through the left T3-T4 foramen resulting in nerve root and spinal cord compression. Following arterial embolization and lesion excision by both neurosurgeons and thoracic surgeons, the patient’s deficits improved. The postoperative computed tomography scan documented complete tumor removal, and the neuropathology revealed a hemangioblastoma. Conclusion: Here, we describe a 58-year-old male with a purely extradural thoracic foraminal T3-T4 dumbbell-shaped hemangioblastoma successfully treated by both embolization and surgical excision.

Arterial Embolization of Polycystic Kidneys for Heterotopic Transplantation

Introduction: The purpose of this study was to evaluate the efficacy of polycystic kidney embolization, performed to reduce kidney volume before heterotopic kidney transplantation, as this technique could be an alternative to pretransplant nephrectomy. Materials and Methods: All patients who underwent pretransplant embolization of polycystic kidneys were included in a prospective register from June 2014 to February 2020. All patients underwent computed tomography (CT) scan with volumetric reconstruction (OsiriX, Bernex, Switzerland) before embolization and were then followed up at 3 and 6 months after embolization. Primary outcome was percentage of kidney volume reduction. Secondary outcomes were 30 day mortality and morbidity. Results: Thirty-one embolizations performed on 29 patients (medium age = 55.6; 62.1% male) were included between June 2014 and February 2020. All patients were under dialysis before embolization (9 peritoneal dialysis and 20 hemodialysis). Technical success was observed in 96.8% of cases. Mean procedural time was 65 minutes (range = 35–106 minutes) and mean length of in-hospital stay was 3.8 days (range = 3–6 days). A volume reduction allowing a kidney transplant was obtained for 28 patients (96.5%). The mean volume reduction was 39.9% (range = 6.01–68.2). The main observed complication was postembolization pain in 10 cases (32.2%). One patient needed complementary nephrectomy due to insufficient volume reduction. Twenty-three patients (79.3%) received renal transplant during follow-up with a mean delay of 19.5 month (range = 4–54). Conclusion: Polycystic kidney embolization is an effective and safe minimally invasive technique. It can be proposed as the first-choice technique for kidney transplant recipients as an alternative to pretransplantation nephrectomy.

Atypical presentation of fistula dysfunction due to brachial arterial embolization mimicking stroke

Vascular access thrombosis is an important complication with great impact on access patency and, consequently, on a patient’s quality of life and survival. We report the case of a 73-year-old woman with chronic kidney disease on hemodialysis with a radiocephalic arteriovenous fistula on the right arm that was brought to the emergency department with decreased strength in her right arm, ipsilateral hypoesthesia and facial hemi-hypoesthesia. The patient was given a brain computed tomographic scan that did not confirm suspicion of stroke. On re-examination, the patient had new-onset pain at arteriovenous fistula level, and her right arm was cold and pale. The nephrology department was called for arteriovenous fistula evaluation. On physical examination, her forearm fistula had a decreased thrill and arm elevation exacerbated its paleness. A bedside ultrasound was performed for arteriovenous fistula assessment. Doppler ultrasound revealed: partial thrombosis at brachial bifurcation, a flow of 80–105 mL/min at brachial artery level and a radial artery with a damped waveform. Anastomosis and draining vein were permeable. In this case, the diagnosis of acute embolic brachial artery occlusion was made by a fast bedside ultrasound evaluation. The patient underwent thromboembolectomy with Fogarty technique, recovering fistula thrill, radial and cubital pulses. Thromboembolism of the fistula feeding artery is a rare cause of vascular access thrombosis and it is rarely mentioned in the literature. In this report, failure to recognize the upper limb ischemia would have led to delayed treatment, potentially resulting in the fistula’s complete thrombosis and further limb ischemia. We highlight the importance of a diagnosis method like Doppler ultrasound, which allows for rapid evaluation at the patient’s bedside.

Transcatheter Arterial Embolization in A Newborn with Cervical Kaposiform Hemangioendothelioma and Kasabach-Merritt Phenomenon.

We report a case of a 9-day-old newborn who underwent arterial embolization for Kaposiform hemangioendothelioma (KHE) with Kasabach-Merritt phenomenon (KMP), combined with sirolimus treatment, and the outcome was favorable. To the best of our knowledge, there are no case reports of such small infants undergoing arterial embolization to treat KHE. Our successful experience of treating KHE with KMP showed that transcatheter arterial embolization is feasible and can be used as an alternative to surgical resection, even in small infants.

Negative renal angiography with subsequent denied angioembolization: findings in a series of 180 patients at a tertiary interventional uroradiology unit

Background Renal arterial embolization (RAE) is considered to be a safe and effective method for treating a variety of renal lesions and pathology. It is the optimal method not only to stop bleeding, but to preserve renal parenchyma and renal function. Patients who are scheduled to RAE who showed negative catheter angiography with the procedure subsequently denied have a special concern because they are subjected to unnecessary procedure with its complications and didn’t get its benefits. This circumstance is infrequently reported in the literature, and that compelled us to identify the predictors of negative renal angiography findings that would result in a failure to undertake RAE. Results The study included 180 patients (126 males; 70%) with a mean ± SD age of 44 ± 14 years. Iatrogenic causes were the most common indication for RAE (108 of 180; 60%), while spontaneous unknown reasons constituted (17 of 180 patients; 9%). Angiography showed various lesions in 148 patients: pseudoaneurysm (80 of 148; 54%), tumours (28 of 148; 19%), arteriovenous (AV) fistulas (22 of 148; 15%) and both pseudoaneurysm and AV fistulas (18 of 148; 12%). However, in the remaining 32 of 180 patients (18%) no lesions were identified on renal angiography and RAE procedures were not undertaken. On bivariate analysis, neither gender, side of the lesions, haematuria prior to RAE, or renal artery anatomy were predictors for negative angiography. However, the indication for RAE (spontaneous unknown reasons) of renal haemorrhage was the only predictor for negative angiography (9/17 (53%), P = 0.001). Conclusion Patients scheduled for RAE may show negative findings with no lesions on renal angiography. Among the different indications for RAE, patients with spontaneous (unknown) have the highest probability (53%) of being associated with negative renal angiography findings, however, those with renal tumours and post-traumatic causes have a low probability. In those patients with spontaneous (unknown), conservative management should be the initial treatment of choice in order to avoid unnecessary RAE and its associated complications.

Is It Beneficial to Optimize Vital Signs Before Embolization for Pelvic Fractures? A Dilemma Between Resuscitation and Hemostasis

Purpose Adequate resuscitation and definitive hemostasis are both important in the management of hemorrhage related to pelvic fracture. The goal of this study was to analyze the relationship between the amount of blood transfused before transcatheter arterial embolization (TAE) and the clinical outcome later in the disease course. Methods Patients with pelvic fractures who underwent TAE for hemostasis from January 2018 to December 2019 were studied. The characteristics of patients who received blood transfusions of >2 U (1000 mL) and ≤2 U before TAE were compared. The mortality rate, blood transfusion-related complications, and length of stay were compared between these two groups. Results Among the 75 studied patients, 39 (52.0%) received blood transfusions of ≤2 U before TAE, and the other 36 (48.0%) patients received blood transfusions of >2 U before TAE. The incidence rates of systemic inflammatory response syndrome, sepsis, and coagulopathy were significantly higher in the >2 U group (97.2% vs 81.1%, P = .027; 50.0% vs 27.0%, P = .045; and 44.4% vs 5.4%, P < .01, respectively). After nonsurvivors were excluded, the >2 U group had a significantly higher proportion (43.8% vs 14.7%, P < .001) of prolonged intensive care unit (ICU) length of stay (7 days or more) and a longer hospital length of stay (33.8 ± 15.1 vs 21.9 ± 94.0, P < .01) than the ≤2 U group. Pre-TAE blood transfusion >2 U serves as an independent risk factor for prolonged ICU length of stay and increased hospital length of stay. Conclusion Early hemostasis for pelvic fracture-related hemorrhage is suggested to prevent pre-TAE blood transfusion-associated adverse effects of blood transfusion.

Thyroid arterial embolization in a patient with congenital heart disease and refractory amiodarone-induced thyrotoxicosis

Introduction Amiodarone-induced thyrotoxicosis (AIT) can sometimes lead to life-threatening complications, especially in patients with congenital heart disease (CHD). We report the case of a patient with refractory AIT that was successfully treated with thyroid arterial embolization (TAE). Case report A 34-year-old man with complex cyanotic CHD complicated with heart failure (HF), pulmonary hypertension, and supraventricular tachyarrhythmias, was treated with amiodarone since 2013. In March 2019, he presented worsening of his cardiac condition and symptoms of thyrotoxicosis that were confirmed by laboratory assessment. Thiamazole 30 mg/day and prednisolone 40 mg/day were prescribed, but the patient experienced worsening of his cardiac condition with several hospital admissions in the next 5 months, albeit increasing dosages of thionamide and glucocorticoid and introduction of cholestyramine and lithium. Thyroidectomy was excluded due to the severity of thyrotoxicosis, and plasmapheresis was contraindicated due to the cardiac condition. TAE of the four thyroid arteries was then performed with no immediate complications. Progressive clinical and analytical improvement ensued with gradual reduction and suspension of medication with the patient returning to euthyroid state and his usual cardiac condition previous to the AIT. Conclusion For patients with medication refractoriness and whose condition precludes thyroidectomy, embolization of thyroid arteries may be an effective and safe option. Established facts Amiodarone-induced thyrotoxicosis (AIT) can be refractory to a combination therapy of thionamides and glucocorticoids. Restoration of euthyroidism is of paramount importance in heart failure (HF) patients. Emergency thyroidectomy for AIT unresponsive to medical therapy is recommended in patients with severe underlying cardiac disease or deteriorating cardiac function. Novel insights Thyroid arterial embolization (TAE) appeared as a salvage therapy in this patient. To the best of our knowledge, few case reports in the literature have described the embolization of the four thyroid arteries in AIT context. Endovascular embolization techniques are a valuable therapeutic option and can be considered in cases where standard forms of treatment are ineffective or involve unacceptable risks.