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Management of Hemorrhage Secondary to Renal Angiomyolipoma with Selective Arterial Embolization
Vol. 117, January THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1977 by The Williams & Wilkins Co.
MANAGEMENT OF HEMORRHAGE SECONDARY TO RENAL ANGIOMYOLIPOMA WITH SELECTIVE ARTERIAL EMBOLIZATION J. DAVID MOORHEAD,* PEGGY FRITZSCHE
AND
HENRY L. HADLEY
From the Departments of Urology and Radiology, Loma Linda University School of Medicine, Loma Linda, California
ABSTRACT
Percutaneous transcatheter arterial embolization was used to manage renal hemorrhage secondary to an angiomyolipoma in a solitary kidney. Angiography 3 months after the embolization showed a marked decrease in the mass and vascularity. There was no evidence of hypertension or renal failure following embolization. The efficacy of selective arterial embolization with autologous clot or foreign particles for the control of renal hemorrhage or for infarction of malignant tissues has been reported previously.'· 2 Herein we report on the use of embolization as an alternative to surgery in a patient with a solitary kidney. Interventional angiography avoided surgery with possible nephrectomy and long-term dialysis. CASE REPORT
J. H., a 27-year-old woman, presented with a painful left abdominal mass. Physical examination revealed a 15 cm. left abdominal mass, subungual fibromas and skin lesions consist-
cent and creatinine 0.4 mg. per cent. An excretory urogram showed a large left renal mass and absent right kidney. Renal arteriography demonstrated a 30 by 17 cm. vascular lower pole mass associated with an approximately 6 cm. perinephric hematoma (fig. 1). The left upper pole was responsible for the majority of the renal function. The initial hospital therapy was conservative. Fluid and blood replacement was required because of continuing hemorrhage. Subselective transcatheter embolization of multiple left lower pole arterial branches with small particles of gelfoam was performed 6 days later. The patient had no immediate complications following embolization. Temperatures of 102.SF were treated with appropriate
Fm. 1. Selective left renal arteriogram. A, accessory upper pole renal artery. Collecting system is distorted by angiomyolipomatosis. Lower pole is displaced medially by perinephric hematoma that is outlined laterally by displaced capsular artery (arrows). B, main renal artery (early phase). There are neovascular vessels and aneurysms clustered typical for angiomyolipoma. C, main renal artery (late phase). Non-homogeneous pattern of tumor extends across midline and reflects mixed mesodermal components of fat, smooth muscle and vessels in varying proportions.
ent with adenoma sebaceum. History included hospitalization for a similar episode 4 years previously that resulted in a right nephrectomy and subsequent diagnosis of angiomyolipomatosis associated with tuberous sclerosis. Laboratory data included hemoglobin 11.8 gm., blood urea nitrogen 17 mg. per Accepted for publication July 16, 1976. * Requests for reprints: Department of Urology, Loma Linda University, Loma Linda, California 92354. 122
antibiotics in conjunction with medical management of pneumonia. Moderately severe flank pain required narcotic analgesia for approximately 36 hours. Initial post-embolization blood pressure was 140/90 and was 115/60 at the time of discharge from the hospital 2 weeks later. At that time the patient had minimal pain, was able to ambulate without difficulty and had stable renal function. Repeat renal arteriography 3 months later demonstrated a generalized decrease of intrarenal arterial caliber and minimal
EI'liBOUZATION OF RENAL ANGIOMYOLIPOMA
FIG. 2. Selective renal arteriogram 3 months post-embolization. A, early phase shows general diminution of intrarenal vessels and residual neovascularity (black arrow). B, late phase reveals 3 by 6 cm. area of residual tumor extending from lower pole (open arrows).
neovascularity supplying a 3 by 6 cm. area of residual tumor (fig. 2). DISCUSSION
Lesions of the skin, central nervous system, kidney, eyes and lungs are known to be associated with tuberous sclerosis. Renal hamartomas are seen with tuberous sclerosis in at least 50 per cent of cases and may be the only manifestations of the disease. The hamartomas are frequently bilateral and can influence renal function by replacement of renal parenchyma. 3· ' Since there is no conclusive evidence of malignant transformation•. 5 conservative treatment is urged unless massive hemorrhage forces surgical intervention. 6 ' 7 A nephrectomy on the right side in our patient had been done 4 years previously because of massive hemorrhage. If the present episode of hemorrhage had forced surgical treatment the massive size and vascularity of the tumor may have severely complicated partial nephrectomy. Angiography may be helpful in the differentiation of an angiomyolipoma from renal cell carcinoma. Multiple grapelike clusters of aneurysmal interlobar and intralobular arteries, and the absence of arteriovenous shunting are the usual characteristic signs of an angiomyolipoma. 8 Subselective embolization offered immediate control of hemorrhage in our patient with continued perfusion of adjacent tissue responsible for maintaining adequate renal function. Gelfoam particles were selected because they produce permanent occlusion secondary to perivascular fibrosis. 2 The absence of arteriovenous channels decreased the risk of accidental
systemic embolization. Subselective catheter position and contrast monitoring were used to prevent reflux of embolic particles. Fever and pain are expected sequelae of embolization and were managed clinically without difficulty. It is noteworthy that significant hemorrhage secondary to extensive angiomyolipomatosis of a solitary kidney was controlled with embolization. It is hoped that recurrent hemorrhage can be similarly managed. REFERENCES
1. Chuang, V. P., Reuter, S. R., Walter, J., Foley, W. D. and
2.
3. 4. 5.
6. 7.
8.
Bookstein, J. J.: Control of renal hemorrhage by selective arterial embolization. Amer. J. Roentgen., 125: 300, 1975. Goldstein, H. M., Medellin, H., Beydoun, M. T., Wallace, S., Ben-Menachem, Y., Bracken, R. B. and Johnson, D. E.: Transcatheter embolization of renal cell carcinoma. Amer. J. Roentgen., 123: 557, 1975. Medley, B. E., McLeod, R. A. and Houser, 0. WI.: Tuberous sclerosis. Sem. Roentgen., H: 35, 1976. Chonko, A. M., \Neiss, S. M., Stein, J. H. and Ferris, T. F.: Renal involvement in tuberous sclerosis. Amer. J. IV!ed., 56: 124, 1973. Farrow, G. M., Harrison, E. G., Utz, D. C. and Jones, D. R.: Renal angiomyolipoma: a clinicopathologic study of 32 cases. Cancer, 22: 564, 1968. McCullough, D. C.: Renal hamartoma. Urology, 4: 235, 1974. Charlot-Charles, J. and Jones, G. W.: Renal angiomyolipoma associated with tuberous sclerosis. Review of the literature. Urology, 3: 465, 1974. Viamonte, M., Jr., Ravel, R., Politano, V. and Bridges, B.: Angiographic findings in a patient with tuberous sclerosis. Amer. J. Roentgen., 98: 723, 1966.
Printed in U.S.A.
Copyright© 1977 by The Williams & Wilkins Co.
MANAGEMENT OF HEMORRHAGE SECONDARY TO RENAL ANGIOMYOLIPOMA WITH SELECTIVE ARTERIAL EMBOLIZATION J. DAVID MOORHEAD,* PEGGY FRITZSCHE
AND
HENRY L. HADLEY
From the Departments of Urology and Radiology, Loma Linda University School of Medicine, Loma Linda, California
ABSTRACT
Percutaneous transcatheter arterial embolization was used to manage renal hemorrhage secondary to an angiomyolipoma in a solitary kidney. Angiography 3 months after the embolization showed a marked decrease in the mass and vascularity. There was no evidence of hypertension or renal failure following embolization. The efficacy of selective arterial embolization with autologous clot or foreign particles for the control of renal hemorrhage or for infarction of malignant tissues has been reported previously.'· 2 Herein we report on the use of embolization as an alternative to surgery in a patient with a solitary kidney. Interventional angiography avoided surgery with possible nephrectomy and long-term dialysis. CASE REPORT
J. H., a 27-year-old woman, presented with a painful left abdominal mass. Physical examination revealed a 15 cm. left abdominal mass, subungual fibromas and skin lesions consist-
cent and creatinine 0.4 mg. per cent. An excretory urogram showed a large left renal mass and absent right kidney. Renal arteriography demonstrated a 30 by 17 cm. vascular lower pole mass associated with an approximately 6 cm. perinephric hematoma (fig. 1). The left upper pole was responsible for the majority of the renal function. The initial hospital therapy was conservative. Fluid and blood replacement was required because of continuing hemorrhage. Subselective transcatheter embolization of multiple left lower pole arterial branches with small particles of gelfoam was performed 6 days later. The patient had no immediate complications following embolization. Temperatures of 102.SF were treated with appropriate
Fm. 1. Selective left renal arteriogram. A, accessory upper pole renal artery. Collecting system is distorted by angiomyolipomatosis. Lower pole is displaced medially by perinephric hematoma that is outlined laterally by displaced capsular artery (arrows). B, main renal artery (early phase). There are neovascular vessels and aneurysms clustered typical for angiomyolipoma. C, main renal artery (late phase). Non-homogeneous pattern of tumor extends across midline and reflects mixed mesodermal components of fat, smooth muscle and vessels in varying proportions.
ent with adenoma sebaceum. History included hospitalization for a similar episode 4 years previously that resulted in a right nephrectomy and subsequent diagnosis of angiomyolipomatosis associated with tuberous sclerosis. Laboratory data included hemoglobin 11.8 gm., blood urea nitrogen 17 mg. per Accepted for publication July 16, 1976. * Requests for reprints: Department of Urology, Loma Linda University, Loma Linda, California 92354. 122
antibiotics in conjunction with medical management of pneumonia. Moderately severe flank pain required narcotic analgesia for approximately 36 hours. Initial post-embolization blood pressure was 140/90 and was 115/60 at the time of discharge from the hospital 2 weeks later. At that time the patient had minimal pain, was able to ambulate without difficulty and had stable renal function. Repeat renal arteriography 3 months later demonstrated a generalized decrease of intrarenal arterial caliber and minimal
EI'liBOUZATION OF RENAL ANGIOMYOLIPOMA
FIG. 2. Selective renal arteriogram 3 months post-embolization. A, early phase shows general diminution of intrarenal vessels and residual neovascularity (black arrow). B, late phase reveals 3 by 6 cm. area of residual tumor extending from lower pole (open arrows).
neovascularity supplying a 3 by 6 cm. area of residual tumor (fig. 2). DISCUSSION
Lesions of the skin, central nervous system, kidney, eyes and lungs are known to be associated with tuberous sclerosis. Renal hamartomas are seen with tuberous sclerosis in at least 50 per cent of cases and may be the only manifestations of the disease. The hamartomas are frequently bilateral and can influence renal function by replacement of renal parenchyma. 3· ' Since there is no conclusive evidence of malignant transformation•. 5 conservative treatment is urged unless massive hemorrhage forces surgical intervention. 6 ' 7 A nephrectomy on the right side in our patient had been done 4 years previously because of massive hemorrhage. If the present episode of hemorrhage had forced surgical treatment the massive size and vascularity of the tumor may have severely complicated partial nephrectomy. Angiography may be helpful in the differentiation of an angiomyolipoma from renal cell carcinoma. Multiple grapelike clusters of aneurysmal interlobar and intralobular arteries, and the absence of arteriovenous shunting are the usual characteristic signs of an angiomyolipoma. 8 Subselective embolization offered immediate control of hemorrhage in our patient with continued perfusion of adjacent tissue responsible for maintaining adequate renal function. Gelfoam particles were selected because they produce permanent occlusion secondary to perivascular fibrosis. 2 The absence of arteriovenous channels decreased the risk of accidental
systemic embolization. Subselective catheter position and contrast monitoring were used to prevent reflux of embolic particles. Fever and pain are expected sequelae of embolization and were managed clinically without difficulty. It is noteworthy that significant hemorrhage secondary to extensive angiomyolipomatosis of a solitary kidney was controlled with embolization. It is hoped that recurrent hemorrhage can be similarly managed. REFERENCES
1. Chuang, V. P., Reuter, S. R., Walter, J., Foley, W. D. and
2.
3. 4. 5.
6. 7.
8.
Bookstein, J. J.: Control of renal hemorrhage by selective arterial embolization. Amer. J. Roentgen., 125: 300, 1975. Goldstein, H. M., Medellin, H., Beydoun, M. T., Wallace, S., Ben-Menachem, Y., Bracken, R. B. and Johnson, D. E.: Transcatheter embolization of renal cell carcinoma. Amer. J. Roentgen., 123: 557, 1975. Medley, B. E., McLeod, R. A. and Houser, 0. WI.: Tuberous sclerosis. Sem. Roentgen., H: 35, 1976. Chonko, A. M., \Neiss, S. M., Stein, J. H. and Ferris, T. F.: Renal involvement in tuberous sclerosis. Amer. J. IV!ed., 56: 124, 1973. Farrow, G. M., Harrison, E. G., Utz, D. C. and Jones, D. R.: Renal angiomyolipoma: a clinicopathologic study of 32 cases. Cancer, 22: 564, 1968. McCullough, D. C.: Renal hamartoma. Urology, 4: 235, 1974. Charlot-Charles, J. and Jones, G. W.: Renal angiomyolipoma associated with tuberous sclerosis. Review of the literature. Urology, 3: 465, 1974. Viamonte, M., Jr., Ravel, R., Politano, V. and Bridges, B.: Angiographic findings in a patient with tuberous sclerosis. Amer. J. Roentgen., 98: 723, 1966.