IMAGING

Blunt renal trauma: minimally invasive management with microcatheter embolization - experience in nine patients
Hans-Peter Dinkel H-P, Danuser H, Triller J
Departments of Diagnostic Radiology and Urology, University of Bern, Inselspital, Bern, Switzerland
Radiology 2002; 223:723-30

• Purpose: To evaluate superselective embolization therapy for the management of arterial damage in patients with severe renal trauma.
• Materials and Methods: Nine consecutive patients with renovascular injuries after blunt trauma underwent superselective embolization. Six patients had pseudoaneurysms or traumatic arteriovenous fistulas. Three patients had frank, uncontained extravasations (2 shattered kidneys, 1 complete pedicle avulsion) and were treated immediately after admission. Two patients were hemodynamically unstable. All patients underwent embolization with 3F coaxial microcatheters and polyvinyl alcohol particles (n=2) or 0.018-inch platinum microcoils (n=7). Procedural and medical success and complications (postembolization syndrome, abscess, permanent serum creatinine elevation, hypertension) were retrospectively assessed from the patients’ records. Mean clinical follow-up was 11.9 months (range, 1–50 months).
• Results: In all cases, bleeding was effectively controlled with superselective embolization in a single session. There was no procedure-related loss of renal tissue in 8 cases; in 1 patient, a lower pole remnant of 20% of viable ipsilateral parenchyma was lost due to the procedure. In 1 patient, a coil migrated into a lumbar artery without causing clinical consequences. None of the patients developed abscess, hypertension, or procedure-related impairment of renal function.
• Conclusion: Superselective embolization may be used for effective, minimally invasive control of active renovascular bleeding.
  
  
• Editorial Comment
  The choice of treatment (surgical or conservative) for major renal trauma still remains controversial, but in patients with hemodynamic stability, conservative treatment is increasingly accepted as the preferred approach to most renal injuries including grades III and IV. Recent studies have been shown a higher nephrectomy rate in the case of primary surgical intervention compared to conservative management (1). Another important point to consider is that the conservative treatment is very well accepted because there is no increase of the immediate or long-term morbidity with this approach. When the patient present with injuries to the vascular pedicle, avulsion of the renal pelvis or life-threatening hemodynamic instability (Grade-V renal trauma), surgical treatment is usually indicated. Penetrating and iatrogenic renal vascular lesion (the latter usually due to percutaneous renal biopsy, percutaneous nephrolithotripsy or development of postoperative AV- fistula) has been treated by percutaneous superselective embolization with Gelfoam particles or micro-coils with prompt effect and minor adverse effect. The authors call the attention for the utility of this technique also for patients with noniatrogenic and blunt renal trauma, particularly in children. They concluded that superselective embolization should be considered a therapeutic option in patients with noniatrogenic and blunt renal trauma, in those institutions where well-trained interventional radiologist and technicians can be quickly available on a 24-hour basis.

Reference
1. Schmidlin FR, Rohner S, Hadaya K: The conservative treatment of major kidney injuries. Ann Urol 1997; 31:246-52.

Dr. Adilson Prando
Department of Radiology
Vera Cruz Hospital
Campinas, São Paulo, Brazil