Hemorrhagic complications after percutaneous nephrolithotomy: angiographic diagnosis and management by transcatheter arterial embolization

Fornazari, Vinicius Adami Vayego; Santos, Rômulo Florêncio Tristão; Nunes, Thiago Franchi; Perrella, Rodrigo; Freire, Tiago Magalhães; Vicentini, Fabio Carvalho; Claro, Joaquim Francisco de Almeida; Szejnfeld, Denis

doi:10.1590/0100-3984.2019.0130

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Original Article • Radiol Bras 53 (6) • Nov-Dec 2020 • https://doi.org/10.1590/0100-3984.2019.0130 copy

Hemorrhagic complications after percutaneous nephrolithotomy: angiographic diagnosis and management by transcatheter arterial embolization

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To identify the main hemorrhagic complications after percutaneous nephrolithotomy, as well as the results obtained with transcatheter arterial embolization (TAE) at an interventional radiology center.

Materials and Methods:

This was a retrospective analysis of patients undergoing TAE for the treatment of hemorrhagic complications after percutaneous nephrolithotomy. All patients underwent computed tomography angiography (CTA).

Results:

We evaluated a total of nine patients. At emergency department readmission, the most common symptom was macroscopic hematuria, which was seen in five patients. Three patients had an isolated pseudoaneurysm, two had a pseudoaneurysm together with active bleeding (perirenal hematoma), and one had a pseudoaneurysm together with arteriocalyceal fistula. Arteriovenous fistula was diagnosed in three patients and was not seen in combination with other vascular lesions. We did not identify arteriocalyceal fistula in isolation. Five patients underwent TAE with 6 × 15 mm and 6 × 20 mm microcoils. Four patients underwent TAE with n-butyl-2-cyanoacrylate and ethiodized oil. Follow-up CTAs revealed no complications.

Conclusion:

Because of its high diagnostic accuracy, CTA provides the interventional radiologist with valuable data for individualized therapeutic planning. The TAE procedure is safe and effective. It can therefore be used as a first-line treatment for hemorrhagic complications resulting from percutaneous renal procedures.

Keywords:
Nephrolithotomy, percutaneous; Aneurysm, false; Arteriovenous fistula; Embolization, therapeutic/methods; Radiology, interventional; Computed tomography angiography

Patient	Operative time	Laterality	Location of puncture (calyx)	Supracostal puncture	Number of punctures	Hemoglobin pre-PCNL (g/dL)	Hemoglobin post-PCNL (g/dL)	Transfusion	ΔSerum creatinine (mg/dL)
1	101 min	Right	Lower	Yes	2	12.1	10.5	No	0.2
1	101 min	Right	Upper	Yes	2	12.1	10.5	No	0.2
2	80 min	Right	Lower	No	1	11.2	8.1	Yes, before endovascular treatment	1.0
3	90 min	Right	Lower	No	2	11.0	8.8	Yes, before endovascular treatment	0.8
3	90 min	Right	Middle	No	2	11.0	8.8	Yes, before endovascular treatment	0.8
4	130 min	Left	Lower	Yes	2	13.0	11.1	No	0.3
4	130 min	Left	Upper	Yes	2	13.0	11.1	No	0.3
5	50 min	Right	Lower	No	1	13.9	11.8	No	0.5
6	60 min	Left	Middle	No	1	13.6	11.9	No	0.5
7	60 min	Left	Lower	Yes	2	14.1	12.4	Yes, before endovascular treatment	0.7
7	60 min	Left	Middle	Yes	2	14.1	12.4	Yes, before endovascular treatment	0.7
8	185 min	Right	Lower	Yes	4	13.8	9.7	Yes, before endovascular treatment	0.8
			Middle
			Middle
			Upper
9	135 min	Right	Lower	Yes	3	12.0	10.2	No	0.8
			Lower
			Upper

Patient	Age (years)	Gender	Symptoms and indication for CTA	CHF or pulmonary embolism
1	42	Male	Macroscopic hematuria	Absent
2	75	Male	Acute flank pain	Absent
3	55	Female	Macroscopic hematuria	Absent
4	64	Male	Macroscopic hematuria	CHF
5	34	Male	Drop in hemoglobin	Absent
6	61	Female	Acute flank pain	Absent
7	53	Female	Macroscopic hematuria	Absent
8	44	Male	Macroscopic hematuria	Absent
9	49	Female	Acute flank pain	Absent

Patient	Iatrogenic renal vascular lesion(s)			Embolization procedure
Patient	Type	Location	Number and size	Agents employed	Parenchymal loss
1	Low flow AVF	Right kidney, lower pole	1 AVF	Histoacryl + Lipiodol	10–25%
2	Pseudoaneurysm and perirenal hematoma	Right kidney, lower pole	1 pseudoaneurysm (22 mm)	Histoacryl + Lipiodol	5–10%
3	Pseudoaneurysm and ACF	Right kidney, middle segment	1 pseudoaneurysm (13 mm), 1 AVF	3 coils (6 × 20 mm)	< 5%
4	High flow AVF (CHF)	Left kidney, middle segment	1 AVF	2 coils (6 × 20 mm)	5–10%
4	High flow AVF (CHF)	Left kidney, middle segment	1 AVF	2 coils (6 × 15 mm)	5–10%
5	Low flow AVF	Right kidney, upper pole	1 AVF	2 coils (6 × 15 mm)	< 5%
6	Pseudoaneurysm	Left kidney, upper pole	1 pseudoaneurysm (30 mm)	Histoacryl + Lipiodol	5–10%
7	Pseudoaneurysm and perirenal hematoma	Left kidney, middle segment	1 pseudoaneurysm (15 mm)	2 coils (6 × 15 mm)	< 5%
8	Pseudoaneurysm	Right kidney, middle segment	1 pseudoaneurysm (18 mm)	3 coils (6 × 15 mm)	< 5%
9	Pseudoaneurysm	Right kidney, lower pole	1 pseudoaneurysm (20 mm)	Histoacryl + Lipiodol	5–10%

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[1] Correspondence: Dr. Vinicius Adami Vayego Fornazari. Radiologia Intervencionista e Cirurgia Endovascular - EPM-Unifesp. Rua Napoleão de Barros, 800, Vila Clementino. São Paulo, SP, Brazil, 04024-002. Email: drviniciusfornazari@rainter.com.br.