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Trans-Arterial Embolization of Renal Cell Carcinoma Prior to Percutaneous Ablation: Technical Aspects, Institutional Experience, and Brief Review of the Literature

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Trans-Arterial Embolization of Renal Cell Carcinoma Prior to Percutaneous Ablation: Technical Aspects, Institutional Experience, and Brief Review of the Literature Surgical Technique Curr Urol 2018;12:43–49 Received: November 25, 2017 DOI: 10.1159/000447230 Accepted: November 29, 2017 Published online: June 30, 2018 Trans-Arterial Embolization of Renal Cell Carcinoma prior to Percutaneous Ablation: Technical Aspects, Institutional Experience, and Brief Review of the Literature Andrew J. Gunna Benjamin J. Mullenbachb May M. Poundstonea Jennifer B. Gordetskyc Edgar S. Underwooda Soroush Rais-Bahramid aDivision of Vascular and Interventional Radiology, Department of Radiology; Department of bRadiology, cPathology, and dUrology, University of Alabama at Birmingham, Birmingham, AL, USA Key Words Introduction Renal cell carcinoma • Embolization • Ablation • Interventional radiology Renal cell carcinoma (RCC) accounts for approxi- mately 4% of all cancer cases in the United States [1]. Abstract Its incidence, however, is increasing secondary to the This report describes the technical aspects of trans-arterial identification of renal tumors in patients who are im- embolization (TAE) of renal cell carcinoma prior to percuta- aged for other reasons [2–5]. One unintentional benefit neous ablation. All patients (n = 11) had a single renal mass of these incidentally-detected renal masses is that they (mean tumor diameter = 50.2 mm; range: 28–84 mm). Selec- are typically smaller, of lower grade, and have been as- tive TAE was performed via the common femoral artery. Em- sociated with longer disease-free survival [6]. Given bolic materials included: particles alone (n = 4), coils alone this smaller size, less invasive treatment options such (n = 1), particles + ethiodized oil (n = 2), particles + coils (n as partial nephrectomy, laparoscopic ablation, and per- = 1), ethiodized oil + ethanol (n = 2), and particles + ethanol cutaneous ablation are being used as safe and effective (n = 1). All embolizations were technically successful and no alternatives to radical nephrectomy [6–12]. Yet, many complications have been reported. After embolization, 10 patients are not optimal operative candidates or may patients underwent cryoablation while 1 patient underwent wish to avoid traditional surgery, thus percutaneous ab- microwave ablation. Ablations were technically successful in lation offers patients a non-surgical, minimally-invasive 10 of the 11 patients. Only 3 minor complications were iden- option with similar outcomes to partial nephrectomy in tified but none required treatment. No adverse effect on the T1a RCC [13]. The outcomes and complications asso- patient’s glomerular filtration rate was seen from the addi- ciated with percutaneous ablation in RCC are dependent tional procedure (p = 0.84). TAE of renal cell carcinoma prior on tumor size, geometry, and vascularity [14, 15]. Since to percutaneous ablation is safe and technically-feasible. RCC is a highly vascular tumor, bleeding is one of the major complications seen after percutaneous ablation © 2018 The Author(s) Published by S. Karger AG, Basel [16]. Nonetheless, the vascularity of RCC could poten- tially provide an intriguing target for adjunctive therapy © 2018 The Author(s) Andrew J. Gunn Published by S. Karger AG, Basel Division of Vascular and Interventional Radiology Fax +41 61 306 12 34 University of Alabama at Birmingham E-Mail [email protected] This article is licensed under the Creative Commons Attribution- 619 19th St S, NHB 623 www.karger.com NonCommercial-NoDerivatives 4.0 International License (CC BY- Birmingham, AL–35249 (USA) NC-ND) (http://www.karger.com/Services/OpenAccessLicense). Usage and distribution for commercial purposes as well as any dis- E-Mail [email protected] tribution of modified material requires written permission. as several reports in the literature describe trans-arterial oral steroids. Blood thinning medications should be held embolization (TAE) of RCC prior to percutaneous abla- according to published guidelines [25]. The pre-proce- tion as a means to improve tumor localization, increase dural consultation also provides the IR with the oppor- tumor ischemia, and decrease post-procedural bleeding tunity to determine whether the patient will be able to [17–24]. Therefore, the purpose of this manuscript is to proceed with the procedures using moderate conscious provide practitioners a guide to the technical aspects of sedation or will require general anesthesia. The majority these procedures, discuss our institutional outcomes, and of patients should be able to comfortably tolerate both provide a brief review of the literature so that they may procedures with moderate conscious sedation but an in- best determine which patients could benefit from this dividualized approach for each patient is recommended. treatment approach. After a discussion of these items with the patient, in- formed consent is obtained. Technical Aspects Procedural Technique for TAE of the Renal Mass The patient is supine on the angiography table. Pro- Patient Selection phylactic antibiotics are not routinely used [26]. The A multi-disciplinary clinic would be an optimal lo- arterial access site (typically the right common femoral cation for the patient to receive concurrent consultation artery) is prepared and draped in standard sterile fashion. from a urologic oncologist and interventional radiolo- At our institution, we gain vascular access under sono- gist. Yet, patients are typically referred from urology to graphic guidance using a micro-introducer kit after the interventional radiology (IR) for evaluation of potential instillation of lidocaine for local anesthesia. After access percutaneous renal tumor ablation. Once referred, the is obtained and a vascular sheath is placed, a flush cathe- patient should ideally have a consultation with the treat- ter (OmniTM Flush, AngioDynamics, Latham, NY, USA) ing IR where the risks, benefits, and alternatives can be is then inserted over the wire and an aortogram is ob- explained in detail. This also provides an opportunity to tained (fig. 1A). The purpose of the aortogram is to iden- thoroughly review the pre-procedural imaging. Special tify the location of the renal arteries and assess for any attention should be paid to the presence of any addi- vascular anomalies, such as supernumerary renal arter- tional renal masses, supernumerary renal arteries, renal ies. The flush catheter is then exchanged over a wire for atherosclerotic disease, abdominal aortic aneurysms, or a diagnostic catheter that is used to select the appropriate peripheral vascular disease that may make TAE more renal artery. The authors prefer a reverse curve catheter, challenging. Moreover, a safe percutaneous route for the such as the 5F SOS 2 OmniTM (AngioDynamics, Latham, ablation that avoids damaging normal structures such as NY, USA) or 5F Sim 1 (Terumo, Somerset, NJ, USA), the renal pelvis, ureter, inferior vena cava, aorta, and ad- although many other diagnostic catheters would also suf- jacent bowel should be identified. While many of these fice. Once the appropriate renal artery is selected with obstacles can be overcome to safely perform both TAE the diagnostic catheter, angiography is again performed and percutaneous ablation, it is advisable to develop a in order to identify the tumor, assess its vascularity, and plan prior to the date of the procedure and make the pa- plot the appropriate course for sub-selection of the renal tient aware of what case specific difficulties may arise. arterial system (fig. 1B). The renal artery or arteries sup- The patient’s laboratory results are reviewed with par- plying the tumor are then selected using a micro-catheter ticular attention to the platelets (should be > 50 × 103/ and micro-wire. There are many combinations of micro- µl), international normalized ratio (should be < 1.5), catheters and micro-wires that would be appropriate for and glomerular filtration rate (GFR). If the patient has use in this situation; although, the authors would advise compromised renal function, one could consider using using a straight-tipped, high-flow (2.7F or 2.8F) micro- generous intravenous hydration with normal saline prior catheter in order to easily accommodate the embolic to and after the procedures. Patients should be asked re- material. Once the renal artery or arteries supplying the garding their medication history, especially with regard tumor are selected, angiography is again performed to to any blood-thinning medications, and allergies, includ- confirm catheter location prior to embolization (fig. 1C). ing those to intravenous contrast media. Patients with The choice of embolic material is operator dependent an allergy to intravenous contrast can be pre-medicated as there is insufficient evidence to say that any one par- prior to TAE according to institutional protocols which ticular embolic approach is superior in RCC [17–24]. typically include a combination of diphenhydramine and Specific types of embolics are discussed to provide the 44 Curr Urol 2018;12:43–49 Gunn/Mullenbach/Poundstone/Gordetsky/ Underwood/Rais-Bahrami Fig. 1. A 58-year-old male with a 3.9 cm RCC in the upper pole of the right kidney. A Digital subtraction angiography (DSA) of the aorta demonstrates a single right renal artery (white arrow) and single left renal artery (black arrow) without evidence renal arterial disease or arterial anomaly. B DSA of the main right renal artery through a diagnostic catheter (white arrow) shows a branch artery (white arrow- head) supplying the RCC in the upper pole (black arrow). The RCC demonstrates neo-vascularity and vascular irregularities. C DSA with the tip of the
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