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Os autores relatam o caso de uma paciente jovem previamente submetida a nefrectomia direita por apresentar angiomiolipomas renais AMLRs e portadora de dois volumosos angiomiolipomas no rim esquerdo remanescente.
A paciente foi encaminhada pelo urologista para tratamento endovascular. Fonte de financiamento: Nenhuma. The authors report on a case of a young woman who had previously undergone a right nephrectomy due to renal angiomyolipomas, currently presenting voluminous angiomyolipomas of the remaining kidney. Superselective arterial embolization of one tumor located at the inferior renal pole , was conducted successfully. Several attempts at selective catheterization were made to embolize the second angiomyolipoma located at the superior lobe , without jeopardizing a significant amount of the surrounding renal parenchyma, but this ultimately proved not to be feasible.
The procedure and recovery were uneventful. The patient was discharged on the first postoperative day and has been followed for 9 months with no complications. The authors provide a brief review of the indications, technical aspects and complications of endovascular treatment of renal angiomyolipomas and also discuss the advantages of the endovascular approach over surgical resection for this kind of tumor.
Renal angiomyolipomas RAMLs are benign hypervascular tumors that involve a risk of hemorrhagic complications. They are hamartomas and they are composed, in varying proportions, of adipose and muscle tissues and blood vessels.
The treatment options for symptomatic RAMLs are surgical removal or embolization. The role of embolization in the presence of bleeding is already well-established.
However, there is no consensus on when to intervene preventively. The patient was a year-old female with tuberous sclerosis complex, who had undergone a right nephrectomy 10 years previously because of renal angiomyolipomas and was being monitored by a urologist because of the presence of angiomyolipomas in the left kidney.
She was referred for endovascular treatment because three RAMLs had been detected in the left kidney, one in the mid third measuring 1. The decision to treat was based on the fact that the patient only had one kidney and on the sizes and sites of the RAMLs.
Preoperative laboratory test results, including urea and creatinine assays, were within normal limits. Superselective embolization of the arteries feeding the tumors at the upper and lower poles of the kidneay was planned. The procedure was conducted under local anesthesia and sedation, achieved via retrograde puncture of the right common femoral artery and placement of a 5F angiographic introducer.
Pig-tail and curved cobra 2 5F catheters were used to conduct angiographs, via the abdominal aorta and the left renal artery. The angiographs showed that the left kidney was vascularized by a single renal artery and by hypervascularized tumors with extra-renal extensions located at the upper and lower poles of the kidney and with an angiographic appearance compatible with RAMLs.
Although several attempts were made, it did n ot prove possible to achieve catheterization that was sufficiently selective to embolize the subcapsular tumor in the upper pole without subjecting a considerable volume of the adjacent renal parenchyma to ischemia. A decision to abort the procedure was taken. A control angiography showed considerable reduction in vascularization of the RAML in the lower pole Figure 2.
The patient retrurned to the ward for postoperative support, there were no notable intercurrent conditions, and she was discharged on the first postoperative day. Embolization of the renal artery was first described in by Lalli and Peterson, primarily for treatment of hematuria and as paliative treatment for malignant kidney tumors.
As materials have evolved and experience has been accrued with endovascular procedures, indications have come to include a vast spectrum of conditions including angiomyolipomas, vascular malformations, preoperative embolizations with the objective of attenuating intraoperative bleeding, 2 , 6 bleeding caused by iatrogenic injuries percutaneous nephrolithotomy, biopsy, nephrostomy , ruptures of renal masses and penetrating and blunt renal traumas. Retroperitoneal bleeding or hematuria may also occur, and invasion of the renal parenchyma can lead to kidney failure.
One rare manifestation that has been described is pulmonary embolism secondary to invasion of the inferior cava by the RAML.
Ultrasonography USG , computed tomography CT or magnetic resonance imaging MRI are normally sufficient for a diagnosis, since they can identify adipose tissue in the interior of the renal parenchyma.
Calcifications typical of more aggressive tumors are rare in RAMLs. In these cases, MRI enables differential diagnosis. Renal cell carcinomas exhibit a low intensity signal on T1 and a high intensity signal on T2, whereas the opposite is true of fatty tissues. Additionally, in the presence of bleeding, RAMLs should be considered on the list of possible differential diagnoses of renal masses, even when there is no sign of fatty tissues within the lesion, because they could be masked by tumoral hemorrhage.
If X-ray findings are characteristic of an RAML, its hypervascularized nature means that biopsy is only indicated in exceptional circumstances because of the risk of hemorrhage and since there is a minimal possibility that the results will change the therapeutic management chosen. Angiography will show anomalous vascularization, with neovessels and microaneurysms. Criteria for intervention include diameter greater than 4 cm some authors state 3.
Several different studies have demonstrated the efficacy of embolization for treatment and prevention of hemorrhage. The procedure can be performed under local anesthesia, with or without sedation, but some authors believe that the procedure can be conducted more quickly and with greater safety under general anesthesia. A full aortography should be conducted in advance of embolization in order to assess the presence of accessory renal arteries or other arteries associated with vascularization of the tumor.
Considering the diameter of the tumor, it is likely that another attempt will be made at embolization directed specifically at this tumor, depending on the opinion of the treating urologist. Several different embolic agents for treatment of RAMLs have been described in the literature, including particles of polyvinyl alcohol PVA , ethanol, microspheres, gelfoam, coils, 1 - 3 , 6 , 8 lipiodol, 2 , 6 n-butyl-cyanoacrylate adhesive, sotradecol 6 and onyx.
The disadvantage of PVA is that its particles have irregular size and shape, making obstruction of the microcatheter more likely, and the lack of particle uniformity can also cause unsatisfactory penetration of the agent into the more distal portions of the tumor vessels. Calibrated microspheres are easy to handle, diluting them in iodinated contrast and employing the zoom facility during injection makes it possible to monitor the embolization agent, and since they have regular sizes and surfaces, they rarely obstruct the microcatheter.
It was because of these characteristics that this was the agent chosen in this case. Coils should be used with care because once released they block access to more distal segments of the vessel into which they are released and which could be needed for early or late reinterventions.
Ruptures of aneurysms in RAMLs have been reported after coil embolization of distal segments of the vessels in which the aneurysms were located. The theory proposed to explain this is that occluding the vessel distal of the aneurysm increased the pressure on its walls, causing it to rupture. Coils can be released into the aneurysm or a proximal site, with the objective of preventing it from rupturing.
Complications after preventative embolization of RAMLs are rare. Hematoma at the puncture site 2 and migration of the embolization agent causing ischemia of other organs 8 are rare, but can occur. The principal advantage that embolization offers over resection of the tumor is preservation of the functioning renal parenchyma. Postoperatively, reduction of the tumor should not be used as the only parameter for assessing the success of embolization.
Disappearance of the symptoms that were initially present, absence of tumor growth and non-recurrence of hemorrhages should also be considered. Financial support: None. National Center for Biotechnology Information , U. Journal List J Vasc Bras v. J Vasc Bras. Author information Article notes Copyright and License information Disclaimer. Received Jul 19; Accepted May 4. Copyright notice. Resumo Os autores relatam o caso de uma paciente jovem previamente submetida a nefrectomia direita por apresentar angiomiolipomas renais AMLRs e portadora de dois volumosos angiomiolipomas no rim esquerdo remanescente.
Open in a separate window. Figura 1. Figura 2. Footnotes Fonte de financiamento: Nenhuma. Tumor necrosis after preventive embolization of large renal angiomyolipomas. Diagn Interv Imaging. Huang Q, Zhai RY. Embolization of symptomatic renal angiomyolipoma with a mixture of lipiodol and PVA, a mid-term result. Chin J Cancer Res. Renoduodenal fistula after transcatheter embolization of renal angiomyolipoma.
Cardiovasc Intervent Radiol. Spontaneous rupture of a renal angiomyolipoma at 25 weeks of pregnancy treated with transarterial embolization: a case report and review of the literature.
Int J Urol. Renal artery embolization in a gross kidney neoplasm: case report. G Chir. Superselective renal artery embolization in the treatment of iatrogenic bleeding into the urinary tract. Med Sci Monit. Superselective renal artery embolization in the treatment of renal hemorrhage. Ir J Med Sci. Pulmonary embolization as the primary clinical manifestation of giant renal angiomyolipoma.
Ann Thorac Surg. Superselective transcatheter renal artery embolization for the treatment of hemorrhage from non-iatrogenic blunt renal trauma: report of 16 clinical cases. Ther Clin Risk Manag. Author information Copyright and License information Disclaimer. Conflicts of interest: No conflicts of interest declared concerning the publication of this article.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract The authors report on a case of a young woman who had previously undergone a right nephrectomy due to renal angiomyolipomas, currently presenting voluminous angiomyolipomas of the remaining kidney.
Keywords: angiomyolipomas, kidney, therapeutic embolization. PART I: CASE REPORT The patient was a year-old female with tuberous sclerosis complex, who had undergone a right nephrectomy 10 years previously because of renal angiomyolipomas and was being monitored by a urologist because of the presence of angiomyolipomas in the left kidney.
Figure 1. Reconstruction from the computed tomography executed for planning of endovascular treatment. The arrowheads indicate the two larger tumors, located at the upper and lower poles of the kidney; the arrow indicates the arterial pedicle associated with vascularization of the lower pole tumor. Note the absence of the right kidney due to the previous nephrectomy. Figure 2. A Selective arteriography of the kidney prior to embolization; the arrows indicate the target tumors for embolization.
B Superselective arteriography of the pedicle feeding the tumor at the lower pole of the kidney.
Embolização arterial superseletiva para tratamento de angiomiolipoma em paciente com rim único
Angiomyolipomas AMLs are rare benign tumors derived from mesenchymal tissue and composed of varying degrees of adipose tissue, muscle and blood vessels. Renal AMLs RAMLs are the result of a sporadic event, and, in most of cases, the diagnosis is usually incidental, but hemorrhage and shock may be present. During pregnancy, the size of AMLs may increase and they may rupture, probably due to the high expression of hormone receptors, and the increase in maternal circulation and abdominal pressure. The authors present a case of a woman with ruptured RAML submitted to urgent endovascular treatment four days after giving birth by cesarean section. Angiomyolipomas AMLs are rare benign tumors derived from mesenchymal tissue. During pregnancy, there is a predisposition to RAML growth and rupture, 2 probably due to the elevated expression of estrogen receptors and progesterone in these tumors, 9 in addition to increased maternal circulation and abdominal pressure.
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Os autores relatam o caso de uma paciente jovem previamente submetida a nefrectomia direita por apresentar angiomiolipomas renais AMLRs e portadora de dois volumosos angiomiolipomas no rim esquerdo remanescente. A paciente foi encaminhada pelo urologista para tratamento endovascular. Fonte de financiamento: Nenhuma. The authors report on a case of a young woman who had previously undergone a right nephrectomy due to renal angiomyolipomas, currently presenting voluminous angiomyolipomas of the remaining kidney. Superselective arterial embolization of one tumor located at the inferior renal pole , was conducted successfully. Several attempts at selective catheterization were made to embolize the second angiomyolipoma located at the superior lobe , without jeopardizing a significant amount of the surrounding renal parenchyma, but this ultimately proved not to be feasible. The procedure and recovery were uneventful.
Angiomiolipoma epitelioide: una variante rara del angiomiolipoma renal. Epithelioid angiomyolipoma: A rare variant of renal angiomyolipoma. Juan Carlos Astigueta 1 , Milagros A. Abad 2 , Mariela R. Palabras clave: Angiomiolipoma epiteliode. Esclerosis tuberosa.