The Maimed Kidney: When Is Endovascular Treatment Appropriate

The Maimed Kidney:
When is Endovascular Treatment Appropriate, and How?
GEST 2016
J\
5/5/2016
Jon Davidson, MD
Fellowship Director
Center of Interventional Radiology
University Hospitals Case Medical
Center
Jon Davidson, M.D.
• No relevant financial relationship reported
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Full Definition of MAIM
transitive verb
1: to commit the felony of mayhem upon
2: to mutilate, disfigure, or wound seriously
• Blunt renal trauma (80-85%)
• Penetrating trauma (10-15%)
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Mechanism of Blunt Renal
Trauma
• Motor vehicle
collision (MVC)
• Fall from height,
• Direct blow to the
torso
• Sports injury
Deceleration
injury
Mechanism of Penetrating
Renal Trauma
• Guns and knives
Iatrogenic Renal Trauma
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Biopsy
ESWL
Surgery (partial nephrectomy, renal transpant)
Nephrostomy
Clinical Features of Renal
Trauma
• Gross or microscopic hematuria (absent
in 5%)
• Flank pain / ecchymosis
• Hemodynamic instability
• Presence of other abdominal injuries
Indications for Imaging
• Universally accepted indications for renal
imaging in blunt trauma include
– Gross hematuria
– Microscopic hematuria and hypotension (systolic blood pressure <90
mm Hg) or other associated injuries requiring CT evaluation
– Blunt trauma with other injuries known to be associated with renal
injury (e.g. rapid deceleration, fall from a height, direct contusion or
hematoma of flank soft tissues, fractures of the lower ribs or
thoracolumbarspine),regardless of the presence of hematuria
Grade
Type of injury
Description
I
Normal contusion
Microscopic or gross
hematuria, urologic
studies normal
Hematoma
Subcapsular, nonexpanding without
parenchymal laceration
Hematoma
Non-expanding
perirenal hematomas
confined to the
retroperitoneum
Laceration
Superficial parenchymal
lacerations less than
1 cm in depth without
urinary extravasation
III
Laceration
Parenchymal
lacerations greater than
1 cm in depth without
urinary extravasation
IV
Laceration
Parenchymal
lacerations extending
through the renal cortex,
medulla, and collecting
system
Vascular injury
Injuries involving the
main renal artery or vein
with contained
hemorrhage
Vascular injury
Completely shattered
kidney
II
V
Complete avulsion of
renal hilum which
devascularized kidney
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Blunt Trauma Algorithm
Interventional Management
Grade
Usual management
Remarks
Grade 1,2,3
Conservative
Management
Intervention needed in presence of active
hemorrhage with angio-embolization/
Surgery in those with hemodynamic
instability
Grade 4
Trial of conservative management
provided the patient is
hemodynamically stable with no
expanding hematoma
Injury can be managed with interventional
radiology techniques
Grade 5
Complete UPJ disruption and renal
pedicle avulsion needs surgical repair
Partial UPJ avulsion treated with
interventional radiology techniques
Renal artery thrombosis and
devascularization -thrombolysis or
stenting within few hours
How?
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Coils
Plugs (MVP, Amplatzer)
Glue, onyx
Stents
Cases
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• 22 year old male s/p stab wound to left flank.
Gross Hematuria
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• 65 year old male recently s/p biopsy of right
kidney. Present with hematuria and right
flank pain
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• 71 year old female s/p right partial
nephrectomy, with persistent hematuria 2
weeks out
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• Similar history s/p robotic partial
nephrectomy
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• 31 year old female 2 days s/p renal transplant
presents with acute drop H/H and fevers,
increased WBC
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• Endovascular management fairly quick and
easy
• Recent studies demonstrating reduced cost
and decrease procedure time with some of
the lesser utilized embolics (glue, plugs)
Thank you for your attention….