Splenic and Renal Embolization
Sebastian Kos
David M. Liu
Stephen G.F. Ho
Embolotherapy of solid organs in the nontrauma patient can be performed for many indications (tumor, aneurysm, hypersplenism, and preoperative). Embolization for trauma, visceral aneurysms, and hepatic malignancies is covered elsewhere in this book. This chapter discusses splenic embolization for hypersplenism and renal embolization for angiomyolipoma (AML), nonfunctioning kidney/nephrotic syndrome, and prior to surgery or renal cell carcinoma (RCC).
Indications
1. Splenic artery embolization for hypersplenism and pancytopenia
a. Hematologic disorders (idiopathic thrombocytopenic purpura, thalassemia, hereditary spherocytosis)
b. Cirrhosis with portal hypertension
c. Primary malignancies (lymphoma, leukemia)
d. Congenital disease (e.g., Gaucher disease, atresia of bile ducts)
e. Idiopathic hypersplenism
f. Chemotherapy-associated splenomegaly
2. Renal artery embolization
a. Total embolization
(1) End-stage renal failure with intractable secondary hypertension
(2) End-stage renal failure with intractable protein loss/nephrotic syndrome
(3) End-stage renal failure with hydronephrosis and intractable secondary flankpain (1)
(4) Failing kidney transplants with graft intolerance syndrome
(5) Inoperable large RCC causing paraneoplastic syndromes
(6) Preparation for surgery in patients refusing blood transfusions
(7) Intractable neoplasm-induced hematuria in the nonsurgical patient
b. Partial embolization
(1) Small RCC with hematuria or paraneoplastic syndromes in the inoperable patient
(2) Large RCC with hematuria or paraneoplastic syndromes in the inoperable patient with a single kidney
(5) Preparation for surgery in patients refusing blood transfusions
Contraindications
Absolute
There are no absolute contraindications for renal and splenic artery embolization. Because these procedures usually involve other clinical disciplines, namely oncologists, nephrologists, urologists, hematologists, etc., a multidisciplinary consensus should be obtained prior to these treatments.
Relative
1. Contraindications to angiography
a. Severe anaphylactoid reaction to iodinated contrast media (alternatives: gadolinium, CO2)
b. Uncorrectable coagulopathy
c. Renal insufficiency
2. Pregnancy
3. Acute or chronic infection of spleen/kidney
4. Acute hyperthyroidism
5. Thyroid carcinoma and planned radioiodine therapy
6. For renal artery embolization: solitary kidney
Preprocedure Preparation
1. Preprocedural assessment
a. Informed consent must be obtained prior to the procedure.
b. Computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) should be obtained prior to the procedure to depict vascular anatomy, extent, and location of the disease (e.g., tumor), size of targeted organs (spleen).
c. Recent laboratory data including partial thromboplastin time (PTT), international normalized ratio (INR), creatinine, glomerular filtration rate (GFR), complete blood count (CBC), platelet count, and C-reactive protein (CRP)
2. Patient preparation
a. Patient preparation and preoperative management vary widely between centers and even operators. For splenic artery embolization, in 1979, Spigos et al. (4) described a regimen, which is still accepted by some authors (5). This includes antibiotic prophylaxis (e.g., cefazolin 1 g; 12 hours before and 1 to 2 weeks after the procedure), additional local antibiotics (e.g., gentamicin) applied with the embolic solution. Note: Other regimens including broadspectrum coverage (e.g., Zosyn, 3.375 mg intravenously [IV] every 12 hours × 3 days posttreatment) and penicillin V 5 million units, coadministered with the embolic agent, have been applied but no evidence exists for “best practice” recommendation. Strict sterility (broad surgical scrub and/or povidoneiodine bath) is emphasized to minimize concerns relating to postembolic infection.
b. For splenic embolization, a (14-valent) pneumococcal vaccine should be given days before the procedure. There is controversy on this subject.
c. Patient on nil per os (NPO) for at least 6 hours prior to the procedure
d. Establish IV access.
e. Supportive therapy (e.g., volume, oxygen)
f. Establish patient monitoring (electrocardiogram [ECG], respiratory rate [RR], heart rate [HR], pulse oximetry).
g. Administer conscious sedation. Note: For total renal embolization, general anesthesia may be required (especially when utilizing liquid embolics).
h. Administer IV antiemetics (e.g., diphenhydramine 50 mg, dexamethasone 10 mg, ondansetron 2 to 4 mg).
i. Standard sterile preparation and draping should be applied.
j. For the majority of cases, a transfemoral access should be chosen. In rare cases (e.g., pelvic artery occlusion), upper extremity access may be used (6).
Procedure
