JOURNAL OF ENDOUROLOGY

Volume 17, Number 6, August 2003

© Mary Ann Liebert, Inc.

Efficacy and Morbidity of Therapeutic Renal Embolization

in the Spectrum of Urologic Disease

AVI I. JACOBSON, M.D.,1 S.A. AMUKELE, M.D.,1 R. MARCOVICH, M.D.,1

O. SHAPIRO, M.D.,1 R. SHETTY, M.D.,1 J. P. ALDANA, M.D.,1 BENJAMIN R. LEE, M.D.,1
ARTHUR D. SMITH, M.D., FACS,1 and D.N. SIEGEL, M.D.2

ABSTRACT

Purpose: We report the largest series of renal embolizations performed for a variety of indications.
Patients and Methods: A retrospective analysis was performed on embolizations performed in our institu-
tion from 1997 to 2002 encompassing 36 patients who underwent 44 procedures.
Results: Embolization was successful on the first attempt in 87% of the patients. A second embolization was
performed in four of the five unsuccessful cases, three successfully, increasing the success rate to 95%. The
mean postoperative narcotic use was 27.2 mg of morphine equivalent, and 10 mg or less was required by 45%
of the patients. In the 14 patients who had not also undergone a surgical procedure, the mean narcotic use
was 21 mg, and 64% required 10 mg or less. Only 15% of the patients developed fever, which resolved within
2 days in all cases. Leukocytosis was seen in 47%. Follow-up creatinine and hypertension information was
available in 16 and 18 patients, respectively. After a mean follow-up of 269 days, only one patient had a clin-
ically significant rise in the creatinine concentration. After a mean follow-up of 496 days, two patients had
new-onset hypertension. There was no statistically significant difference in the success rate, narcotic use, com-
plications, creatinine concentrations, or the likelihood of fever, leukocytosis, or hypertension according to the
indication for embolization or the agent used. Use of a microcatheter was associated with less parenchymal
loss, and decreased parenchymal loss was associated with a significant reduction of narcotic use.
Conclusions: Renal embolization is a highly effective and well-tolerated procedure in a variety of urologic
conditions. The indications and material used did not have a significant effect on the outcome. Reducing
parenchymal loss can significantly reduce morbidity.

INTRODUCTION hort, and the data for this subgroup were not analyzed sepa-
rately.

T HERAPEUTIC RENAL EMBOLIZATION was intro-

duced by Bookstein and Goldstein for control of postbiopsy
arteriovenous fistula.1 Since that time, the indications have
grown to include the treatment of renal malignancy,2–4 angio-
myolipoma,5 trauma,6,7 and renal artery aneurysms,8,9 as well
as ablation of nonfunctioning kidneys.10–12 Although numerous
case reports and small series have been published, there are few
large series that evaluated efficacy and morbidity. Hemingway
and Allison,13 reporting on the complications of 410 em-
bolization procedures of all types, saw postembolization syn-
drome (fever, pain, and leukocytosis) in 42.7% of patients, mi-
nor complications in 16.3%, and major complications in 6.6%.
However, renal embolization represented only 7% of their co-
We report the largest series of therapeutic renal angioin-
farction for a variety of urologic conditions. Success rate, pain,
leukocyte count, fever, complications, and long-term effect on
renal function and blood pressure are presented. As well, the
effect on these factors of the various indications, materials, and
percent parenchymal loss is analyzed.
PATIENTS AND METHODS
A retrospective analysis was performed on renal emboliza-
tion procedures performed in our institution from 1997 to 2002.
Twenty female and sixteen male patients underwent 44 proce-

Departments of 1Urology and 2 Radiology, Long Island Jewish Medical Center, New Hyde Park, New York.

385
 386
dures, including four rescue procedures after failed primary at-
tempts. The patient age ranged from 16 to 77 years, with a mean
of 47.6 years. Twenty-eight percent of the patients had elevated
serum creatinine concentrations (.1.3 mg/dL) before the pro-
cedure, and 25% had controlled hypertension. The most com-
mon indication for embolization was control of hemorrhage af-
ter percutaneous renal surgery (N 5 23): nephrolithotomy (17),
endopyelotomy (4), or resection of transitional-cell carcinoma
(2) (Fig. 1). In this group of patients, 43% presented immedi-
ately postoperatively, 13% had bleeding on removal of the
nephrostomy tube, and 43% returned with hematuria after hav-
ing been discharged home. Patients in the latter group were
treated a mean of 9.8 days after the initial surgery. The other
indications for embolization were angiomyolipoma (Fig. 2),
nonfunctioning kidneys (Fig. 3), congenital arteriovenous mal-
formation (Fig. 4), postbiopsy or postheminephrectomy bleed-
ing, and prophylaxis of bleeding during nephrectomy for a large
renal-cell carcinoma with tumor thrombus (Table 1). The em-
bolization material was steel coils alone in 60%, coils and
polyvinyl alcohol particles (PVA) in 23%, and PVA alone in
12%. One patient was embolized using N-BCA glue, and in a
final patient, a 5F cobra catheter became occlusive, and no fur-
ther embolization material was required.
The procedure was performed through a 6F sheath placed in
the femoral artery following puncture using the standard
Seldinger technique. Digital subtraction angiography was uti-
lized in all cases. Selective arteriography was accomplished af-
ter abdominal aortography with a 5F flush catheter by ad-
vancement of a 5F cobra catheter or, when necessary, a 5F
Simmon catheter, into the renal artery. The catheter was then
advanced selectively over a nontraumatic wire until it was as
close as possible to the desired site of embolization, and the
embolization material was deployed. When appropriate, a 2.8F
A B
FIG. 1. Control of hemorrhage after percutaneous nephrolithotomy. (A) Postprocedure bleeding. (B) After embolization.
JACOBSON ET AL.
microcatheter was utilized to reach smaller peripheral vessels.
After embolization, the catheter was withdrawn into the main
renal artery, and an angiogram was performed to confirm ab-
sence of flow to the embolized segment and evaluate the re-
maining renal vessels. All postembolization angiograms were
reviewed by two radiologists, who estimated the percent
parenchymal loss. The mean of the two values was used for
further analysis.
All statistics were analyzed using commercially available
software. Continuous variables were analyzed with the Mann-
Whitney rank-sum test or the Kruskal-Wallis test. Differences
in proportions were analyzed using the chi-square test or the
Fisher exact test, as appropriate.
RESULTS
The procedure was successful at the first attempt in 34 of
the 39 cases (87%). A second embolization was performed in
four of the five initially failed cases. The fifth patient was suf-
fering from advanced AIDS and was found to be coagulopathic;
bleeding resolved after multiple transfusions and treatment of
the coagulopathy. The second embolization was successful in
three of the four cases. If these are included as successes, the
total success rate improves to 95%. In the patient who under-
went embolization prior to radical nephrectomy for a large re-
nal cancer with vein thrombus, success was not objectively as-
sessable.
The mean narcotic use was 27.2 mg of morphine equivalent.
Only 10 mg or less was required by 45% of patients, and, of
these, half required none. However, it is difficult to distinguish
postembolization pain from postoperative pain in patients who
had undergone a recent surgical procedure. The subgroup of 14
 RENAL EMBOLIZATION IN UROLOGY 387

B C

FIG. 2. Embolization of angiomyolipoma. (A) CT scan in patient with tuberous sclerosis and bilateral angiomyolipomas.
(B) Preembolization angiogram. (C) Postembolization angiogram.

patients who had not undergone surgery therefore was evalu-
ated separately. Their mean narcotic use was 21 mg, with 64%
required ,10 mg and 36% requiring none.
Fever was noted in only 15% of patients and resolved within
2 days in all. However, transient leukocytosis was common, oc-
curring in 47% of the patients. Complications were seen in 10%
of cases. None was directly related to the technique of em-
bolization, and there were no nontarget embolizations and no
abscesses. One patient suffered a myocardial infarction. Two
patients continued to have profuse bleeding and developed hy-
povolemic shock. One patient, who failed initial and repeat em-
bolization, underwent nephrectomy and died of sepsis in the
postoperative period.
Delayed morbidity of embolization can include renal failure
and hypertension. Although it is admittedly an insensitive
marker, the serum creatinine concentration was used as a clin-
ical measure of renal function. Follow-up creatinine values were
available in 16 patients at a mean of 269 days. Only one pa-
tient was noted to have a significant rise, from 1.2 mg/dL to
1.9 mg/dL, and it is unlikely that the rise was attributable to the
embolization, as the procedure was performed for a nonfunc-
tioning, chronically infected kidney. Postoperative blood pres-
sure measurements were available in 18 patients, with a mean
follow-up of 496 days. Sixty-seven percent of the patients were
normotensive, 22% had hypertension unchanged from prior to
embolization, and 11% (2 patients) developed new-onset hy-
 388 JACOBSON ET AL.

A B

FIG. 3. Embolization of nonfunctioning kidney. (A) Angiogram before embolization. (B) Postembolization angiogram.

pertension. Both patients’ hypertension was controlled, one
with a single daily dose of a beta-blocker and one without med-
ication (Table 2).
Postembolization angiograms were available in 39 patients.
The interobserver correlation was very strong: the mean dif-
ference between the observers was 2.6%, and the Spearman
rank correlation coefficient was 0.96 with a P value of ,0.05.
The mean parenchymal loss was 33.8%. However, in eight pa-
tients, the aim was 100% embolization, so these patients were
excluded from the second analysis of attempted selective em-

A B

FIG. 4. Control of arteriovenous malformation. (A) Pretreatment angiogram shows upper-pole lesion. (B) Postembolization
angiogram.
RENAL EMBOLIZATION IN UROLOGY
TABLE 1. INDICATIONS FOR EMBOLIZAT ION IN 40 PATIENTS
No.
PCNL complication 17
Angiomyolipoma 8 of patients. However, although leukocytosis may be a source
Antegrade endopyelotomy complication 4 of concern to physician and patient alike, on its own, it does
Nonfunction 4 not cause symptoms and should not be included as a source of
Percutaneous resection of TCC 2 morbidity.
Arteriovenous malformation 2
Renal biopsy 1
Partial nephrectomy 1 trations and the development of hypertension. A significant rise
Prenephrectomy 1 in serum creatinine was noted in only 1 of 16 patients in whom
bolizations. In these patients, the mean parenchymal loss was
16.7%. In 49% of patients and 61% of the patients having se-
lective embolization, a 2.8F coaxial microcatheter was utilized.
In cases of selective embolization, the mean parenchymal loss
in the microcatheter group was significantly reduced (12.2% v
23.7%, P 5 0.017). Parenchymal loss was also analyzed with
regard to its effect on success, fever, leukocyte count, narcotic
use, and complications. Although successful and uncomplicated
cases had less parenchymal loss (25.9% v 45.8% and 29.5% v
63.5%), only the difference in narcotic use was found to be sta-
tistically significant. Patients who required .10 mg of narcotics
had significantly greater parenchymal loss than those who re-
quired ,10 mg (38.5% v 19.9%; P 5 0.01).
Success, narcotic use, fever, leukocyte count, complications,
and parenchymal loss were also evaluated in relation to the in-
dications for the embolization and the embolization materials
used (Tables 3 and 4). The only significant difference was that
parenchymal loss was significantly greater in patients with non-
functioning kidneys than in those treated after percutaneous
stone extraction (P 5 0.046). However, in the former group,
complete renal embolization was attempted in three of the four
patients. The remaining patient had embolization of a non-
functioning upper-pole moiety of a duplex system. The mater-
ial used did not significantly affect any outcome measure.
DISCUSSION
The efficacy of therapeutic renal embolization has been shown
in numerous series to be between 82% and 100%.6,10–12,14–17 In
our patients, the success rate of the initial procedure was 87%.
In four patients who failed initial embolization, a second em-
bolization was attempted and was successful in three, improv-
ing the overall success rate to 95%. Open exploration, espe-
cially in the face of severe bleeding, mandates a large incision
and carries a significant risk of nephrectomy. In hemodynami-
cally unstable patients, this is clearly warranted. However, in
the stable patient, a 75% success rate justifies an attempt at res-
cue embolization prior to submitting the patient to the morbid-
ity of an open procedure.
In this series, renal embolization was well tolerated. Classi-
cally, embolization is associated with a transient (3–5 days)
postembolization syndrome, which consists of pain, fever, and
leukocytosis. Although some discomfort was common, in pa-
tients who had no other important source of pain, 64% required
389
,10 mg of morphine equivalent; of these, half did not require
any narcotics at all. Fever, was noted in only 15% of patients,
and all fevers resolved within 2 days. The most common find-
ing was an elevated leukocyte count, which occurred in 47%
Long-term morbidity was assessed with creatinine concen-
this follow-up information was available. As mentioned earlier,
this patient underwent embolization for a chronically infected
nonfunctioning kidney, so it is unlikely that the embolization
contributed to the renal failure. New-onset hypertension was
seen in 2 of 18 patients in whom follow-up blood pressure mea-
surements were available. Both of these patients were controlled
by minimal therapy. There is very little postrenal-embolization
follow-up information available in the literature. Takebayashi
and associates17 reported on 30 patients treated with emboliza-
tion for renal arteriovenous malformations. After a mean fol-
low-up of 6.2 years, only one patient had developed hyperten-
sion, and all had normal creatinine concentrations.
The various indications for embolization did not significantly
affect outcome. However, it is possible that our small subgroups
lacked the power to demonstrate differences. In Hemingway
and Allison’s study, embolization was associated with postem-
bolization syndrome in 52.2% of tumor cases and only 11.1%
of bleeding cases.13 This study was not specifically aimed at
renal procedures. However, in the kidney, the same seems to
hold true. Wallace and colleagues18 evaluated 100 cases of em-
bolization for renal-cell carcinoma and reported that postem-
bolization syndrome occurred in almost every patient. Transient
hypertension was also seen frequently but was not persistent in
any case. In two series that evaluated embolization for bleed-
ing, fever was seen in 1 of 15 and 1 of 16 patients, and only 1
patient developed hypertension, which did not persist.19,20 The
increased morbidity in the tumor group might be explainable
by a larger area of ischemia (although this information was not
available) or by tumor necrosis.
TABLE 2. MORBIDITY OF EMBOLIZATION
No. (%)
of patients
Early
Pain necessitating .10 mg 22 (55%)
narcotics
In patients without other 5 (36%)
surgery
Fever 6 (15%)
Leukocytosis 18 (47%)
Complication 4 (10%)
Hypovolemic shock 2
Myocardial infarction 1
Death 1
Late
Creatinine rise 1 (6%)
New-onset hypertension 2 (11%)
390 JACOBSON ET AL.

TABLE 3. RESULTS ACCORDING TO INDICATION

Renal
Narcotic loss
Success .10 mg Fever ­WBC Complication ­Cr HTN (%)

PCNL 15/17 9/17 3/17 8/17 1/17 0/50 1/80 22.4

AML 8/8 1/8 2/80 3/7 0/80 0/30 1/40 15.3
Nonfunction 3/4 3/4 0/40 3/3 0/40 1/20 0/20 66.5
Endopyelotomy 4/4 3/4 0/40 1/4 0/40 0/20 0/10 16.1
AVM 2/2 1/2 0/20 1/2 0/20 — 0/10 5.8
TCC 1/2 2/2 1/20 1/2 2/20 0/20 0/10 60.5
Heminephrectomy 1/1 1/1 0/10 1/1 0/10 0/10 0/10 25.0
Postbiopsy 0/1 1/1 0/10 0/1 1/10 0/10 — 100.0
Prenephrectomy N/A 1/1 0/10 0/1 0/10 — — 100.0
34/39 22/40 6/40 18/38 4/40 1/16 2/18
Total (%)
(87) (55) (15) (47) (10) (6) (11) 33.8

In other studies where large-volume ablation was performed,
morbidity was also increased. Da Baere et al12 reported 20 cases
of embolization for persistent urine leak. All except one patient
complained of fever and nausea, and pain was reported by 55%.
In a series of embolizations for polycystic kidney disease,11
where an extremely large area was targeted, pain and fever was
seen in all patients. In fact, pain was so severe that most pa-
tients required epidural anesthesia. In our series, pain was sig-
nificantly associated with greater parenchymal loss, and use of
a microcatheter, which can be passed coaxially through stan-
dard angiographic catheters into 1- to 2-mm peripheral vascu-
lar branches, was significantly related to less parenchymal loss.
The use of a microcatheter, when appropriate, therefore should
decrease patient morbidity.
Many embolization agents have been employed. The most
popular are absorbable materials such as Gelfoam and autolo-
gous clot and nonabsorbable materials such as metal coils, PVA
particles, and absolute alcohol. To our knowledge, there has
been no study demonstrating a significant advantage of one ma-
terial over another. Our personal preference is steel coils, which
are inexpensive, easily deployed, and highly effective. Coils
alone were utilized in 60% of our cases. In patients in whom
only partial occlusion was noted, PVA particles were added to
complete the occlusion, and in 12% of patients, PVA particles
were used alone. No significant difference was found in the re-
sults according to the material used. Other authors have advo-
cated Gelfoam as the material of choice for renal emboliza-
tion.15 Although Gelfoam is compressible when wet, it has a
tendency to fragment or plug the catheter, and when force is
used to eject the plugs, the turbulence can lead to reflux and
nontarget embolization.21 The theoretical advantage is that
Gelfoam is reabsorbed within days to weeks. However, in an
end-artery system such as the kidney, one would not expect
nephrons to survive this prolonged period of ischemia. Absolute
alcohol has also been promoted as the embolization agent of
choice.22 Its effect is mediated through direct endothelial dam-
age and perivascular necrosis. Vascular resistance can increase
rapidly, causing reflux into unselected vessels.23 As well, al-
though it is rarely seen if the agent is used properly, systemic
toxicity is always a concern. Other inert materials such as de-
tachable balloons24,25 and cyanoacrylate26 have also been de-
scribed. Despite our personal preferences, until a significant ad-
vantage is demonstrated, all commercially available agents are
acceptable. It is key that the physician performing the emboliza-
tion have knowledge of the physical properties of each material
and understand their potential advantages and limitations.
CONCLUSION
Renal embolization is highly effective and can be performed
with minimal short- and long-term morbidity and excellent re-
nal preservation. Embolization therefore represents an attrac-
tive alternative to open surgery for a wide spectrum of urologic
conditions. In the present study, different indications and em-
bolization agents were not significantly associated with out-
come measures. However, the percent parenchymal loss was
found to be associated with the amount of narcotic use. The
goal of embolization should be to target the affected area as
specifically as possible, sparing normal parenchyma. The use
of a microcatheter for superselective embolization significantly
decreased damage to nontarget areas.

TABLE 4. RESULTS ACCORDING TO MATERIAL

Renal
Narcotic loss
Success .10 mg Fever ­WBC Complication ­Cr HTN (%)

Coils 22/26 16/24 3/24 11/24 4/24 0/11 1/10 23.5

PVA 3/4 3/9 1/3 5/7 0/9 1/5 1/6 41.3
Coils 1 PVA 9/10 2/3 1/9 2/4 0/4 — 0/2 51.6
RENAL EMBOLIZATION IN UROLOGY
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Address reprint requests to:
Arthur D. Smith, M.D., FACS
Dept. of Urology
Long Island Jewish Medical Center
270-05 76th Ave.
New Hyde Park, NY 11040
E-mail: ASmith@lij.edu