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274
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J.J. Trambert
Successful revascularization of the renal artery is thus
more likely to partially ameliorate the hypertension than
to cure it. In addition, a large percentage of
atherosclerotic lesions are ostial lesions related to overhanging aortic atherosclerotic plaque. Therefore, it is
more difficult to produce a lasting dilation. It is possible
that the results might be improved by the use of stents
in ostial lesions.
Fibromuscular dysplasia, on the other hand, tends to
occur in younger patients who do not have atherosclerosis or essential hypertension. Successful renal artery
revascularization thus intuitively has a greater chance of
effecting a cure. Nonetheless, because long-standing hypertension can result in renal damage and acceleration
of atherosclerosis, it is important that young patients with
renovascular hypertension be diagnosed and treated as
early as possible.
Renal PTA also has been evaluated as a measure to
improve renal function in patients in whom renal insufficiency is presumed to be due to bilateral renal artery
stenosis or to a renal artery stenosis in a unilateral solitary
kidney. Miller et al. reported their experience in 44 such
patients and noted a significant improvement in glomerular filtration rate that persisted for up to 6 months.
Although the improvement may not last indefinitely, the
resultant improvement in renal function from PTA may
delay the need for placing a patient on dialysis.
20
Expandable metal stents
Expandable metal stents, which have had extensive evaluation in the iliac arteries, have recently been used in the
renal arteries with promising results. There are technical
differences between the placement of stents in renal arteries and placing them in the iliac arteries. Placement
and positioning of the renal artery stent are more difficult because of the inherent limited margin of error.
Renal artery stents are, by necessity, shorter than iliac
stents. Because of respiratory motion, the exact position
of the renal artery stenosis with respect to bony landmarks is harder to pinpoint than in the iliac arteries;
therefore, roadmapping is of more limited use. Treatment of an ostial lesion is more difficult because the
stent, must straddle the lesion; therefore, the stent protrudes slightly into the aorta. Excessive stent protrusion
into the aortic lumen may increase the risk of a thrombogenic nidus. Nonetheless, metal stents are valuable for
treating post-PTA occlusions secondary to dissections and
for increasing the revascularization success rate in ostial
atherosclerosis renal artery stenosis.
One recent study reported a 19% rate of renovascular
hypertension cure and a 60% rate of improvement using
Palmaz (Johnson and Johnson Interventional Systems,
Warren, NJ) stents.
patency rate of 69% and a secondary patency rate of 90%.
21
It also described a 6-year primary
Clearly, expandable stents substantially improve the longterm amelioration of renovascular hypertension, particularly that resulting from atherosclerosis with its high incidence of ostial stenosis.
■ Renal Transplantation
Renal transplantation is increasingly becoming a treatment option for patients with end-stage renal diseases. As
surgical techniques of harvesting and transplantation become more refined and immunosuppressive regimens
are improved, renal transplants are being performed
with greater success, with patient and allograft survival
rates at 1 year in the 80 to 95% range.
22
As a result,
vascular and interventional radiologists are being consulted more frequently regarding the preoperative evaluation of potential renal donors and to assess the failing
renal transplant.
Arteriography prior to transplant
Radiologic evaluation of the prospective kidney donor
should ensure that there are two normally functioning
kidneys and that the kidneys are free from neoplasm or
vascular disease that may disqualify the donor or harm
the patient. Clinical screening and preceding noninvasive cross-sectional or nuclear studies are used to assess
function and may uncover the presence of renal mass.
Whereas aortography, with or without selective renal arteriography, may uncover abnormal parenchymal morphology, its primary role is to map the renal arterial
blood supply. The number of renal arteries is of extreme
importance to the transplant surgeon. When the number
of renal arteries is equal on both sides and both kidneys
are functioning equally well, the left kidney is usually
harvested because of its longer renal vein;
23
however, the
presence of accessory renal arteries on the left side alone
usually changes the donor side. The need for multiple
anastomoses, yielding longer warm ischemia times, and
the smaller vessels involved will increase the technical
difficulty of the transplant. Furthermore, the presence of
multiple renal artery anastomoses increases the chance
for subsequent anastomotic strictures. The aortogram,
with selective renal arteriography as necessary, depicts
arterial stenoses (e.g., from FMD) and may reveal small
arteriovenous malformations not seen on cross-sectional
imaging studies (Fig. 23-6).
Arteriography after transplant
Arteriography in the posttransplant recipient is performed to diagnose an anatomically correctable cause of
transplant failure or the cause of renovascular hypertension (i.e., a transplant renal artery stenosis). Renal trans-
Vascular Manifestations of Renal Disease 275
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FIGURE 23-6. Aortogram in a prospective kidney donor revealing two left renal arteries as well as fibromuscular dysplasia with bilateral aneurysms (
arrows
).
plant artery stenosis, usually a consequence of a fibrotic
stricture at the anastomosis site, is thus a different disease
process from atherosclerosis. Clinical consequences include renovascular hypertension and renal transplant insufficiency. In situations of renal transplant insufficiency,
renal transplant malfunction resulting from rejection
must be ruled out before embarking on a search for an
arterial lesion.
Because contrast load hazards are much higher in this
group of patients, the workup and evaluation of suspected transplant renal artery stenosis should favor the
use of modalities not dependent on iodinated contrast,
such as Doppler ultrasound and MRA. When necessary,
angiographic evaluation should be as goal directed as
possible, using nonionic contrast, digital subtraction to
minimize the overall contrast dose needed for diagnostic
arteriography, and directed selective arteriography based
on a knowledge of anastomosis anatomy from the operative report. Usual anastomosis sites are either the internal
or the external iliac artery (Fig. 23-7). Experience with
renal PTA in this subgroup of patients is more limited;
however, reported success rates have ranged from a low
of 22.7% to a maximum of 80.5%.
19
Acute transplant rejection presents angiographically as
stenosis and occlusions of intrarenal branch vessels as well
as rapid tapering and pruning of interlobar branches. In
chronic rejection, the kidney appears shrunken, with the
FIGURE 23-7. Right external iliac arteriogram demonstrating
an end-to-side renal transplant artery anastomosis to the external iliac artery. Note postanastomotic stenosis (
Also note the catheter-induced spasm of the external iliac
artery distal to the transplant artery (
open arrows
solid arrow
).
number of intrarenal vessels diminished. These intrarenal branches also appear to be pruned.
■ Renal Trauma
Blunt renal trauma results from deceleration type injuries associated with motor-vehicle accidents, sportsrelated collisions, and external impact as in assault with
a blunt weapon. Penetrating trauma usually results from
stab or gunshot wounds, renal biopsy, percutaneous
nephrostomy, or nephrolithotomy (Fig. 23-8)
Blunt trauma causes impact distributed over a wide
area and can have a spectrum of consequences ranging
from mild renal contusion (which may result in transient
hematuria and resolve spontaneously) fracture of the
kidney or dehiscence of the renal pedicle. Severe injuries
of this sort usually are associated with injuries to other
abdominal viscera.
24
Penetrating trauma, with the exception of gunshot
).
276 J.J. Trambert
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A
FIGURE 23-8. A: Right renal arteriogram demonstrating ex-
travasation (
ing percutaneous nephrolithotomy. B: Renal transplant arteriogram demonstrating pseudoaneurysm (
arterial branch, a complication of percutaneous nephrostomy.
C: Renal transplant arteriogram in the same patient as (B)
following superselective embolization of the pseudoaneurysm
with steel coils (
the adjacent arterial branches.
arrows
) from a branch resulting from trauma dur-
arrow
) of a peripheral
arrows
). Note the sparing of the remainder of
B
wounds, results in a more focal injury, often to a segmental intralobar renal artery branch. The consequence
can be active perirenal extravasation and hematoma formation, arteriovenous fistula, and arteriocaliceal fistula.
The refinement of selective catheter technique, fluoroscopic equipment, embolization particles, and the development of coaxial microcatheters have made superselective catheterization and embolization of the involved
renal artery branch possible, thus allowing the cessation
C
of bleeding or the elimination of an arteriovenous fistula
while preserving the kidney.
Renal trauma patients who are hemodynamically unstable should not undergo radiologic imaging or angiography but should proceed straight to surgery. Gunshot
wounds involving the kidney generally warrant relatively
urgent surgery because of the high likelihood of injury to
intraperitoneal viscera as well as the high likelihood of
“blast” injury to renal tissue surrounding the bullet’s path.
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Penetrating trauma in the posterior flank region that
is confined to the retroperitoneal tissues may not require
surgery. When intraperitoneal injury is excluded by peritoneal lavage, patients can be observed expectantly. If
clinical evidence of bleeding is present, such as hematuria, or an expanding flank hematoma, the patient can
be evaluated arteriographically and superselective
embolotheraphy instituted if an internal bleeding point
is identified. Attempts at operative control of hemorrhage from small intrarenal branch vessels is sometimes
quite difficult and can result in the loss of renal
substance, even nephrectomy. Hemostasis with minimal
or no loss of renal parenchyma can be obtained with
superselective percutaneous transcatheter embolotherapy.
25–28
Superselective renal catheterization
and embolization
Superselective catheterization of renal artery branches
can be accomplished using 5 Fr catheters with or without
2 to 3 Fr coaxial microcatheters. Specifics regarding the
technique and equipment needed for superselective
catheterization are covered in Chapter 2. The available
techniques and equipment now make it possible to expeditiously superselect the arterial branch that is the site
of hemorrhage, arteriovenous malformation (AVM), or
pseudoaneurysm, and to place embolic materials precisely at that site while sparing the vasculature to the
uninvolved portions of the kidney (see Fig. 23-8). The
preferred embolic material for treating renal artery hemorrhage is metal coils. The advantage of coils is that they
can be deployed precisely, and they can be advanced
through coaxial microcatheters. Gelfoam plugs and
autologous blood clot can be extremely difficult to inject
through the tiny lumen of coaxial microcatheters, and
there is a greater risk of unintended nontarget vessel
embolization with these agents. In hemodynamically stable patients, success rates of 88 to 100% have been reported for percutaneous transcatheter embolotherapy in
renal artery injury from penetrating trauma.
27,28
tiple intrarenal arterial aneurysms includes polyarteritis
nodosa (renal microaneurysms in 80%), hypersensitivity
necrotizing angiitis, mycotic aneurysms from septic emboli related to bacterial endocarditis, Wegener’s granulomatosis, and systemic lupus erythematosus.
29
Congenital AVMs have been reported as rare causes of
30
hematuria.
Superselective embolization (see section on
renovascular trauma) can be effective if a distinct arteriovenous communication can be identified and occluded.
Renal vein hypertension is a condition that manifests
in the left kidney when the left renal vein is subject to
compression between the superior mesenteric artery and
aorta (the nutcracker syndrome). This results in increased pressure in the left renal vein and formation of
intrarenal, parapelvic and periureteric varices that may
cause hematuria.
31
Intrarenal varices secondary to
the nutcracker syndrome causing caliceal filling defects
mimicking transitional cell carcinoma also have been reported (Fig. 23-9).
32
Rarely, the cause of a patient’s hematuria is never determined, despite careful selective arteriography and
venography. Venous communications with the caliceal
fornices have been identified on careful sectioning of
nephrectomy specimens from some patients with idiopathic hematuria.
33
■ Renal Neoplasms
Although renal neoplasms can be either benign or malignant, malignant tumors constitute the majority of renal
masses encountered in clinical practice probably because, in part, benign tumors rarely cause symptoms;
hence, although benign adenomas have been reported in
up to 3% of autopsies,
34
they are uncommonly encountered in clinical situations, and, when they are, it is usually
as incidental findings. Even though many malignant kidney tumors present as incidental findings without causing
symptoms, the overwhelming majority of solid renal
masses are malignant.
Nonneoplastic causes of hematuria
Patients rarely present with gross or microscopic hematuria without any antecedent history of trauma, and neoplasm is excluded on the basis of extensive workup.
Other possible etiologies for hematuria include renal
artery aneurysm rupture, renal arteriovenous malformations, calculi, renal vein hypertension secondary to the
nutcracker syndrome, sickle cell disease, pyelonephritis,
and idiopathic causes. The usual cause of single renal
artery aneurysms is atherosclerosis. Fibromuscular dysplasia may result in single or multiple renal artery aneurysms (see Fig. 23-6). The differential diagnosis of mul-
Benign renal tumors
Adenomas
Adenomas constitute the largest group of the benign
renal tumors. There are four types: papillary adenomas
(also called cyst adenomas) constitute 38%, tubular adenomas another 38%, alveolar adenomas 3%, and mixedtype adenomas 21%.
Arteriographically, the papillary type tends to be hypovascular. The other adenoma types tend to be hypervascular, but their boundaries tend to be better circumscribed than those of renal adenocarcinomas.
Oncocytomas represent a specific subset of tubular ade-
35
278 J.J. Trambert
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A
FIGURE 23-9. Intrarenal and retroperitoneal venous varices
due to the nutcracker syndrome. A: Intravenous pyelogram
showing extrinsic impression of varices on the lower pole infundibulum and calix mimicking a urothelial neoplasm (
B: Left renal venogram demonstrating the intrarenal varices
causing the impression (
retroperitoneal varices (
teric and other retroperitoneal varices (
gradient between peripheral left renal vein and inferior vena cava
(IVC) was 4 mm Hg (normal ⱕ1 mm Hg). C: Magnetic resonance
imaging (MRI) demonstrating compression of left renal vein (x)
between the superior mesenteric artery (SMA) and aorta (Ao),
the nutcracker phenomenon.
teric and other retroperitoneal varices.
arrow
) as well as periureteric and other
arrowheads
). Pressure gradient periure-
arrowheads
Black arrowheads
point to periure-
arrow
). Pressure
).
B
nomas. They display a pattern of hypervascularity that can
often be described as a “spoke wheel” pattern (Fig. 23-
36
10).
On CT and ultrasound,oncocytomas tendto display
a central stellate scar.
37
Although imaging and arteriographic features may
suggest renal adenoma, particularly in the case of oncocytoma, these features are not diagnostic, and in no way
do they rule out an adenocarcinoma. Surgical resection
is mandatory in all solid renal masses in the absence of
medical contraindications. Indeed, at pathological examination, it is sometimes difficult to distinguish renal
adenoma from a well-differentiated adenocarcinoma.
Nonetheless, because renal adenomas can be cured by
simple extirpation, preoperative suspicion of a renal adenoma based on imaging studies and arteriography can
allow a surgical approach geared toward local tumor excision and sparing of the kidney. The potential of the
preservation of the kidney makes it of utmost importance
to be aware of the imaging and arteriographic features of
renal adenomas.
Angiomyolipoma
Angiomyolipomas are not true neoplasms but are actually
hamartomas consisting of fat, muscle, and angioid elements in varying relative amounts. Angiomyolipomas can
spontaneously hemorrhage, causing retroperitoneal hematoma, hematuria, or both. There is an association
between renal angiomyolipomas and tuberous sclerosis.
Tuberous sclerosis syndrome is characterized by mental
retardation and epilepsy associated with various cutaneous lesions, retinal phakomas, and cerebral hamartomas.
Renal angiomyolipomas have been reported in 40 to 80%
of patients with tuberous sclerosis, but the converse is not
true: Only a small minority of patients with a renal
angiomyolipoma have tuberous sclerosis.
38
Angiomyolipomas occuring as part of the tuberous sclerosis syndrome are often bilateral and multicentric.Lesions not associated with tuberous sclerosis are almost always
unilateral and solitary. Angiomyolipomas constitute 0.3 to
3% of renal masses and 1% of surgically resected renal
tumors.
39
C
FIGURE 23-10. Oncocytoma. Renal arteriogram demonstrat-
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ing typical “spoke wheel” distribution of tumor vessels and
well-defined boundaries of tumor vascularity.
Angiographically, angiomyolipomas tend to be hypervascular with irregular, tortous vessels, often with
aneurysms (Fig. 23-11A). In short, angiographically, angiomyolipomas are often indistinguishable from adenocarcinomas.
Angiomyolipomas possess unique features on ultra-
Vascular Manifestations of Renal Disease
279
sound and CT studies. Because most of these tumors possess a large percentage of fat, they tend to be hyperechoic
on ultrasound and hypodense (fat density) on CT (Fig.
23-11B). The CT finding of fat density in a renal mass is
virtually diagnostic of angiomyolipoma, with only rare exceptions. As such, surgical resection is not indicated.
Of the angiomyolipomas larger than 4 cm in diameter,
50 to 60% bleed spontaneously, sometimes catastrophically; so prophylactic transcatheter embolotherapy may
be indicated. Embolization, as the sole means of treatment, has been reported to be effective in 90% of patients
with angiomyolipomas 4 cm or larger.
39
For angiomyolipomas, superselective embolization with absolute ethanol is preferred over coils because ethanol causes devascularization at the capillary level and infarction of the
lesion. Proximal embolizations with coils can allow collaterals to develop and revascularize the lesion. As with superselective embolotherapy for renal trauma complications, therapeutic benefit is obtainable while sparing the
remaining normal kidney.
Renin-secreting adenomas
Renin-secreting adenomas (reninoma, juxtaglomerular
tumor) are rare, histologically benign tumors occurring
in the cortical tissue, usually just below the renal capsule.
They tend to be small, on average around 2 to 3 cm in
diameter, but perhaps as small as a few millimeters. As
such, they may be undetectable on imaging studies, including angiography. Nonetheless, they constitute an uncommon cause of renin-mediated hypertension in young
patients and may be suspected when lateralizing renalvein renin levels are obtained, arteriography fails to disclose a renal artery stenosis, and there is no underlying
renal parenchymal disease. Tumor extirpation or partial
A
FIGURE 23-11. Angiomyolipoma. A: Renal arteriogram displaying irregular neovascularity and some puddling within lesion. B:
Computed tomography finding of fat within left renal lesion is diagnostic of angiomyolipoma.
B
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J.J. Trambert
nephrectomy of the involved portion of kidney is cura-
40,41
tive.
Malignant tumors
Malignant neoplasms of the kidney include primary renal
tumors and secondary or metastatic tumors of the kidney.
Metastases are the most common malignant tumor of the
kidney, twice as common as primary tumors.
to the kidney are seldom symptomatic, because patients
with disseminated malignancies usually die before their
renal metastases have a chance to become symptomatic.
Breast and lung carcinomas constitute approximately
half of the lesions that metastasize to the kidney, followed
by lymphoma and metastatic renal cell carcinoma from
the contralateral kidney.
Of the primary renal malignancies, adenocarcinoma
(also known as renal cell carcinoma and hypernephroma)
constitutes approximately 83%. Carcinoma of the urothelium constitutes approximately 8%, nephroblastoma
(Wilms’ tumor) 5.5%, and sacromas 3%.
Renal cell carcinoma
Renal cell carcinoma, or hypernephroma, is an adenocarcinoma that arises from renal tubular cells. It has approximately a 2:1 male predilection and tends to occur in the
fifth through seventh decades, although it occasionally
presents in young adults. Symptoms are classically hematuria, weight loss, anemia, and flank pain. Sometimes the
tumor is asymptomatic and is discovered incidentally. Occasionally, this tumor is not detected until it is already
large and disseminated.
Most renal cell carcinomas are single, unilateral lesions.
In patients with von Hippel-Lindau disease (VHL), renal
cell carcinomas occur in 38 to 55%,
often are bilateral and multiple. VHL is an autosomal
dominant disorder comprising retinal, cerebellar,and spinal hemangioblastomas, pheochromocytomas, and renal
cell carcinomas. In patients without VHL, renal cell carcinoma can be bilateral in up to 5%.
Imaging
Renal cell carcinoma usually is confirmed on the basis of
urography, ultrasound, and CT. CT is most valuable for
staging renal cell carcinoma by assessing its level of extension, presence of contralateral renal masses, presence of
renal metastases to retroperitoneal nodes or liver, and, at
times, venous invasion. As such, preoperative arteriography becomes more of an option when much of the requisite preoperative information is supplied by CT. Arteriography is valuable in clarifying the indeterminateappearing masses on CT, and many surgeons prefer an
anatomic roadmap of the number of arteries supplying
the kidney. A 3- to 5-sec-long contrast injection usually
allows good visualization of the renal vein as well and
42
Metastases
43
44
and such tumors
allows determination of the presence of tumor extension
into the renal vein and inferior vena cava (Fig. 23-12).
Such extension is sometimes not apparent on CT or
ultrasound and is of vital importance to surgical planning, as the surgeon will know to exercise caution when
cross clamping the inferior vena cava to avoid dislodging
tumor thrombus causing symptomatic pulmonary embolus or lung metastases. MRA and spiral CTA have excellent potential to provide much of this information, and it
is likely that in the future angiography will be performed
less frequently in the preoperative evaluation. Nonetheless, angiography presents detailed information about
the peripheral vascularity of the mass from a diagnostic
standpoint that is not yet attainable by CTA or MRA;
these modalities currently are reliable for the central
main vasculature. Arteriography is also essential in preoperative planning for renal cell carcinomas in patients
with VHL disease, because it may detect additional tumors or contralateral tumors too small to be detected on
CT. In such situations, attempts at partial nephrectomies
are justified to conserve renal function, and the anatomic
information provided by arteriography is essential in
planning partial nephrectomies.
Renal cell carcinoma manifests usually, but not universally, as a hypervascular lesion. Approximately 62% are
distinctly hypervascular, 16% moderately vascular, 16%
minimally vascular, and 6% avascular.
45
Specific angiographic features associated with renal cell carcinoma
include random irregular vessel distribution, lack of peripheral tapering of vessels, puddling of contrast or aneurysmal-type vascular spaces, and arteriovenous shunting.
Tumor neovascularity often is displayed in renal vein and
interior vena cava extensions of tumor, referred to as tu-
mor thrombus (Fig. 23-12A,C). Otherangiographic features
of renal vein involvement on arteriography include nonvisualization of the renal vein with opacification of multiple collaterals (Fig. 23-12B). If doubt exists as to the presence of tumor extension into the vena cava, inferior
venacavography must be performed, preferably using a
pigtail catheter in the lower inferior vena cava. Care
should be exercised to minimize manipulation of catheters and guidewires around a suspected tumor thrombus
to avoid the risk of detaching a tumor embolus. If renal
vein thrombus is suspected, selective renal vein catheterization is contraindicated. Tumor extension presents on
the inferior venacavagram as a distinct constant filling
defect within the lumen, in contradistinction to the inconstant striated hypodense appearance caused by
unopacified inflowing blood from patent renal veins.
(Preoperative embolization of large, hypervascular renal
cell carcinomas can decrease intraoperative blood transfusion requirements significantly. The success of embolization depends on achieving complete devascularization,
preferably with absolute ethanol, and embolizing any accessory feeding vessels as well.)
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281
A B
FIGURE 23-12. Hypervascular renal cell carcinoma. A: Right
renal arteriogram, midarterial phase, showing large tumor with
tumor neovascularity extending into the right renal vein (
). B: Late venous phase of arteriogram showing opacifica-
row
tion of capsular and other retroperitoneal collateral veins (
rows
) resulting from renal vein occlusion by tumor thrombus.
C: Aortogram in another patient demonstrating hypervascular
C
tumor thrombus from a right renal cell carcinoma occupying
entire suprarenal inferior vena cava (IVC) (
arrows
).
ar-
ar-
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Angioinfarction
Preoperative embolization of large hypervascular renal
cell carcinomas can decrease intraoperative blood transfusion requirements significantly. The success of embolization depends on achieving complete devascularization,
preferably with absolute ethanol, and embolizing any accessory feeding vessels.
46
Angioinfarction is also a valuable palliative procedure in patients with advanced renal
cell carcinoma causing unremitting hematuria or pain,
who, because of metastatic disease, are ineligible for surgical nephrectomy.
47
Technique
After diagnostic arteriography to assess the blood supply
and vascular nature of the renal tumor, an occluding
balloon is positioned securely in the renal artery. Estimation of the volume of the vascular space of the kidney and
tumor is done by measuring the volume required to fill
the vascular spaces almost to venous reflux with contrast
while the occlusion balloon is inflated. This same measured volume of absolute ethanol then is infused after
reinflation of the occlusion balloon, allowing it to sit for
several minutes. Before deflating the balloon, blood is
gently aspirated through the balloon catheter lumen to
eliminate the risk of ethanol backflow into the aorta (Fig.
23-13).
Ethanol angioinfarction for ablation is a safe procedure. The risk of abscess formation in the infarcted kidney is slight as long as the procedure is done under strict
sterile conditions and patients are protected with prophylactic antibiotics.
48
The risk is further decreased if a
nephrectomy is performed within 24 to 48 hr after embolization. Many patients who undergo renal artery embolization will experience a postembolization syndrome
A B
C
FIGURE 23-13. Ethanol angioinfarction of the left kidney to
treat hematuria from an inoperable renal cell carcinoma.
A: Aortogram demonstrating hypervascular lesion (
Balloon inflated in preparation for anhydrous ethanol infusion.
C: Aortogram after ethanol embolization showing occluded left
renal artery.
arrows
). B:
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A B
FIGURE 23-14. Transitional cell carcinoma. A: Retrograde pyelogram demonstrating a lesion occupying much of the right renal
arrows
pelvis (
). B: Right renal arteriogram showing typical lack of arterial abnormality in the region of the tumor (
consisting of pain, fever, and leukocytosis, which is selflimited and amenable to supportive measures. There is
evidence that complete renal infarction with absolute
ethanol, rather than partial or incomplete embolization
with larger particles such as Gelfoam, results in less severe
postembolization syndrome.
46,48
the history, physical examination, and noninvasive imaging studies. Wilms’ tumors are bilateral in approximately
9% of cases.
49
Angiographically, the lesions look similar
to renal cell carcinoma.
It must be emphasized that there is no distinguishing
angiographic appearance that can give a histologic diag-
arrows
).
Urothelial neoplasms
Urothelial neoplasms are the second most common primary tumors involving the kidney, and most are transitional cell carcinomas (TCC). Usually TCC is confined to
the urothelium and collecting system, and it almost never
presents any significant arterial abnormality (Fig. 23-14).
When the lesions grow bulky and invade the renal parenchyma, they can appear as hypovascular or, at most, minimally vascular masses.
Wilms’ tumor
Wilms’ tumor, or nephroblastoma, is the third most common primary renal malignancy. It tends to occur in early
childhood, usually before the age of 5 years, although,
rarely it does occur in adults. The tumors usually present
as a palpable abdominal mass and can be associated with
hematuria, anemia, fever, and weight loss, much like renal cell carcinoma. The lesion is usually identified from
FIGURE 23-15. Avascular renal cell carcinoma.
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