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Embolization of Giant
Angiomyolipoma
Adam S. Fang, MD
David S. Wang, MD
Division of Interventional Radiology
Stanford University School of Medicine
Disclosures
• No relevant disclosures
Case
HISTORY OF PRESENT ILLNESS:
 27 year old female, 35 weeks pregnant, presented to ER 11/2014 with acute
left flank pain.
PAST MEDICAL HISTORY:
 None
PAST SURGICAL HISTORY:
 D+C x 2
FAMILY HISTORY:
 No renal tumors
 Uncle with colon cancer
 Father died of heart disease
SOCIAL HISTORY:
 Has 2 children, youngest age 4. No prior difficulties with pregnancy.
Physical Exam & Labs
• BP: 135/77, Pulse: 75, Resp: 17, SpO2: 98%
• Abdomen: soft, NT, ND, no mass palpated
• Labs
-Normal UA
 Renal ultrasound showed a complex left renal mass in the superior pole, measuring
8.2 x 7.0 x 6.1 cm
 Contrast-enhanced CT and MRI showed a large complex
heterogeneous mass in the left upper quadrant emanating from
superior pole of left kidney with associated fatty elements and
hemorrhage, compatible with a large AML.
 Left posterior division superior segmental artery supplying the giant AML
was embolized with 3 cc mixture of 7:3 ethanol:lipiodol
 Left anterior division superior segmental artery and lateral branches
supplying the AML was embolized with 5 cc mixture of 7:3 ethanol:lipiodol.
Contrast is noted pooling within pseudoaneurysm
 Follow-up 3 month contrast-enhanced MRI showed interval decrease in
size of the left upper pole giant AML (green). However, there was
persistent heterogeneous enhancement.
 CT angiogram shows a parasitized vessel (yellow) arising from the left
posterior aspect of aorta.
Arteriogram of parasitized branch vessel arising from the left posterior aspect of aorta
 Large arterial network supplies the
upper half of the giant AML.
 Dominant superior and inferior
divisions.
 Distal branches appear to communicate
with a network of capsular branches.
Superior and distal branches of parasitized vessel arising from left posterior aspect of aorta
 Pre-embolization arteriogram of
superior and distal branches of
parasitized vessel arising from
left posterior aspect of aorta
shows supply to AML.
 Embolization of distal
branches of parasitized
vessel w/ 6 cc mixture of
7:3 ethanol:lipiodol to
stasis
Post-embolization arteriogram of parasitized branch vessel arising from left
posterior aspect of aorta
 No residual arterial enhancement of the
AML.
 No antegrade flow in the treated renal
artery branches. The rest of the mid to
inferior pole left kidney enhances.
Post-embolization
 5 months after embolization, CT showed replacement of the
treated AML with a large fluid collection.
 The collection was managed with percutaneous drainage.
 Thick brown milky fluid was removed.
 Analysis of the fluid showed 98% neutrophils, creatinine level of 0.6
mg/dL, triglyceride 34 mg/dL, and negative cultures.
 After removal of the drain, the collection recurred 3 months
later. This was treated with percutaneous drainage and
ethanol sclerosis.
Question 1
• What size AML are at risk for acute hemorrhage?
A. 1.5 cm
B. 2.0 cm
C. 2.5 cm
D. 4.0 cm
Answer
•
What size AML are at risk for acute hemorrhage?
A. 1.5 cm
B. 2.0 cm
C. 2.5 cm
D. 4.0 cm
• More than 50% of AML 4 cm or larger hemorrhage and one-third
present with acute hemorrhagic shock.1
Discussion
 Renal angiomyolipomas (AMLs) comprise of vascular, smooth muscle and
adipose tissue
 80% (sporadic), 20% (tuberous sclerosis complex)
 Large AMLs become symptomatic (80%, >4 cm)
 Giant AML associated with significant morbidities including insidious flank
pain ,renal insufficiency, and eventual renal failure
 Risk of hemorrhage increases with size
 Treatment options:
-conservative management: AML <4 cm & asymptomatic
-selective transarterial embolization: parenchyma-sparing
-partial or total nephrectomy.
Question 3
• What is the preferred embolic agents for treating AML with selective
transarterial embolization?
A. Gelfoam
B. 7:3 ethanol to Lipiodol
C. Coils
D. Polyvinyl alcohol spheres
Answers
•
What is the the preferred embolic agents for treating AML with selective
transarterial embolization?
A. Gelfoam
B. 7:3 ethanol to Lipiodol
C. Coils
D. Polyvinyl alcohol spheres
• Ethanol provides permanent occlusion at arteriolar and capillary
levels distal to level of collateral inflow and effectively necrotizes
tumor tissue.1
• Polyvinyl alcohol spheres fail to penetrate capillary level and are
less effective agent.1
• Coils should never be used as collateral vessels may form around
level of occlusion. 1
References
1. Bishay VL, Crino PB, Wein AJ, et al. Embolization of giant renal
angiomyolipomas: technique and results. J Vasc Interv Radiol
2010; 21:67-72.
2. Dickinson M, Ruckle H, Beaghler M, et al. Renal angiomyolipoma:
optimal treatment based on size and symptoms. Clin Nephrol 1998;
49:281–286.
3. Hao LW, Lin CM, Tsai SH. Spontaneous hemorrhagic
angiomyolipoma present with massive hematuria leading to urgent
nephrectomy. Am J Emerg Med 2008; 26:249.