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. 2010 May;21(5):711-8.
doi: 10.1016/j.jvir.2010.01.027. Epub 2010 Mar 21.

Endovascular temporary vessel occlusion with a reverse-thermosensitive polymer for bloodless minimally invasive renal surgery

Sebastian Flacke  1 , Alirezah Moinzadeh, John A Libertino, John Merhige, Jean-Marie Vogel, Kathy Lyall, Urmila Khettry, Curtis W Bakal, Peter N Madras
Affiliations

Endovascular temporary vessel occlusion with a reverse-thermosensitive polymer for bloodless minimally invasive renal surgery

Sebastian Flacke et al. J Vasc Interv Radiol. 2010 May.

Abstract

Purpose: To demonstrate the feasibility of reversible vessel embolization with angiographic guidance for delivery of a rapid reverse-thermosensitive polymer to provide hemostasis as an aid for minimally invasive renal surgery in a porcine model.

Materials and methods: After isolation of the left kidney of seven anesthetized pigs (50-70 kg) with a surgical robot, a renal angiogram of both kidneys was obtained. A 5-F angiographic catheter was used to selectively embolize a lower-pole segmental artery of the right and left kidney with a thermosensitive polymer (LeGoo-XL). Distal and proximal embolization of the target vessel was compared. Degree and duration of hemostasis and reversibility was determined. After complete hemostasis was obtained angiographically, a partial robotic lower-pole nephrectomy was performed on the left kidney only.

Results: Only proximal embolization provided controllable hemostasis. A 20% polymer concentration in a buffer solution of 40% saline solution and 40% iodine contrast medium by weight injected at room temperature resulted in a reproducible embolus for more than 30 minutes, the time needed to perform a partial nephrectomy. The radiographic appearance of the embolus was used to determine the total amount of polymer needed. Cold saline solution completely dissolved any residual polymer at the end of surgery.

Conclusions: Proximal arterial occlusion with a thermosensitive polymer can be rapidly reversed with selective intraarterial infusion of chilled saline solution. Preceding nephron-sparing surgery with transcatheter embolization of the relevant branch of the renal artery with the polymer can facilitate the procedure and ought to be investigated further.

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Figures

Figure 1
Figure 1
Images are showing the right kidney of pig 6. The 5F catheter is advanced into the lower pole artery through the guiding catheter in the main renal artery (a). The radiopaque polymer is injected with a forceful manual injection creating an intial plug (b, arrow head) which is further expanded using a screw driven injection with a handheld injector (c, arrow head). An angiogram post embolization demonstrates complete occlusion of the lower pole renal artery with unimpaired perfusion of the upper pole of the kidney. A small amount of contrast in seen around the proximal portion of the plug (d, arrow head).
Figure 1
Figure 1
Images are showing the right kidney of pig 6. The 5F catheter is advanced into the lower pole artery through the guiding catheter in the main renal artery (a). The radiopaque polymer is injected with a forceful manual injection creating an intial plug (b, arrow head) which is further expanded using a screw driven injection with a handheld injector (c, arrow head). An angiogram post embolization demonstrates complete occlusion of the lower pole renal artery with unimpaired perfusion of the upper pole of the kidney. A small amount of contrast in seen around the proximal portion of the plug (d, arrow head).
Figure 1
Figure 1
Images are showing the right kidney of pig 6. The 5F catheter is advanced into the lower pole artery through the guiding catheter in the main renal artery (a). The radiopaque polymer is injected with a forceful manual injection creating an intial plug (b, arrow head) which is further expanded using a screw driven injection with a handheld injector (c, arrow head). An angiogram post embolization demonstrates complete occlusion of the lower pole renal artery with unimpaired perfusion of the upper pole of the kidney. A small amount of contrast in seen around the proximal portion of the plug (d, arrow head).
Figure 1
Figure 1
Images are showing the right kidney of pig 6. The 5F catheter is advanced into the lower pole artery through the guiding catheter in the main renal artery (a). The radiopaque polymer is injected with a forceful manual injection creating an intial plug (b, arrow head) which is further expanded using a screw driven injection with a handheld injector (c, arrow head). An angiogram post embolization demonstrates complete occlusion of the lower pole renal artery with unimpaired perfusion of the upper pole of the kidney. A small amount of contrast in seen around the proximal portion of the plug (d, arrow head).
Figure 2
Figure 2
The peritoneal reflection over the left kidney was removed to allow for better visual inspection and future robotic lower pole partial nephrectomy (a). After complete occlusion of the segmental artery the lower pole blanched. The distal portion of the lower pole is resected and the cutting plane is free of blood (b).
Figure 2
Figure 2
The peritoneal reflection over the left kidney was removed to allow for better visual inspection and future robotic lower pole partial nephrectomy (a). After complete occlusion of the segmental artery the lower pole blanched. The distal portion of the lower pole is resected and the cutting plane is free of blood (b).
Figure 3
Figure 3
Initial (a) and selective angiograms (b) show catheter positioning and the extent of the target area. After injection of the polymer, which can be seen as a small plug in the lower pole renal artery (c, arrow head), the upper pole perfusion remains unimpaired. At the end of the surgical resection complete organ perfusion is restored with the injection of cold saline. The surgical defect after resection of a portion of the lower pole is seen. (d, arrow heads).
Figure 3
Figure 3
Initial (a) and selective angiograms (b) show catheter positioning and the extent of the target area. After injection of the polymer, which can be seen as a small plug in the lower pole renal artery (c, arrow head), the upper pole perfusion remains unimpaired. At the end of the surgical resection complete organ perfusion is restored with the injection of cold saline. The surgical defect after resection of a portion of the lower pole is seen. (d, arrow heads).
Figure 3
Figure 3
Initial (a) and selective angiograms (b) show catheter positioning and the extent of the target area. After injection of the polymer, which can be seen as a small plug in the lower pole renal artery (c, arrow head), the upper pole perfusion remains unimpaired. At the end of the surgical resection complete organ perfusion is restored with the injection of cold saline. The surgical defect after resection of a portion of the lower pole is seen. (d, arrow heads).
Figure 3
Figure 3
Initial (a) and selective angiograms (b) show catheter positioning and the extent of the target area. After injection of the polymer, which can be seen as a small plug in the lower pole renal artery (c, arrow head), the upper pole perfusion remains unimpaired. At the end of the surgical resection complete organ perfusion is restored with the injection of cold saline. The surgical defect after resection of a portion of the lower pole is seen. (d, arrow heads).
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