title: First Prize (tie): Hemorrhage following percutaneous renal surgery: characterization of angiographic findings.
abstract: OBJECTIVE
  Percutaneous surgery is an established approach to a spectrum of renal pathology, and hemorrhage is the most concerning complication of this technique. We determined the frequency of postoperative hemorrhage requiring selective angioembolization (sae), the efficacy of this approach, and characterized the angiographic findings.
  
  
  METHODS
  We reviewed our database of 4695 patients who underwent percutaneous renal surgery and identified patients requiring SAE for postoperative hemorrhage. Angiographic findings were recorded and efficacy of SAE documented.
  
  
  RESULTS
  Patients undergoing percutaneous stone extraction (PSE; 3685), percutaneous antegrade endopyelotomy (PAE; 850), and upper-tract transitional cell carcinoma (UTTCC) resection (160) were reviewed. We identified 57 patients requiring SAE (1.2%) who underwent 44 PSEs (77.2%), 7 PAEs (12.3%), and 6 UTTCC resections (10.5%). This represented 1.2%, 0.8%, and 3.2% of all PSE, PAE, and UTTCC resections, respectively. Angiography revealed treatable lesions in 94.7% of patients. Overall, 64 angiographic findings were encountered including 30 pseudoaneurysms (53% of patients, 47% of findings), 14 arteriovenous fistulas (AVFs) (25% of patients, 22% of findings), and 14 instances of contrast extravasation (25% of patients, 22% of findings). Two arterial dissections and one instance each of a hypervascular area, a vascular "cut-off" sign, and a fistula between an artery and the percutaneous tract were identified. One bleeding vessel identified at the base of a UTTCC resection was not amenable to embolization. Ten patients (17.5%) had >or=1 angiographic finding. Three patients (5.3%) had no angiographic findings to account for hemorrhage. No angioembolization-related complications occurred. Complete resolution of bleeding was observed in 54 patients (95%).
  
  
  CONCLUSIONS
  Major hemorrhage requiring intervention after percutaneous renal surgery is uncommon. The most common angiographic finding is arterial pseudoaneurysm, followed by arteriovenous fistula, and contrast extravasation. In 95% of cases angiography reveals a demonstrable and treatable etiology. This strongly supports the first-line use of angiography for intractable bleeding in this setting.
authors.affiliation: Laparoscopy and Robotic Surgery, The Smith Institute for Urology, North Shore-Long Island Jewish Health System, New Hyde Park, New York 11040, USA.
authors.forename: Lee
authors.initials: L
authors.lastname: Richstone
authors.forename: Ernesto
authors.initials: E
authors.lastname: Reggio
authors.forename: Michael C
authors.initials: MC
authors.lastname: Ost
authors.forename: Casey
authors.initials: C
authors.lastname: Seideman
authors.forename: Lindsey K
authors.initials: LK
authors.lastname: Fossett
authors.forename: Zeph
authors.initials: Z
authors.lastname: Okeke
authors.forename: Ardeshir R
authors.initials: AR
authors.lastname: Rastinehad
authors.forename: Igor
authors.initials: I
authors.lastname: Lobko
authors.forename: David N
authors.initials: DN
authors.lastname: Siegel
authors.forename: Arthur D
authors.initials: AD
authors.lastname: Smith
mesh_terms: D017541:Aneurysm, False / Q000150:complications / Q000000981:diagnostic imaging; D000792:Angiography; D001164:Arteriovenous Fistula / Q000150:complications / Q000000981:diagnostic imaging; D001363:Awards and Prizes; D004621:Embolization, Therapeutic / Q000009:adverse effects; D006801:Humans; D007674:Kidney Diseases / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D009403:Nephrostomy, Percutaneous / Q000009:adverse effects*; D019106:Postoperative Hemorrhage / Q000150:complications / Q000000981:diagnostic imaging* / Q000209:etiology*; D012077:Renal Artery / Q000000981:diagnostic imaging; D016896:Treatment Outcome