In this episode, host Dr. Chris Beck interviews Dr. Nima Kokabi about renal trauma embolizations, including imaging workup, embolization technique, and a warning on renal biopsies.
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SHOW NOTES
Dr. Kokabi was born in Iran, then moved to Canada where he grew up. He attended medical school in Australia due to the shortage of English speaking medical schools in Canada. After his medical training, he was interested in IR, and came to Yale for a fellowship. He then joined Emory as an attending, where he serves one of the largest trauma hospitals in the country. IR and trauma surgery have a close relationship at Emory, and Dr. Kokabi notes they rely more and more on IR for trauma management, even for things such as penetrating trauma, which is traditionally handled by surgery.
Most IR consults for kidney injury are iatrogenic from non-target renal biopsies in a nephrology office. The rules for getting access to a kidney that IRs are trained in are generally not followed by nephrology, and only some have ultrasound guidance for their biopsies. Other consults for bleeding from kidney injury are post-op from a partial nephrectomy or from blunt trauma. To work it up, he gets a 2 phase arterial and venous CT. All kidney injuries are evaluated and reported using the American Association for the Surgery of Trauma (AAST) grading scale. If there is an active bleed, they will go to IR for embolization. If the injury is severe, and there is no parenchymal enhancement, this indicates either the artery or both the artery and vein were transected, and this patient requires surgery. In cases where there is only a small pseudo-aneurysm or a perinephric hematoma, these patients can be monitored with repeat imaging.
For the embolization, Dr. Kokabi uses radial access. For his microcatheter, he likes the True Select. He always uses coils in the kidney, while in the liver, he uses gel foam. Some of his colleagues use glue for the kidney. He prefers detachable Embold coils, which are fiber coils with a nitinol pusher, so they don’t kink when being pushed very fast, and can be adjusted if positioning is unsatisfactory. When he is finished, he injects first through the microcatheter and then again through the base catheter to ensure he hasn’t missed any bleeding. He generally follows patients in the hospital for 1-2 days, before signing off. His parting advice to trainees and anyone doing kidney biopsies is to exercise caution, because although it is just a biopsy, it can cause life-threatening bleeding.
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RESOURCES
AAST Kidney Injury Scale:
https://radiopaedia.org/articles/aast-kidney-injury-scale
