Transcription:
What is a Kidney Embolization and Who Might Need One?

Carl Maronich (Host): And this is the Well Within Reach Podcast. I’m Carl Maronich. Joining us today is Dr. Arun Jagannathan. Dr. welcome.

Arun Jagannathan, MD (Guest): Welcome Carl. Thank you for having me.

Carl: Well I am glad you are able to make it. And you are an interventional radiologist, not telling you anything you don’t already know; but that’s what you are, and we need to find out a little bit about what that exactly is. What does an interventional radiologist do?

Dr. Jagannathan: That’s a good question Carl. So, a lot of people when they think of a radiologist, they think of someone who is sitting in a dark room, reading studies and probably having very little interaction with other people outside of other specialists that they discuss those cases with. But actually, some of us that specialize in vascular and interventional radiology actually do procedures on patients and we use our specialized imaging knowledge in order to use that as a guide to perform procedures.

Carl: Sure, that makes sense, so and what parts of the body do you work with?

Dr. Jagannathan: It is actually a better question, what parts of the body do we not work in and we are essentially everywhere in the body with exception of the heart and the head. We work in all organ systems; arterial and venous circulation and we use all forms of different types of modalities to do our procedures. Everything from ultrasound guidance to x-ray guidance to CT-guidance.

Carl: So, you, in your education, you went to medical school and when is it, you had to decide that what your specialty was going to be?

Dr. Jagannathan: So, just as in any other residency decision, we decide towards the end of medical school what residency we would like to go into and at the time in which I trained; we would – there was only one pathway to become a vascular and interventional radiologist and you had to go through a full diagnostic radiology residency after medical school, so one year of internship followed by four years of diagnostic radiology followed by the interventional fellowship. Now, they have actually added a few additional pathways in which you can start specialization a little bit earlier.

Carl: Yeah, and what drew you to that specialization?

Dr. Jagannathan: The specialization was, I made that decision based on the fact that I liked imaging, I liked looking at images, but I also like to get my – you know I would like to be a little active and I would like to have a little bit of patient interaction and I like to do procedures so, it was perfect fit for me.

Carl: So, that interventional component allowed you to do that.

Dr. Jagannathan: Absolutely.

Carl: Interventional radiologists have been in the news recently because of a procedure that Melania Trump had, a kidney embolization, I believe it was. Talk a little bit about what that specific procedure is.

Dr. Jagannathan: So, with regards to Melania Trump, we don’t have a whole lot of details. They haven’t provided a lot of details regarding what exact procedure she had done.

Carl: And to make it clear, you were not her doctor, you didn’t – so we are not violating any HIPAA rules here or anything, you have no patient – direct patient information on the case.

Dr. Jagannathan: Correct, absolutely. We are just – we are making inferences regarding what type of procedure she may have had, based on the information that was provided to us. An embolization procedure in general, is essentially a procedure that decreases flow, that’s strictly what it means. And you can decrease flow in a multitude of different fashions using different types of devices. And these are performed using a catheter which is place through the arteries and that can placed from a multitude of different approaches, from the groin, from a common femoral artery all the way to potentially the radial artery. And that catheter is then directed into the organ in which you would like to decrease blood supply and then either particles, medications, or coils or other forms of closure devices are then implanted via that catheter in order to decrease the blood supply.

Carl: And why would you want to decrease blood supply? Why would someone have an embolization?

Dr. Jagannathan: So, embolizations can be done for acute traumatic reasons, bleeding from an organ. It can be done from a postoperative bleeding complication after a procedure. It could be done in order to decrease blood supply to a tumor and that could be to a benign tumor, it could be to a malignant tumor. It could be done to close down an abnormal communication between an artery and a vein, arteriovenous malformation or an arteriovenous fistula.

Carl: When we talk about the kidney embolization procedure, who would be at risk for needing that type of procedure? What type of patient would be at risk for that?

Dr. Jagannathan: So, the type of patients that develop benign kidney tumors, the majority of these are called angiomyolipomas. They can develop in anyone and they tend to develop as people age and they are a little bit more common in women about four to one. The majority of patients that have these are patients that are over the age of forty or patients that suffer from tuberous sclerosis and those are patients that can develop potentially multiple of these angiomyolipomas. Malignant tumors, there are a multitude of different malignant tumors that can occur in the kidneys and they can occur in all ages. Post-traumatic injuries can obviously occur to anyone, post-surgical complications and those things can occur to anyone at any age.

Carl: Sure. And so how would this initially present? If it’s in the kidneys, as you try to go to the bathroom or how do these things usually present and what would cause someone to think heh, I better – this is something I better get checked out?

Dr. Jagannathan: No, that’s a good question. Angiomyolipomas honestly, are – the majority of them are not symptomatic. They are small, they are not symptomatic, and they are mostly – most often incidentally discovered on an imaging exam. For example, a patient may have a CAT scan for some other reason and we may discover a small 5-millimeter, 1-centimeter, 2-centimeter angiomyolipoma which is really of very little clinical significance. Patients that have larger angiomyolipomas, greater than 4 centimeters or so are at much higher risk of developing bleeding. When they develop bleeding complications, they can have acute onset of flank pain, they can have blood in their urine and those are the two most common ways in which those things can present.

Carl: And can be the indicators of something more serious potentially?

Dr. Jagannathan: Definitely.

Carl: Yeah so that is really not something you want to let go.

Dr. Jagannathan: No, if you are having symptoms from potentially from a bleeding lesion in the kidney, then definitely you need to be evaluated. You need to have a cross sectional imaging study either a CAT scan or an MRI and then potentially be treated for that.

Carl: For most people, a sudden discomfort, or a feeling or blood in the urine or those kinds of things, their normal path probably is going to be to their family doctor, we’ll say, their primary care provider, is that what you would recommend and then if they that provider finds something serious they would refer to you? Is that the typical path a patient would take?

Dr. Jagannathan: So, the typical pathway for a patient that may have bleeding or symptoms from a benign tumor such as an angiomyolipoma is that they will oftentimes either present to their primary care provider as you said, or present to the emergency department because a lot of these symptoms are often seen with something more benign like a renal stone obstructive process. From that point on, we may, once we have determined there is a lesion, we will have the patient evaluated by a urologist as well and then in conjunction with the urologist and a primary care position, we will make a determination if we feel that the patient would be better suited to a minimally invasive treatment option or an open or laparoscopic surgical option.

Carl: And for most of these patients, it may be difficult to say all, but the prognosis is it generally a positive path or what would you talk about the prognosis of these patients long-term.

Dr. Jagannathan: Long-term prognosis is very good. Generally speaking, if we do a minimally invasive embolization approach, these tumors respond very, very well. We decrease the blood supply, the tumor then it scars down and decreases in size. Very, very small number of them, a small percentage of them may require a second embolization or potentially need to have a more invasive surgical option. So, yes, patients that have angiomyolipomas that may have symptoms from them or may have a concern for future bleeding based on the size of them, they are often – those patients tend to do very, very well with these treatments.

Carl: Yeah, I going to, I think I know the answer to the question, but I will certainly ask it and that is, is there things people can do to avoid getting in this situation? You know we should all eat healthy and exercise more and all those kinds of things, but specific to the kidney, good hydration, is there anything else folks should do to try to keep positive kidney health?

Dr. Jagannathan: Specifically, to prevent development of angiomyolipomas or this benign type of tumor, there really is nothing that you can do specifically. Obviously, in order to prevent other types of kidney issues, maintaining good blood sugar control, blood pressure control, maintaining hydration; those are all things that we can do to prevent kidney failure; but with regards to this tumor, there is nothing that can be done from a preventative standpoint.

Carl: Yeah. If someone at home is looking for more information, are there places you would recommend they look to try - you know the internet is full of all kinds of information, some better than other. Is there anywhere you would recommend someone look to try to learn more on their own?

Dr. Jagannathan: Well, I don’t think the majority of people probably really need to be too focused on this particular type of benign tumor.

Carl: You have mentioned a benign status a few times. What if there is a malignant finding in what’s been done with the patient? What happens then?

Dr. Jagannathan: No, that’s a good question Carl. Honestly, malignant tumors in the kidneys depending on the size of the tumor, they can potentially be treated minimally invasively if they are small enough, we can actually perform a CT-guided ablation in which we use either heat or cold-therapy in order to destroy the tumors. Larger tumors will oftentimes need to be resected by the urologist. Even in those tumors, if the tumor is large and has a very, very large blood supply, and there is a concern for significant blood loss during the procedure, we will perform an embolization prior to the surgery in order to decrease that blood loss during the procedure.

Carl: And when you are doing a procedure, is it an office-based procedure or is it in the OR, or how do those go?

Dr. Jagannathan: So, the procedures that we do that are CT-guided for example an ablation procedure for a malignant small tumor in the kidney, we do that in the CAT-scan machine itself. Procedures that we do for embolization, we do in an angiography suite where we have real-time x-ray available for us to be able to visualize the catheters and the blood supply to the organ as we shut it down.

Carl: So, having that ability to really watch as you go real-time as you said, I’m going to guess that that is something that is fairly new. In the years you have been in practice, have you seen a lot of change in the way technology is assisting the work that you do?

Dr. Jagannathan: I think that what really has changed a lot. The technology is always advancing obviously, and then the devices are also advancing at the same time, so we have a lot of new more advance catheters, smaller catheters. We have newer techniques that we are able to do. From a minimally invasive radial artery approach, we can actually, we can access the kidney from the wrist, something that we were not doing when I first started training. We were doing all of these cases from the groin. The types of devices that we use to embolize, the type of coils, the type of particles; all of these things have advanced since I first started training. So, we have a lot larger armamentarium in order to do these procedures than we did previously so, there is no doubt that we are just going to continue to see more and more advances and probably be able to treat an even wider array of diseases moving forward in the kidneys.

Carl: Very good. Well Dr. Jagannathan, we appreciate your time today. You have given us a lot of information on kidney embolization and we appreciate you being part of the podcast.

Dr. Jagannathan: Alright, thanks Carl.