Cotton Fiber Embolization During Angiography

THE INJECTION of particulate foreign material into blood vessels during angiography obviously should be judiciouslyavoided. This report emphasizes one potential mechanism of accidental injection of foreign material. Case Reports CASE I: K. S., a 42-year-old man, entered the hospital for evaluation of hypertension. Intravenous pyelography showed a mass in the lower pole of the right kidney, and renal arteriography was performed. A PE 240 catheter was passed into the aorta through the right femoral artery by the Seldinger percutaneous technic. Abdominal aortography was performed twice with the injection of 30 ml of Renografin 764 during each procedure. The PE 240 catheter was then replaced with a radiopaque catheter (Kifa No.2, green) for selective renal arteriography. Ten milliliters of Renografin 60 was injected into the right main renal artery, and serial films were obtained. A lower pole right renal artery could not be catheterized, and 10 ml of Renografin 60 was injected in the aorta near the origin of this accessory artery. The angiographic diagnosis was hypernephroma. During the angiographic procedure the catheters were irrigated with sterile saline containing heparin. This solution was placed in an open container on the angiographic table and subsequently drawn from this container into a syringe used for irrigating the catheters. During the procedure the guide wire was cleansed with a gauze sponge moistened in the open container of saline solution. The right kidney was removed five days after angiography. Pathology: In addition to a ,5 ern hypernephroma, there were three conical areas of recent cortical infarction, the largest 6 mm in maximum dimension. The center of each area was firm and gray-yellow with peripheral hyperemic zones, as if it were about one week old. Arterioles throughout the kidney contained emboli of strongly birefringent, semicrystalline fibers, of variable width and length, usually about 8 by 50 micra. One or two such emboli were present in most of the 10 by 20 mm sections. Together with endothelial cell proliferation and hypertrophy, they occluded some of the arteriolar lumens which were 50 to 150 micra in diameter (Fig. 1). Inflammatory cell exudation was not evident, though mural fibrinous deposits were present in some instances. The fibers were darkly colored by the periodic acid-Schiff stain and appeared identical to fragments of cotton surgical sponges suspended in saline or mixed with tissue, fixed, paraffin-imbedded, sectioned, and stained in the ordinary fashion. They often demonstrated a central slit-like cavity and resembled in every way the cotton fibers described by others (5, 9, 17). CASE II: H. L. was a 63-year-old male with urinary tract symptoms of prostatic hypertrophy. Intravenous pyelography performed prior to surgical correction of the prostatic hypertrophy revealed a mass in the lower pole of the right kidney.