Transrenal Ureter Occlusion with an Amplatzer Vascular Plug Hans H. Schild, MD, Carsten Meyer, MD, Markus Mo ¨ hlenbroch, MD, Stefan C. Mueller, MD, Birgit Simon, MD, and Christiane K. Kuhl, MD The Amplatzer vascular plug has been used as an embolic device in a variety of cardiovascular interventions. The present report describes successful transrenal ureter occlusion with an Amplatzer plug inserted into an excised latex cover. The procedure led to immediate ureter occlusion in a patient with vesicovaginal fistula. Further investigation into the use of this technique for ureteral occlusion is warranted. J Vasc Interv Radiol 2009; 20:1390 –1392 PLACEMENT of a nephrostomy tube reduces— but does not completely abolish— urinary flow down the ure- ter. However, complete interruption of flow may be desired, such as in pa- tients with advanced pelvic malignan- cies and urinary fistulas. Blockade of urinary flow can be achieved percuta- neously via several previously de- scribed techniques (1–11), each of which has its pros and cons. In gen- eral, embolic materials may dislodge allowing for recurrent urinary flow. Also, some techniques require special equipment and materials that may not be readily available. Herein we de- scribe a new technique with an Am- platzer vascular plug (AGA Medical, Plymouth, Minnesota), which was in- serted into a sterile latex cover. CASE REPORT The reported intervention was ap- proved by the department‘s internal review board. A 62-year-old female patient presented with a large vesico- vaginal fistula from extensive untreat- able cervical cancer. In the setting of a nonfunctioning right kidney, a left- sided nephrostomy was placed. Pelvic leakage improved only slightly. A bal- loon catheter was placed into the left distal ureter by an attending urologist and the balloon was inflated until complete obstruction was achieved. With this catheter in place, the pa- tient‘s condition improved markedly, so it was decided to permanently oc- clude the ureter, and the patient was referred for a percutaneous interven- tion. We exchanged the nephrostomy catheter for a 12-F vascular sheath, which was inserted via the renal pelvis down the ureter. The occlusion was performed with use of a modified Am- platzer vascular plug II (Fig 1): an Am- platzer vascular plug with an outer diameter of 12 mm was chosen be- cause it corresponded to the size of detachable balloons formerly used for this purpose (6,8). The device was placed with its tip in a sterile latex finger stall obtained from a commercially available condom tip (MAPA, Zeven, Germany), which was approximately 2 cm in length. The latex hood was then fastened by knotting nonabsorbable su- ture material proximal to the plug. The device was then advanced through the sheath. When exiting the sheath, the Amplatzer plug expanded, pressing the latex finger stall firmly against the inner ureteral wall. Contrast medium injec- tion via the sheath showed immediate and complete ureteral obstruction. Al- though initially the Amplatzer plug was still deformed, its shape was reconsti- tuted by the next day (Fig 2). Clinical follow-up over a period of 2 months showed the ureter occlusion to still be efficient. DISCUSSION Transrenal ureter occlusion with permanent urinary diversion may be indicated as a palliative treatment in patients with urinary fistulas, intrac- table cystitis, or incontinence. Vari- ous techniques have been described with Gianturco coils with or without Gelfoam pledgets (Pharmacia & Up- john, Kalamazoo, Michigan), percu- taneous clips, nondetachable and de- tachable balloons, tissue adhesive, electrocautery, and silicone occlud- ing devices (1–11). However, none of the described techniques is ideal. Among the disadvantages may be the large access size required, the need for special equipment, ques- tionable or temporary effectiveness, or long delay time until ureter occlu- sion if it results from an inflamma- tory response and not a plug effect. In our experience, ureter occlu- sion with coils with and without Gel- From the Department of Radiology (H.H.S., C.M., M.M., B.S., C.K.K.) and Department of Urology (S.C.M.), University of Bonn Hospital, Sigmund Freud Strasse 25, 53105 Bonn, Germany. Received January 15, 2009; final revision received May 10, 2009; accepted June 14, 2009. Address correspon- dence to H.H.S.; E-mail: schild@uni-bonn.de None of the authors have identified a conflict of interest. © SIR, 2009 DOI: 10.1016/j.jvir.2009.06.032 1390