Predictors For Failure Of Angiographic Management Of Hemorrhage After Percutaneous Nephrolithotomy And Establishment Of Prediction Models

Objective:To retrospectively analyze the characteristics of severe or persistent and delayed hemorrhage after percutaneous nephrolithotripsy(PCNL),and to explore the characteristics of vascular injury under digital subtraction angiography(DSA)and the related risk factors of the failure of the first angiographic management(AM),establish a logistic regression prediction model according to the results.Methods:The data of 122 patients who received angiographic management for severe or persistent or delayed bleeding after PCNL in the second affiliated Hospital of Kunming Medical University from January 2014 to December 2020 were analyzed retrospectively.Univariate and multivariate logistic regression analysis was performed on 14 patients with initial AM failure(group A)and 108 patients with initial AM success(group B)to screen out the early warning factors of first AM failure after PCNL,and to establish a logistic regression-based prediction model.At last,the goodness of fit of the test prediction model was tested by Hosmer and Lemeshow,and the efficiency of the prediction model was evaluated by the area under the ROC curve.Results:The success rate of the first AM treatment was 88.52%(108/122)in the 122 patients who were bleeding after PCNL.In these cases,digital subtraction angiography(DSA)showed contrast extravasation(26.2%),pseudoaneurysm(19.7%),arteriovenous fistula(17.2%)and multiple combined signs.The failure of the initial AM treatment of bleeding after PCNL in 14 cases(11.5%),of which 13 cases were completely stopped by re-AM treatment,and only 1 case underwent interventional nephrectomy after 3 times of AM.Univariate analysis showed that multiple percutaneous renal channels,urine WBC count pre-PCNL,blood WBC count pre-AM,neutrophil count pre-AM,multiple bleeding lesions and blood transfusion volume after PCNL were related to the failure of the initial AM for bleeding after PCNL.Multivariate Logistic regression analysis showed that pre-AM WBC count(OR=5.270,P=0.021),pre-AM neutrophil count(OR=6.024,P=0.015)and multiple bleeding sites(OR=6.649,P=0.017)were independent predictors of the first AM failure after PCNL.The multivariate logistic regression analysis variables with statistical significance were added to a regression equation,and the prediction model was P=1/[1+EXP(-1.266+1.662× AM pre-blood WBC count+1.794 × AM pre-blood neutrophil count+1.894 × multiple bleeding sites)].The Hosmer-Lemeshow test indicated that the fitting degree of the prediction model was χ2=4.677(P=0.791);and the area under the ROC curve was 0.878 with 95%CI(0.782-0.904).Conclusion:The main manifestations of bleeding after PCNL under DSA were contrast medium extravasation,pseudoaneurysm,arteriovenous fistula and the above combined signs.Pre-AM blood WBC count,pre-AM blood neutrophil count and multiple bleeding sites are independent risk factors for the first AM failure after PCNL.The prediction model has a certain early warning and evaluation value.Bleeding after PCNL should be actively controlled.We should pay more attention to identify all bleeding lesions during angiography,which can reduce the risk of initial AM failure after PCNL.