Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y • R ev i ew

Fowler et al.
Adrenal Artery Embolization

Vascular and Interventional Radiology

Review
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Adrenal Artery Embolization:

Anatomy, Indications, and
Technical Considerations
Amy M. Fowler 1 OBJECTIVE. The purpose of this review is to describe adrenal arterial anatomy and to
John F. Burda2 discuss the indications, outcomes, and technical considerations of adrenal artery embolization.
Seung Kwon Kim1 CONCLUSION. Adrenal artery embolization can be used for management of adrenal tu-
mors (palliative for pain relief, debulking, or hormone suppression) and treatment of acute bleed-
Fowler AM, Burda JF, Kim SK ing from ruptured adrenal tumors, traumatic adrenal injury, and aneurysms. Variant arterial sup-
plies, options for embolic agents, and potential complications are important considerations.

Keywords: adrenal metastasis, adrenal tumor,
aneurysm, retroperitoneal hemorrhage, transarterial
embolization, trauma
DOI:10.2214/AJR.12.9507
Received September 22, 2012; accepted after revision
January 7, 2013.
Presented as an educational poster (abstract 327) at the
2012 annual meeting of Society of Interventional
Radiology, San Francisco, CA.
1Mallinckrodt Institute of Radiology, Washington University,
660 S Euclid Ave, Campus Box 8131, St. Louis, MO 63110.
Address correspondence to S. K. Kim (kims@mir.wustl.edu).
2 Mid-South Imaging and Therapeutics, Memphis, TN.
CME/SAM
This article is available for CME/SAM credit.
AJR 2013; 201:190–201
0361–803X/13/2011–190
© American Roentgen Ray Society
A
drenal artery embolization is a
minimally invasive procedure that
can be used as an alternative or
adjunct to surgery [1]. Because
this procedure is rarely encountered in routine
clinical practice, published reports of its use
are limited to case reports and small case se-
ries. The purpose of this review is to describe
adrenal arterial anatomy and the indications,
outcomes, and technical considerations for
adrenal artery embolization.
Arterial Supply to the Adrenal Gland
Proper interpretation of adrenal arteriograms
obtained for embolization relies on a thorough
knowledge of the complex vascular supply to
the adrenal gland. The adrenal gland classical-
ly has three arterial sources (Fig. 1A). Superior
adrenal arteries, which are often multiple, sup-
ply the superomedial gland and arise almost ex-
clusively from the inferior phrenic artery [2]. In
rare instances, they arise from the aorta, celiac
axis, or an intercostal artery [2, 3]. The middle
adrenal artery supplies the anteromedial gland
and most often arises from the lateral aspect of
the aorta [2]. Less frequently, it originates from
the inferior phrenic artery, renal artery, or celiac
axis [2, 3]. Often it is replaced by the superior
or inferior adrenal artery [2]. Inferior adrenal
arteries supply the posterior and inferolateral
gland, which is the thickest portion of the gland,
and most often arise from the superior aspect of
the renal artery [2]. In rare instances, they arise
from the aorta, a polar renal artery, or inferior
phrenic artery [2, 3]. The left inferior adrenal
artery has also been reported to arise from the
celiac axis or gonadal artery [4, 5].
Adrenal arteries are of small caliber, can
be visualized at catheter aortography in 57–
92% of patients without adrenal disease [3],
and can occasionally be seen on CT angio-
grams of the abdomen acquired with small
slice thickness (Figs. 1B–1E). Further visu-
alization of the subsequent branches of these
arteries is beyond the resolution of catheter
angiography. Most divide into 10–50 smaller
branches over the capsule [6, 7].
Small capsular arteries form a capsular
plexus from which relatively straight cap-
illaries pass through the zona fasciculata to
form a deep vascular plexus of capillary si-
nusoids near the zona reticularis. They end so
abruptly that it has been referred to as a vas-
cular dam [7]. This configuration is one pos-
sible reason that the adrenal gland is particu-
larly prone to hemorrhagic necrosis [8].
Because of the complex vascular supply to
the adrenal gland by three arteries, emboli-
zation of a single artery will not likely result
in infarction of the entire gland. If infarction
does occur, the presence of an intact contra-
lateral gland will prevent the development of
life-threatening adrenal insufficiency.
Indications for Adrenal Artery
Embolization
A variety of indications exist for adrenal
artery embolization. Most involve oncologic
applications for palliation, such as pain relief,
reduction of tumor bulk, and preoperative re-
duction of tumor vascularity. Emergency em-
bolization for hemostasis of ruptured tumors
with retroperitoneal hemorrhage is an addi-
tional oncologic application. Adrenal artery

190 AJR:201, July 2013

 Adrenal Artery Embolization

embolization can also be used to suppress ex-

cess adrenal hormone production, to treat trau-

decrease in size of mass

matic adrenal artery injury, and to occlude ad-

Dead at 3 mo of disease
progression and brain

Alive at 5-mo MRI with

Alive at least 3.5 mo

renal artery aneurysms.

Alive at least 4.5 mo

Alive at least 18 mo
Outcome

Alive at least 3 mo

Alive at least 1 mo

Alive at discharge

Alive at least 28 d
Alive at least 21 d

Alive at least 11 d

from 12 to 8 cm
Palliative Pain Relief and Tumor Debulking

metastasis
Large adrenal tumors can be painful for
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patients if inoperable and pose challenges for

resection if highly vascular. Arterial emboli-
zation of primary adrenocortical carcinomas
and adrenal metastatic lesions from renal cell
Coils (seven 3 mm × 2 cm, one 4 mm × 2 cm)

spheres (Embozene, CelaNova) (250 μm),

Polyvinyl alcohol particles (355–500 μm)

Polyvinyl alcohol particles (355–500 μm)

carcinoma and melanoma have been reported

Platinum 0.018-in coils (Tornado, Cook),

gelatin sponge (Gelfoam, Pfizer) slurry
Polymer-coated hydrogel core micro-

for reducing tumor bulk, pain relief, and pre-

Gelatin sponge particles (0.5–1 mm)

three 3 and 4 mm and one 5 mm)
operative reduction of vascularity [9]. Of the
Embolization Agent

five patients with adrenal metastases treated

with arterial embolization described in the re-
port by O’Keeffe et al. [9], three experienced
effective pain relief. Furthermore, tumor bulk
stabilized or decreased in three of the four pa-
tients who underwent follow-up CT. Figure 2
shows adrenal artery embolization performed
for pain relief for a patient with bilateral adre-
NRa

NRa
Coil

Coil
NR

nal gland metastases from melanoma.

There are currently no substantial data to
Right adrenal artery embolization,

support the use of embolization for patients

Left adrenal artery embolization,

Left adrenal artery embolization,

TABLE 1:  Reported Cases of Hemorrhagic Adrenal Masses Treated With Embolization

embolization, Adrenalectomy

embolization, Adrenalectomy
embolization, adrenalectomy

embolization, adrenalectomy

embolization, adrenalectomy

embolization, adrenalectomy
embolization, chemotherapy

with inoperable adrenal cortical carcinoma

Right superior adrenal artery
Right inferior phrenic artery
Right inferior adrenal artery

Right inferior adrenal artery

Left superior adrenal artery

Right middle adrenal artery

Right middle adrenal artery

Left middle adrenal artery

or isolated metastasis to the adrenal gland for

Treatment

the purpose of prolonging overall survival

beyond palliation. Li et al. [10] reported the
adrenalectomy

adrenalectomy

adrenalectomy

longest survival time (58 months) after recur-

embolization

rence of adrenal cortical carcinoma. The pa-

bTumor histologic features could not be definitely classified as adenoma or adrenal cortical carcinoma.

tient was a 60-year-old man treated with three

sequential transarterial embolization proce-
dures for tumor recurrence in the adrenal-
ectomy bed and liver and spleen metastases.
non–small cell carcinoma of the

For comparison, survival times for the four

Metastatic poorly differentiated

patients with inoperable adrenocortical carci-

Pathologic Finding

Adrenocortical neoplasmb
Metastatic hepatocellular

nomas reported by O’Keeffe et al. [9] were

20, 12, 2, and 2 months. Published reports of
Pheochromocytoma

Pheochromocytoma

Pheochromocytoma

Pheochromocytoma

Pheochromocytoma

embolization for the primary management of

adrenal metastases are limited to hepatocel-
Myelolipoma

Myelolipoma
carcinoma

lular carcinoma [11–16]. Shuto et al. [16] re-

ported the longest survival time (68 months)
lung

aPatient had multiple endocrine neoplasia 2A syndrome.

after transarterial embolization treatment of

ND

right adrenal metastasis in a 66-year-old man

Note—NR = not reported, ND = not determined.

with hepatocellular carcinoma. Other report-

Age (y)

38a
68

54
32

67

37

37

62
42

31
51

ed survival times range from 3 to 12 months

for patients treated with transarterial embo-
lization alone. In most of the studies trans-
Sex

M
F

arterial embolization was performed before

Hendrickson et al. 2001 [67]

adrenalectomy as transarterial chemoemboli-

Pua and Wong 2008 [22]

zation or in combination with 3D conformal

radiation therapy, percutaneous ethanol in-
Ambika et al. 2009 [44]
Hanna et al. 2011 [23]
Park et al. 2003 [21]

Nakajo et al. 2003 [25]

Chng et al. 2002 [24]

Marti et al. 2012 [17]

Yang et al. 2007 [40]
Habib et al. 2010 [19]
Ito et al. 1997 [20]
Source

jection therapy, or percutaneous intratumor-

al chemotherapy with mitoxantrone. Despite
the varied success reported, the only poten-
tially curative approach in these situations is
complete surgical resection of the tumor.

AJR:201, July 2013 191

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192
Hemorrhagic Adrenal Masses

stasis before adrenalectomy.

melanoma [27, 28, 31, 40, 41].

rhage from adrenal myelolipomas [24, 25].
stabilization before elective surgery [19–23].
lization was used for hemostasis and patient
sular pressure resulting in capsular tear and

44]. Other primary malignancies include two

renal metastases is the lung [26, 29–39, 42–
19 reports involving 25 patients in the English
tastasis accounts for only 13% of reported
sion from massive release of catecholamines
bleeding. It accounted for approximately 48%
Pheochromocytoma is the most common

primary tumors resulting in hemorrhagic ad-

hemorrhagic adrenal masses [17]. We found
common but rarely causes hemorrhage. Me-
Metastatic disease to the adrenal glands is
my in two patients with retroperitoneal hemor-
for successful hemostasis before adrenalecto-
rial embolization with polyvinyl alcohol (PVA)
covered incidentally, they can hemorrhage and
account for approximately 10% of reported
most myelolipomas are asymptomatic and dis-
of fat and bone marrow elements. Although
ma, metastases, and an adrenal cortical neo-
rhage from pheochromocytoma, myelolipo-
used for patients with retroperitoneal hemor-
arterial embolization has been successfully
conservative approaches have failed, trans-
leads to capsular tear and hemorrhage. When
result in elevated intracapsular pressure that
Rapid tumor growth has been postulated to
can cause massive retroperitoneal bleeding.

mangioendotheliosarcoma, and two cases of

hepatic angiosarcoma, one case of hepatic he-
cases of hepatocellular carcinoma, one case of
literature [26–44]. The most frequent site of
Myelolipomas are benign tumors composed
ported for cases in which transarterial embo-
high mortality rate, no deaths have been re-
chromocytoma has been associated with a
emergency adrenalectomy for ruptured pheo-
retroperitoneal hemorrhage [19]. Although
crosis and hemorrhage, and elevated intracap-
with associated vasoconstriction, tumoral ne-
to pheochromocytoma may involve hyperten-
tional possible mechanism of rupture specific
py, anticoagulation, and trauma [18]. An addi-
ture include the initiation of α-blocker thera-
133 reported cases [17]. Risk factors for rup-
of hemorrhagic adrenal masses in a review of
primary adrenal tumor to cause massive
11), embolization was performed for hemo-
Spontaneous rupture of adrenal tumors

particles or gelatin sponge particles was used

hemorrhagic adrenal masses [17]. Transarte-
plasm (Table 1). In most of these cases (9 of

TABLE 2:  Reported Cases of Embolization Used for Adrenal Hormone Suppression
Source Sex Age (y) Pathologic Finding Treatment Embolization Agent Outcome
Bunuan et al. 1978 [45] M 45 Pheochromocytoma Right inferior adrenal artery Gelatin sponge Asymptomatic at least 5 mo
embolization, adrenalectomy (Gelfoam, Pfizer)
Horton et al. 1983 [46]; M 13 Pheochromocytoma Left adrenal artery embolization, Polyvinyl alcohol foam, gelatin sponge Asymptomatic more than 1 y
Hrabvosky et al. 1982) [68] adrenalectomy (Gelfoam, Pfizer)
O’Halpin et al. 1984 [47] M 35 Pheochromocytoma (inoperable) Left middle and inferior adrenal Bucrylate-iophendylate (Myodil, Initial response then
artery embolization Glaxo) recurrence and death after
6 wk
Fowler et al.

Hokotate et al. 2003 [48]
D’Angelo 2007 [49]
Uflacker et al. 1986 [50]
O’Keeffe et al. 1988 [9]
Ueno et al. 1999 [66]
Ueno et al. 1999 [66]
Inoue et al. 1993 [69]
Blunt et al. 1989 [70]
Bourlet et al. 2007 [71]
8 M, 25 F 28–68 Aldosteronoma Adrenal artery embolization High-concentration ethanol-iohexol 82% success rate
F 56 Aldosteronoma Left adrenal artery embolization Alcohol–iodized oil (Lipiodol, Guerbet) Asymptomatic 4 mo
F 32 Adrenal cortical carcinoma, Right middle adrenal artery Absolute ethanol Symptom and hormone
Cushing syndrome embolization reduction for at least 1 y
F 63 Adrenal cortical carcinoma, Left inferior adrenal and left Polyvinyl alcohol foam (Ivalon, Initial clinical and biochemi-
Cushing syndrome inferior phrenic artery Unipoint Industries) 150–590 μm cal response with relapse at
embolization 1y
F 45 Adrenal adenoma, Cushing Left inferior adrenal artery Ethanol-iohexol Symptom and hormone
syndrome embolization reduction for at least 9 mo
F 42 Adrenal adenoma, Cushing Right inferior adrenal artery Ethanol-iohexol Procedure aborted because
syndrome embolization of marked tachycardia and
hypertension
F 55 Adrenal hyperplasia, corticotropin- Left superior adrenal artery Absolute ethanol Symptom and hormone
dependent Cushing syndrome embolization reduction for at least 7 mo
F 51 Ectopic corticotropin syndrome from Bilateral superior and middle Dura mater, alcohol, miniature steel Asymptomatic at least 10 mo
medullary thyroid carcinoma adrenal artery embolization, coils
metyrapone, bilateral
adrenalectomy
M 56 Ectopic corticotropin syndrome from Left inferior adrenal artery Trisacryl gelatin microspheres Symptom and hormone
medullary thyroid carcinoma embolization, hepatic artery (Embosphere Microspheres, reduction for at least 5 mo
chemoembolization, mitotane, Biosphere Medical) (900–1200 μm)

AJR:201, July 2013

chemotherapy
 Adrenal Artery Embolization

TABLE 3:  Reported Cases of Traumatic Adrenal Hemorrhage Treated With Embolization
Source Sex Age (y) Mechanism of Injury Angiographic Findings Embolization Agent Outcome
Igwilo et al. 1999 [53] F 58 Motor vehicle Right inferior adrenal Platinum coil (3 mm/2 cm; Tornado, Cook) Alive at least 8 d
collision artery, extravasation
Dinc et al. 2002 [54] F 23 Motor vehicle Right inferior adrenal Polyvinyl alcohol particles (45–150 μm) Alive at least 4 mo
collision artery, extravasation
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Kish et al. 2004 [55] M 33 Fall from height, Inferior adrenal artery, N-butyl cyanoacrylate glue with Alive at least 3 wk
suicide attempt extravasation ethiodized oil
Ikeda et al. 2006 [56] M 50 Fall Right inferior adrenal Vortex microcoils (Boston Scientific) and Alive at least 3 mo
artery, extravasation interlocking detachable coils

Two reports [40, 44] have been published
regarding the use of transarterial emboliza-
tion for acute control of retroperitoneal hem-
orrhage due to adrenal gland metastases from
hepatocellular carcinoma and non–small cell
lung cancer. Yang et al. [40] used coil embo-
lization before adrenalectomy, and Ambika et
al. [44] used it as the sole treatment method.
The former patient was alive 18 months after
treatment, and the latter died of overall disease
progression and brain metastasis 3 months af-
ter embolization. Figures 3 and 4 show the
cases of two patients with retroperitoneal
hemorrhage arising from adrenal gland metas-
tases (one with metastatic lung cancer and one
with metastatic melanoma) treated with tran-
sarterial embolization to achieve hemostasis.
Adrenal Hormone Suppression
Reported cases of transarterial embolization
for suppression of excess adrenal hormone
production (catecholamines, aldosterone, cor-
tisol) are summarized in Table 2. Endocrino-
logically active adrenal tumors treated with
embolization include pheochromocytoma, al-
dosteronoma, adrenal cortical carcinoma, and
adrenal adenoma.
Pheochromocytoma is a neuroendocrine tu-
mor of the adrenal medulla that secretes exces-
sive amounts of catecholamines. This tumor
can cause life-threatening hypertensive crisis
and cardiac arrhythmia. The use of transarteri-
al embolization to deactivate an endocrinolog-
ically active tumor was reported first in 1978
and again in 1983 for patients with pheochro-
mocytoma with the intended goals of reduc-
ing intraoperative and perioperative compli-
cations related to blood pressure control and
decreasing the vascularity of the tumor to min-
imize blood loss [45, 46]. Although the out-
comes for these patients were good with no
recurrence of symptoms after 5 months and
1 year after adrenalectomy, one patient with
hypertension and heart failure due to inoper-
able pheochromocytoma treated with bucry-
late (isobutyl-2-cyanoacrylate) embolization
alone had an initial response then recurrence
of symptoms and died after 6 weeks [47]. Be-
cause approximately 10% of pheochromocy-
tomas are malignant and embolization alone
appears to be inadequate for long-term symp-
tom and hormone control, surgical resection
remains the definitive treatment of choice.
Primary aldosteronism (Conn syndrome)
is caused by excessive secretion of aldoste-
rone from the outer layer (zona glomerulo-
sa) of the adrenal cortex and results in sec-
ondary hypertension and hypokalemia. Most
cases are caused by an adenoma, or so-called
aldosteronoma. Adrenalectomy is the treatment
of choice; however, ethanol embolization has
been used for patients refusing surgery and pa-
tients at high risk of surgical complications [48,
49]. Hokotate et al. [48] reported on the larg-
est series, consisting of 33 cases of aldosterono-
ma treated with embolization. They reported an
82% primary success rate using superselective
adrenal arterial embolization with high-con-
centration ethanol, compared with greater than
90% with open or laparoscopic adrenalectomy,
and observed no severe complications.
Cushing syndrome can be caused by exces-
sive secretion of cortisol from the middle lay-
er (zona fasciculata) of the adrenal cortex and
can result in central obesity, hypertension,
and insulin resistance. Transarterial emboli-
zation has been used to treat corticotropin-in-
dependent causes (adrenal adenoma, adrenal
cortical carcinoma) and corticotropin-depen-
dent causes (ectopic corticotropin syndrome
from medullary thyroid carcinoma) of Cush-
ing syndrome (Table 2). Embolization was ef-
fective in hormone and symptom control for
two of the three patients with Cushing syn-
drome due to inoperable adrenal cortical car-
cinoma reported by O’Keeffe et al. [9] and for
the one patient reported by Uflacker et al. [50]
for at least 1 year.
Posttraumatic Adrenal Hemorrhage
The adrenal glands are relatively protect-
ed from blunt trauma because of their small
size and deep location in the retroperitone-
um. However, adrenal hemorrhage has been
found in 13 of 50 (26%) autopsies of patients
who died of severe blunt trauma to the chest
or abdomen [51].
Several mechanisms have been proposed
to explain why adrenal hemorrhage occurs in
blunt trauma. The first mechanism involves
direct compression of the gland against the
spinal column. The anterior surface of the
right adrenal gland closely opposes the liv-
er, and this may be why hemorrhage involv-
ing the right adrenal gland is more common
than hemorrhage involving the left [51, 52].
Furthermore, most adrenal hemorrhages oc-
cur on the same side as the side affected by
the blunt traumatic event, supporting the di-
rect compression mechanism [51, 52]. A sec-
ond proposed mechanism is a secondary reac-
tion due to an acute increase in intraadrenal
venous pressure from compression of the in-
ferior vena cava. This again would be expect-
ed to occur more commonly on the right be-
cause the right adrenal vein drains directly into
the inferior vena cava whereas the left adre-
nal vein first joins the left renal vein. Last, de-
celeration forces may shear small vessels that
penetrate the gland capsule.
At least four published case reports have
described the successful treatment of isolated
adrenal artery hemorrhage after blunt trauma
with embolization [53–56] (Table 3). The pro-
cedures described in these reports were per-
formed with microcoils, PVA particles, and
N-butyl cyanoacrylate glue. Figure 5 shows
a case of right inferior adrenal artery hem-
orrhage treated with coil embolization in an
18-year-old male pedestrian struck by a mo-
tor vehicle. Follow-up CT after embolization
is helpful to document resolution of the hem-
orrhage and to exclude an underlying mass.
Iatrogenic Adrenal Hemorrhage
An iatrogenic cause of adrenal artery hemor-
rhage is also conceivable, yet to our knowledge
no reports exist in the literature. Unintentional

AJR:201, July 2013 193

 Fowler et al.

injuries during surgery and as a result of percu- Technical Considerations

Adrenalectomy 12 days later; alive at

taneous biopsy and postoperative bleeding af-
ter adrenalectomy from the ligated or clipped
arterial stumps are three possible scenarios.
Figure 6 shows a case of active extravasation
Outcome
General Procedure
Patients are given moderate sedation and
local anesthetic at the vascular access site.
Access is achieved via common femoral ar-

from the remnant right inferior adrenal artery tery puncture with an 18-gauge puncture nee-
Alive at least 12 mo
Alive at least 11 mo

treated with glue and microcoils in a 35-year- dle in a single-wall modified Seldinger tech-
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Not reported
old woman who had undergone right adrenal- nique. A guidewire is passed centrally under
least 20 d

ectomy for adrenal cortical adenoma.
Adrenal Artery Aneurysms
Visceral artery aneurysms are uncommon
Polyvinyl alcohol particles (355–500 μm) distally,
fluoroscopic guidance, and a 6-French vascu-
lar sheath is placed and connected to a low-
pressure heparinized saline flush. Through the
sheath, a 5-French pigtail catheter can be used

but have a high risk of rupture and life-threat- for nonselective aortography to define the ar-
ening hemorrhage, particularly for hyperten- terial supply to the adrenal gland. Because of
Coils (interlocking detachable and metric)

sive patients and pregnant women in the third the variable anatomy, additional arteriograms
Microcoils (2 × 20 mm fibered platinum)

three 2 × 20 mm microcoils proximally

Microcoils (6 fibered 0.018” platinum)

trimester [57]. Aneurysms involving the adre- of the inferior phrenic and renal arteries are
Embolization Agent

nal arteries are particularly rare, there being
limited reports in the literature [58–63].
Spontaneous rupture may be related to
states of increased blood flow as seen dur-
ing pregnancy or uncontrolled hypertension
[57]. At least three published case reports
have described successful treatment of spon-
taneously ruptured adrenal artery aneurysms
with embolization [58–60] (Table 4). These
TABLE 4:  Reported Cases of Adrenal Artery Aneurysms Treated With Embolization
obtained. For catheterization of the inferior
phrenic artery, main renal artery, and mid-
dle adrenal artery originating from the aorta,
a 5-French SOS Omni (AngioDynamics), C2
Cobra (Terumo Medical), or Mickelson cath-
eter (Cook Medical) can be used.
For superselection, a 3-French microcath-
eter system is used with coaxial technique.
Examples include Mass Transit (Cordis) and

reports all involved men with hypertension. Progreat (Terumo Medical) microcatheters
The embolic agents used included microcoils and GT (Terumo Medical) and Transcend
Left inferior adrenal artery aneurysm

Left inferior adrenal artery aneurysm

with or without PVA particles. Coil emboli- (Boston Scientific) microguidewires. Digital
Left middle adrenal artery aneurysm

zation with a 2 × 20 mm fibered platinum coil subtraction angiography is performed to con-

Angiographic Findings

was also performed for active extravasation firm appropriate catheter placement. The em-
from the left middle adrenal artery found at bolic agent is administered by flow-control
catheter angiography in a 32-year-old preg- technique [65]. Postembolization angiography
with extravasation

with extravasation

nant (39 weeks) woman with retroperitoneal is performed to evaluate for additional arteries
hemorrhage; however, no direct evidence of that may be supplying the tumor.
Not reported

aneurysm could be detected [64]. The patient

was alive 5 months after the initial presenta-
tion, and repeat CT showed resolving retro-
peritoneal hemorrhage. Figure 7 shows a case
of spontaneous hemorrhage from the right
Spontaneous
Choice of Embolic Agent
To our knowledge, there are no reports in
the literature showing superiority of one em-
bolic agent over others. Considerations in

Spontaneous

Spontaneous

middle adrenal artery without evident aneu- choosing an embolic agent include the clini-
Cause

rysm formation. The patient was a 54-year- cal application and endpoint desired (perma-
Trauma

old man treated with gelatin sponge particle
and microcoil embolization.
Pseudoaneurysm formation, which is con-
Age (y)
68
nent versus temporary occlusion), experience
and preference of the radiologist, and cost
and availability of the agent [1].

49
42

70

tained rupture of the vessel wall, can occur Permanent proximal vessel occlusion can
in cases of trauma, postbiopsy or postsurgical be achieved with microcoils. An advantage
Sex

complication, vascular invasion by malignant of coils over glue or gelatin sponge particles
M

tumor, and vasculitis secondary to adjacent is that they occlude the proximal part of the
inflammation [63]. It can result in massive artery and can preserve the distal and paren-
González Valverde et al. 2007 [59]

hemorrhage, and conventional treatment has chymal circulation. Use of coils may be prob-
been surgical ligation or resection of the an- lematic if the vessel is of small caliber or tor-
tuous. Coils have been predominately used
Manners et al. 2010 [58]

eurysm. Transcatheter coil embolization of a

Nakano et al. 2003 [60]
Source

for treating adrenal artery aneurysms, trau-

Ikeda et al. 2010 [63]

traumatic adrenal artery pseudoaneurysm in a

49-year-old man has been reported [63] (Ta-
ble 4). An isolation technique consisting of
embolization of the vessels both distal and
proximal to the pseudoaneurysm was suc-
cessfully performed.
matic adrenal artery injury, and hemorrhagic
adrenal masses (Tables 2–4). The combina-
tion of coils and PVA particles has been used
for ruptured adrenal artery aneurysms. In
these procedures the coils are used proximal-

194 AJR:201, July 2013


ly to occlude the main arterial supply to stop
the acute bleeding, and the PVA particles are
used distally to prevent later recanalization
from the distal arterial collateral supply [58].
Gelatin sponge particles (Gelfoam, Pfiz-
er) are the least expensive particulate embolic
agent and have a temporary effect. They have
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been used to treat hemorrhagic adrenal mass-
es and to suppress the hormonal function of
pheochromocytomas (Tables 1 and 2). Mix-
ing the particles with a contrast agent aids in
visualization during placement, so nontarget
embolization can be identified immediately
and the procedure terminated.
Semipermanent particulate agents include
PVA and trisacryl gelatin microspheres (Em-
bosphere Microspheres, Biosphere Medical).
These have mainly been used for tumor em-
bolization and traumatic adrenal hemor-
rhage (Tables 2 and 3). PVA particles can
clump and occlude the catheter, which is a
disadvantage of this agent. Trisacryl gelatin
microspheres are less susceptible to clump-
ing because of their hydrophilic nature and
deeper permeation compared with PVA par-
ticles of comparable sizes [1].
Liquid embolic agents include ethanol, bu-
crylate (isobutyl-2-cyanoacrylate), and N-bu-
tyl-2-cyanoacrylate. These agents have low
viscosity and thus may be easier to use in cases
of small or tortuous vessels. Embolization of
tumors not complicated by hemorrhage is typ-
ically achieved with ethanol, which scleroses
the endothelium and causes a fibrotic reaction
with the lumen. Because ethanol is nonpartic-
ulate, it can permeate and cause coagulative
necrosis of a tissue bed. Adhesive agents such
as bucrylate and N-butyl cyanoacrylate do not
permeate to the capillary level, so tissue in-
farction is avoided. A disadvantage of adhe-
sive agents is the possibility of entrapment of
the catheter in the embolized artery, which
necessitates prompt removal of the catheter
after each injection. The addition of oil-based
contrast agents can help by prolonging their
polymerization time. Use of these agents has
been reported in one case of traumatic adre-
nal hemorrhage and for hormonal suppres-
sion of pheochromocytoma (Tables 2 and 3).
Complications
Care is taken during the procedure to avoid
reflux of embolic agents into normal arter-
ies and to avoid contrast extravasation from
too forceful an injection. Accidental nontarget
embolization can lead to ischemia. Transverse
palsy of the lower extremities occurred in a pa-
tient in whom inadvertent embolization of the
AJR:201, July 2013 195
Adrenal Artery Embolization
anterior spinal artery occurred at adrenal ar-
tery embolization for adrenal metastasis from
hepatocellular carcinoma [12]. The spinal ar-
tery can originate from the middle adrenal ar-
tery, and embolization was thus not performed
in a different patient with aldosteronoma to
avoid possible spinal infarction [48].
Precise microcoil placement is important.
The proximal end of a 2 × 20 mm fibered
platinum coil placed in a left middle adrenal
artery for hemostasis due to vessel rupture in
a 32-year-old pregnant woman was noted to
project into the aortic lumen at the ostium of
the adrenal artery, indicating a more proxi-
mal location of coil deployment than intend-
ed [64]. Because the coil was thought to be a
potential source of thrombus, it was removed
with a gooseneck snare 26 days after emboli-
zation without complication.
Patients generally tolerate adrenal artery
embolization well with typically self-limited
symptoms that can be treated conservative-
ly. Mild to moderate flank pain lasting less
than 48 hours and low-grade fever are the
most common complications [9]. Transient
pleural effusion has been observed and was
thought to be reaction to transient ischemia of
the diaphragm from embolization of the in-
ferior phrenic artery [48]. Persistent hiccups
due to diaphragmatic irritation has also oc-
curred after inferior phrenic artery emboli-
zation [9]. Transient hypertension is another
reported effect [9, 48]. Ueno et al. [66] re-
ported that embolization in a patient with ad-
renal adenoma and Cushing syndrome was
discontinued because of marked hyperten-
sion and tachycardia thought to be induced
by massive release of catecholamines. Adre-
nal infarction or insufficiency after emboli-
zation has not been reported, likely owing to
the extensive collateral vascularization of the
adrenal gland. No immediate deaths or seri-
ous complications have been reported.
Conclusion
Adrenal artery embolization is a less in-
vasive, safe alternative or adjunct to surgery
with technical success for palliative adrenal
tumor control, suppression of excess adrenal
hormone production, and hemostasis of rup-
tured adrenal tumors, traumatic adrenal in-
jury, and adrenal artery aneurysm occlusion.
Because multiple arteries can supply the ad-
renal gland, it is important to investigate all
of the potential sources of bleeding or tumor
vascularity. The choice of embolic agent gen-
erally depends on the clinical application and
preference of the radiologist. Embolic ma-
terials with proven success include ethanol,
PVA particles, microcoils, gelatin sponge,
and N-butyl cyanoacrylate glue. With care-
ful embolization technique to avoid nontarget
embolization, patients tolerate the procedure
well with self-limited symptoms that can be
treated conservatively.
Acknowledgments
We thank G. M. Salazar (Division of Vas-
cular Imaging and Intervention, Massachusetts
General Hospital, Harvard Medical School,
Boston, MA), K. R. Kim (Department of Ra-
diology, University of North Carolina at Cha-
pel Hill, Chapel Hill, NC), and J. H. Shin (De-
partment of Radiology and Research Institute
of Radiology, University of Ulsan College of
Medicine, Asan Medical Center, Seoul, Korea)
for contributing images.
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Inferior
Superior adrenal phrenic
artery artery
Fig. 1—40-year-old woman undergoing CT evaluation
for hereditary hemorrhagic telangiectasia.
Adrenal Middle A, Diagram shows classic arterial anatomy of adrenal
gland adrenal
artery
gland.
B, CT angiogram shows inferior phrenic (arrow),
middle adrenal (asterisk), and inferior adrenal
Inferior Aorta
(arrowhead) arteries. Superior adrenal arteries were
adrenal too small to visualize.
artery C–E, T31-year-old women undergoing CT evaluation
Kidney for living renal donor.
C, Transverse maximum-intensity-projection (MIP)
Renal artery CT image shows right inferior phrenic artery (arrow)
arising from celiac axis. Left inferior phrenic artery
(arrowhead) also is evident. Superior adrenal arteries
were too small to visualize.
D, Transverse MIP CT image shows right middle
adrenal artery arising from aorta.
E, Coronal CT image of right adrenal gland shows
small inferior adrenal arteries.

A B

C D E

AJR:201, July 2013 197

 Fowler et al.
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A B
Fig. 2—43-year-old woman with metastatic melanoma and bilateral flank pain.
A, Coronal CT image shows bilateral adrenal gland metastases.
B, Arteriogram of right middle adrenal artery shows tumor blush and neovascularity (arrow). Adrenal artery
embolization for pain palliation was performed with 300- to 500-μm polyvinyl alcohol particles.
C, Postembolization arteriogram shows cessation of flow in right middle adrenal artery. Embolization was also
performed on left middle adrenal artery (not shown).

A B C
Fig. 3—58-year-old man with metastatic lung cancer and left flank pain.
A, CT image shows bilateral adrenal masses and left retroperitoneal hemorrhage.
B, Left middle adrenal arteriogram shows contrast extravasation from inferior branch (arrow) of left middle adrenal artery and tumor staining from superior branch
(arrowhead).
C, Angiogram obtained after polyvinyl alcohol particle (300–500 μm) embolization shows no extravasation from inferior branch and minimal residual tumor staining.

198 AJR:201, July 2013

 Adrenal Artery Embolization
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B C
Fig. 4—38-year-old woman with metastatic melanoma and left flank pain.
A, CT image shows left retroperitoneal hemorrhage and left adrenal mass.
B, Angiogram shows left superior adrenal artery (arrow) arising from left inferior phrenic artery and contrast
blush (arrowheads) in region of left adrenal hemorrhagic mass.
C, Angiogram obtained after polyvinyl alcohol particle (300–500 μm) and coil embolization (two 3-mm platinum
microcoils [Tornado, Cook]) shows complete stasis of flow in left superior adrenal artery.

AJR:201, July 2013 199

 Fowler et al.
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A B

C D
Fig. 5—18-year-old male pedestrian struck by motor vehicle. (Courtesy of Kim KR, University of North Carolina
at Chapel Hill, NC)
A, Coronal CT image shows lacerations of right hepatic lobe and right kidney, large perinephric and
retroperitoneal hematoma, and right adrenal hematoma with active extravasation.
B, Right inferior adrenal arteriogram via renal artery shows contrast extravasation (arrow).
C, Right renal arteriogram obtained after coil embolization of right inferior adrenal artery shows additional site
of active extravasation (arrow) from small artery off proximal portion of right renal artery.
D, Angiogram obtained after microcoil embolization shows complete occlusion of right inferior adrenal artery
and small renal artery branch.

200 AJR:201, July 2013

 Adrenal Artery Embolization
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A B C
Fig. 6—35-year-old woman who has undergone right adrenalectomy for adrenal cortical adenoma. (Courtesy of Shin JH, University of Ulsan College of Medicine, Asan
Medical Center, Seoul, Korea)
A, CT image shows hematoma in right adrenal resection bed with central active extravasation.
B, Right renal arteriogram shows contrast extravasation from remnant right inferior adrenal artery (arrow).
C, Angiogram obtained after embolization with glue and microcoils (arrowhead) shows complete occlusion of right inferior adrenal artery.

A B C
Fig. 7—54-year-old man with spontaneous adrenal hemorrhage. (Courtesy of Salazar GM, Massachusetts General Hospital, Harvard Medical School, Boston, MA)
A, CT image shows right adrenal hematoma extending into right anterior pararenal space with active extravasation (arrow).
B, Right middle adrenal arteriogram from aorta shows contrast extravasation (arrows).
C, Angiogram obtained after gelatin sponge and microcoil embolization shows complete occlusion of right middle adrenal artery.

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