Department of Urology, Civil Hospital, Ahmedabad, Gujarat 380016, IndiaIndia
Apollo Hospital International LTD, Ahmedabad, Gujarat 382428, India; Chief Urologist, SAL Hospital, Ahmedabad, Gujarat 380054, IndiaIndia
Department of Urology, Shrey Hospital Pvt Ltd, Ahmedabad, Gujarat 380009, IndiaIndia
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Vascular complications following renal transplant surgery are extremely uncommon, and pseudoaneurysm is even rarer, with an incidence of 0.3%. The presentation can vary from acute blood loss to chronic dull aching pain, anorexia, etc. Majority of pseudoaneurysms are associated with allograft loss. We present a case of an anastomotic pseudoaneurysm successfully managed with an endovascular approach. A 54-year-old female, post cadaveric renal transplant (end-to-end anastomosis between the renal artery and right internal iliac artery) presented on post-operative day 159 with complaint of fever with chills. On treating conservatively with antibiotics, the fever subsided, only to recur after 5-days. On further investigation, c-reactive protein (CRP) was found to be persistently elevated. Patient’s fever of unknown origin was further investigated with repeat blood culture and fluoro-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT). Blood culture was positive for Klebsiella pneumoniae sensitive to colistin and tigecycline and FDG-PET showed a 5 cm aneurysm of the juxta anastomotic segment of the right internal iliac vessels, a possible pseudoaneurysm. After a multidisciplinary discussion, the patient underwent renal angiography, an aneurysm was delineated, and a covered stent was placed which partially excluded the aneurysm. The patient responded well to the intervention. Pseudoaneurysm formation is a rare and potentially life-threatening complication and can present even in the late post-operative period. Endovascular management can be a safe approach in carefully selected cases with allograft preservation being of paramount importance.
Keywords: Endovascular; Pseudoaneurysm; Renal transplant; C-reactive protein (CRP); Endovascular; Pseudoaneurysm; Renal transplant; C-reactive protein (CRP)
Vascular complications in post-renal transplant is rare, but result in a high rate of allograft loss. The overall incidence rate of loss with pseudoaneurysm is 6-30%.1 Vascular complications include renal artery stenosis, arterial/venous thrombosis, arteriovenous fistulas, and renal artery pseudoaneurysm, where renal artery stenosis is the most common followed by renal artery thrombosis, renal vein thrombosis and lastly aneurysm formation.2 The aneurysm can be intrarenal or extrarenal (EPSA). Intrarenal aneurysms are most commonly secondary to renal biopsy.
The incidence of extra-renal aneurysms is less than 1%.1 The etiology can be either infectious or non-infectious.3 EPSA can occur at or adjacent to the surgical anastomosis, usually secondary to a mycotic or bacterial infection. Previous literature reviews place the incidence of allograft loss at 56%, concurrence with an infective pathogen at 62%, and mortality at 14%. The mechanism by which infections cause pseudoaneurysm formation is an inflammatory process that invades and compromises the arterial wall’s structural integrity.4
Vascular complications usually occur in the immediate post-operative period but can also present late, like our patient who presented after 6-months. The presentation can be dramatic with possible emergency like sudden cardiovascular collapse secondary to rupture of the aneurysm; or can be a more insidious presentation in the form of abdominal tenderness, pulsatile mass, indolent infection, anemia, and allograft dysfunction. Lastly, there is a chronic, or a late stage, presentation which typically takes the form of diminished allograft function.
In our case, the patient had an insidious presentation, almost 6-months after the transplantation. Her urine culture was positive for Klebsiella pneumoniae; as per the review of the literature, this is the most common bacterial infection associated with EPSA formation. She was treated with culture-sensitive antibiotics. The diagnosis can be simplified with a Doppler ultrasound, and more details can be further elucidated by CT angiogram or conventional angiography. Our patient was subjected to a CT angiogram to delineate the anatomical details followed by conventional angiography to decide the precise management approach. The repair can be evoked either by open surgery or lesser invasive modalities, like endovascular management. Indications for repair include symptomatic aneurysms, a size larger than 2.5 cm, the presence of infection, and the progressive increase in size that precipitates a life-threatening rupture.6 EPSA smaller than 2 cm can be managed conservatively.
Current literature on this topic quotes allograft nephrectomy as the most definitive treatment option. But with the advancement in endovascular techniques, a greater number of allografts can be
Allograft preservation should be a prime consideration in the management of renal transplant vascular complications. Endovascular management provides a potential definitive cure, with allograft preservation, in properly selected cases. Prevention of urinary tract infection (UTI) post-transplant is of utmost importance as most pseudoaneurysms are of infectious a etiology. Peri-operative bladder irrigation with an aminoglycoside antibiotic solution significantly decreases the overall incidence of UTIs in the first 3-months after kidney transplantation.8
The authors have received written informed consent from the patient.
The authors declare that they have no conflicts of interest.