Extrarenal Transplant Artery Pseudoaneurysm: A Combined Therapeutic Approach

Management of Transplant Renal Artery Pseudoaneurysm and Literature Review

Renal transplantation is the ultimate treatment for end-stage renal disease patients. However, vascular complications can impact renal allograft outcomes. Extrarenal pseudoaneurysms (EPSA) are a rare complication occurring in 1% of transplant recipients. We report a case series of extrarenal pseudoaneurysm after kidney transplant with different clinical presentations and management strategies. Given the rarity of EPSA, literature describing this complication is limited to single case reports or small retrospective case series. We also provide an up-to-date review of 76 articles on mycotic, bacterial, and idiopathic EPSAs. Allograft removal is considered standard treatment, but new endovascular alternatives may allow allograft salvage. EPSA should be managed with a multidisciplinary approach. Surveillance with renal ultrasound is recommended in patients considered high risk.

Early renal arterial rupture and arterial pseudoaneurysm in graft kidneys from the same deceased donor

Vascular complications are serious problems after kidney transplantation. An aneurysm or rupture in a graft artery is a rare but potentially devastating complication, which may lead to renal function impairment, graft loss, or even death. In this paper, we present two rare vascular complications in the early postoperative course after renal transplantation from the same deceased donor. In the first case, a 49-year-old woman who had spontaneous graft arterial rupture 13 days after kidney transplantation presented with sudden distension in the right lower abdomen. In the second case, a 56-year-old woman recipient with a graft renal arterial pseudoaneurysm presented with decreased urine output and deteriorating renal function 32 days after transplantation. Immediate surgical repair was performed, and fibrin sealant was applied to strengthen the fragile renal arterial wall. Although the function of both graft kidneys recovered well after surgery, the first graft kidney was removed 2 months later because of repeated fungal and bacterial infections. Aggressive surgical reconstruction may preserve graft kidneys in patients with vascular complications after kidney transplantation, but recovery of the graft condition remains a demanding challenge in renal transplantation.

Endovascular Repair of Renal Artery Anastomotic Pseudoaneurysm Following Living Donor Kidney Transplant

Renal artery anastomotic pseudoaneurysms, an uncommon complication of transplantation, may result in aneurysm rupture and loss of allograft. We report the case of 50-year-old female with back pain 3 weeks post renal transplantation. CT scan revealed transplant renal artery anastomotic pseudoaneurysm arising from anastomosis of two renal arteries joined together to form a single renal artery that was joined to the aorta. Successful endovascular treatment was achieved with covered stents, resulting in preserved renal function. Follow-up ultrasound at one-day post procedure and CT at 2 months revealed satisfactory renal perfusion with no pseudoaneurysm. Endovascular treatment of transplant renal artery pseudoaneurysms with covered stent and ostial flare balloon technology may be preferred in patients with extensive prior pelvic surgery, as illustrated in this case.

Vascular complication in live related renal transplant: An experience of 1945 cases

Introduction and Objective:

Among the surgical complications in renal transplantation, the vascular complications are probably most dreaded, dramatic, and likely to cause sudden loss of renal allograft. We present our experience and analysis of the outcome of such complications in a series of 1945 live related renal transplants.

Materials and Methods:

One thousand nine hundred and forty five consecutive live related renal transplants were evaluated retrospectively for vascular complications. Complications were recorded and analyzed for frequency, time of presentation, clinical presentation, and their management.

Results:

The age of patients ranged from 6 to 56 years (mean = 42). Vascular complications were found in 25 patients (1.29%). Most common among these was transplant renal artery stenosis found in 11 (0.58%), followed by transplant reznal artery thrombosis in 9 (0.46%), renal vein thrombosis in 3 (0.15%), and aneurysm formation at arterial anastmosis in 2 (0.10%) patient. The time of presentation also varied amongst complications. All cases of arterial thrombosis had sudden onset anuria with minimal or no abdominal discomfort, while venous thrombosis presented as severe oliguria associated with intense graft site pain and tenderness. Management of cases with vascular thrombosis was done by immediate surgical exploration. Two patients of renal artery stenosis were managed with angioplasty and stent placement.

Conclusions:

Major vascular complications are relatively uncommon after renal transplantation but still constitute an important cause of graft loss in early postoperative period. Aneurysm and vessel thrombosis usually require graft nephrectomy. Transplant renal artery stenosis is amenable to correction by endovascular techniques.

Endovascular repair of a para-anastomotic pseudoaneurysm after renal autotransplantation: an alternative to open reconstruction

Renal artery anastomotic pseudoaneurysms are rare after renal transplantation. The etiology tends to be technical, infectious, or degenerative, and repair is difficult with a high postsurgical complication rate. We report the first case of a complex autotransplant renal artery pseudoaneurysm repaired with kissing covered stents. A 52-year-old woman presented with severe left lower quadrant abdominal pain 6 years after a renal autotransplant for ureteral stenosis and recurrent pyelonephritis. A computed tomographic angiography (CTA) scan revealed a bilobed aneurysm arising at the anastomosis between the renal and common iliac arteries. Kissing covered stents were placed within the common iliac artery proximally and extending into the transplant renal artery and external iliac artery. Postdeployment angiography confirmed complete exclusion of the pseudoaneurysm and excellent flow into the transplant kidney and left lower extremity. A follow-up CTA scan at 1 month revealed continued stent-graft patency and complete exclusion of the pseudoaneurysm. An endovascular approach to transplant anastomotic pseduoaneurysms using kissing covered stents is a viable option to exclude aneurysmal changes and preserve flow to the transplanted organ in carefully selected patients.

Mycotic pseudoaneurysms complicating renal transplantation: a case series and review of literature

Introduction

Kidney transplantation can be complicated by infection and subsequent development of mycotic aneurysm, endangering the survival of the graft and the patient. Management of this condition in five cases is discussed, accompanied by a review of the relevant literature.

Case presentations

Five patients, three men 42-, 67- and 57-years-old and two women 55- and 21-years-old (mean age of 48 years), all Caucasians, developed a mycotic aneurysm in the region of the anastomosis between renal graft artery and iliac axes. Four patients presented with systemic fever and iliac fossa pain and one presented with hemorrhagic shock. Morphologic investigation by color doppler ultrasonography revealed a pseudoaneurysm at the anastomotic site. A combination of antibiotic therapy, surgery and interventional procedures was required as all kidney transplants had to be removed. No recurrence was recorded during the follow-up period.

Conclusions

A high index of suspicion is required for the timely diagnosis of a mycotic aneurysm; aggressive treatment with cover stents and/or surgical excision is necessary in order to prevent potentially fatal complications.

Renal pseudoaneurysm following laser lithotripsy: endovascular treatment of a rare complication

Hemorrhagic complications of renal transplantation can be life threatening and require prompt and timely intervention. This brief report describes the exceedingly rare formation of an extrarenal pseudoaneurysm of a transplant renal artery following laser lithotripsy for nephrolithiasis in a teenage male. The pseudoaneurysm ruptured into the renal collecting system. Transarterial coil embolization of the wide-neck saccular pseudoaneurysm of the extraparenchymal renal artery with the assistance of a 'safety microguidewire' was successfully performed and the allograft was preserved.

Anastomotic pseudoaneurysm complicating renal transplantation: treatment options

INTRODUCTION

Anastomotic pseudoaneurysm following renal transplantation is uncommon. Indications for repair, treatment options and outcomes remain controversial.

REPORT

We present 6 renal transplant recipients with large anastomotic pseudoaneurysms. Five of the patients underwent open repair while one had a stent-grafting and delayed transplant nephrectomy for a ruptured pseudoaneurysm. A transplant nephrectomy was needed in all cases but one. Arterial reconstruction enabled limb salvage in all cases. One patient died of sepsis postoperatively. No patient presented late infection, failure of vascular reconstruction, nor pseudoaneurysm recurrence.

CONCLUSIONS

Surgical excision of anastomotic pseudoaneurysms results in high rates of allograft loss. Less invasive techniques have a place in selected cases.

Vascular complications in renal transplantation: a single-center experience in 1367 renal transplantations and review of the literature

Renal transplantation is the treatment of choice for end-stage renal disease. Vascular complications in renal transplantation are not uncommon and may often lead to allograft loss. The most common vascular complications are transplant renal artery stenosis, transplant renal artery thrombosis, transplant renal vein thrombosis, biopsy-induced vascular injuries, pseudoaneurysm formation, and hematomas. Transplant renal artery and vein thrombosis have an early onset and a dramatic clinical manifestation and usually lead to allograft loss. In contrast, transplant renal artery stenosis has better treatment possibilities, whereas the rest do not occur so often. In our institution, 1367 renal transplantations were performed from September 1980 to April 2005. During this period, we encountered 38 major vascular complications leading to graft loss and 19 transplant renal artery stenoses with successful treatment in the majority of cases. According to these data, we can conclude that renal transplantation is a safe therapeutic procedure for renal failure.

Surgical treatment of an extrarenal pseudoaneurysm after kidney transplantation

A 69-year-old man who underwent a kidney transplantation developed a large pseudoaneurysm at the anastomosis between the right external iliac artery and renal transplant artery. After an unsuccessful attempt using percutaneous thrombin injection, the patient underwent open exploratory laparotomy and surgical ligation of the pseudoaneurysm with preservation of renal graft function.