Endovascular repair as first-choice treatment of iliac pseudoaneurysms following renal transplantation

Anastomotic Pseudoaneurysm in Kidney Transplant: A Challenging Management for a Rare Entity

PURPOSE

Anastomotic pseudoaneurysms of transplanted kidneys are a very rare complication encountered in less than 1% of cases. They may be devastating, leading to functional impairment, kidney transplantectomy, or death. Treatment has not been standardized, with open surgical repair considered the safest procedure even if it is often complicated by bleeding and graft loss. The purpose of this case report is to describe an endovascular treatment of this condition, consisting of the combination of coil embolization and arterial stenting.

CASE REPORT

A 61-year-old woman developed an anastomotic pseudoaneurysm 2 months after kidney transplantation, causing acute kidney injury related to ab-extrinsic stenosis of the transplant renal artery (TRA) and external iliac artery. The pseudoaneurysm was successfully treated by coil embolization, and the arterial patency was restored by the stenting of TRA and external iliac artery. The patient completely recovered kidney function, and after a 6-month-follow-up, creatinine values were stable with normal renal perfusion.

CONCLUSION

Endovascular repair through coil embolization and TRA stenting can be a safe and effective option to treat anastomotic pseudoaneurysm in kidney transplant.

Successful Endovascular Repair of Infectious External Iliac Artery Anastomotic Pseudoaneurysm With Graft Preservation Post-Kidney Transplantation: Case Report and Review of Literature

BACKGROUND

Allograft artery-infected pseudoaneurysm (PA) represents a rare but life-threatening complication of kidney transplantation (KT). A review of the literature, showed that nearly all these cases ended resulted in graft loss. We presented a case of post-KT-infected external iliac artery anastomotic PA successfully managed by endovascular stenting with graft preservation. Additionally, we reviewed the pertinent literature.

METHOD

In this article, we described a hypertensive, 47-year-old man who presented 1 month post-cadaveric KT with acute kidney injury and gram-negative bacteremia secondary to a large infectious anastomotic PA of the external iliac artery.

RESULTS

Because of favorable anatomy, successful arterial angio-stent fixation of the main renal artery PA, sparing the lower polar artery, was performed after 1 week of antibiotic and fungal coverage.

CONCLUSION

Patient was discharged after 2 weeks with functioning graft. Graft function was stable after 3 months.

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.

Coil embolization of ruptured distal renal artery pseudoaneurysm with gross hematuria and hemorrhagic shock

Renal artery pseudoaneurysms have been infrequently reported in the literature. In the present report, we have described a case of a ruptured renal artery pseudoaneurysm requiring coil embolization. A 49-year-old man had presented to our institution with a hypertensive emergency. Computed tomography revealed a 3.4-cm right renal artery pseudoaneurysm. Nonemergent coil embolization was planned for the following day. However, he became hypotensive, exsanguinating frank blood from the urethra. An arteriogram showed extravasation of contrast into the pseudoaneurysm sac, renal pelvis, and ureter, consistent with intrarenal pseudoaneurysm rupture. We have demonstrated coil embolization as a method of repairing a ruptured renal artery pseudoaneurysm with gross hematuria.

Renal artery infectious (mycotic) pseudoaneurysms in renal transplantation recipients

INTRODUCTION

Infection of the artery at or around the anastomotic site is an ominous complication commonly presenting as a leak and/or local dissolution of the arterial wall.

MATERIAL AND METHODS

Narrative review based on relevant PubMed, EMBASE, and Scielo indexed English or Spanish-written articles for the period January 2000-December 2019. A pooled analysis regarding etiology was performed. Based on the results obtained with this approach, a diagnostic/therapeutic algorithm is suggested in order to optimize its clinical management.

FINDINGS

Arterial pseudoaneurysms are pseudocapsuled contained hematomas generated as the result of an arterial leaking. They are infrequent (<1% of cases), mostly related with infection (contamination of preservation fluid or sepsis) and located at the arterial anastomotic site in renal transplantation recipients. Although they are frequently diagnosed in symptomatic patients days/weeks after transplantation, they may remain unnoticed for long periods being diagnosed incidentally. Color coded-Doppler ultrasound confirms the clinical suspicion. Angio CT-scan and angiography are used for surgical planning or endovascular treatment, respectively. The etiological diagnosis is made on a basis of excised tissue culture. The decision-making process regarding the treatment approach, mostly relies on clinical presentation and anatomical location. Therapeutic options include ultrasound-guided percutaneous thrombin injection, endovascular treatment, and surgery.

CONCLUSIONS

Mycotic pseudoaneurysms in renal transplantation recipients may pose a significant challenge in cases of spontaneous rupture, given the risk for massive bleeding and death. Adequate management requires accurate diagnosis. Early endovascular stenting remains the treatment of choice in hemodynamically unstable patients. Percutaneous injection and vascular reconstruction present variable success rates in preserving graft function.

Renal artery infectious (mycotic) pseudoaneurysms in renal transplantation recipients

INTRODUCTION

Infection of the artery at or around the anastomotic site is an ominous complication commonly presenting as a leak and/or local dissolution of the arterial wall.

MATERIAL AND METHODS

Narrative review based on relevant PubMed, EMBASE, and Scielo indexed English or Spanish-written articles for the period January 2000-December 2019. A pooled analysis regarding etiology was performed. Based on the results obtained with this approach, a diagnostic/therapeutic algorithm is suggested in order to optimize its clinical management.

FINDINGS

Arterial pseudoaneurysms are pseudocapsuled contained hematomas generated as the result of an arterial leaking. They are infrequent(<1% of cases),mostly related with infection(contamination of preservation fluid or sepsis) and located at the arterial anastomotic site in renal transplantation recipients. Although they are frequently diagnosed in symptomatic patients days/weeks after transplantation, they may remain unnoticed for long periods being diagnosed incidentally. Color coded-Doppler ultrasound confirms the clinical suspicion. Angio CT-scan and angiography are used for surgical planning or endovascular treatment, respectively. The etiological diagnosis is made on a basis of excised tissue culture. The decision-making process regarding the treatment approach, mostly relies on clinical presentation and anatomical location. Therapeutic options include ultrasound-guided percutaneous thrombin injection, endovascular treatment, and surgery.

CONCLUSIONS

Mycotic pseudoaneurysms in renal transplantation recipients may pose a significant challenge in cases of spontaneous rupture, given the risk for massive bleeding and death. Adequate management requires accurate diagnosis. Early endovascular stenting remains the treatment of choice in hemodynamically unstable patients. Percutaneous injection and vascular reconstruction present variable success rates in preserving graft function.

Renal Transplant Artery Autologous Saphenous Vein Graft Aneurysms: Late Presentation and the Need for Recall and Surveillance

Autologous saphenous vein grafts are occasionally used in renal transplant recipients, particularly in living donors with short donor vessels or after donor vessel injury during allograft procurement. Autologous saphenous vein graft aneurysm formation is described as a late complication following the use of this conduit in renal transplant. We report a case of a 45-year-old woman who developed an autologous saphenous vein graft aneurysm 21 years after her living donor transplant, which was successfully managed with explantation of the graft, cold perfusion ex situ, and resection of the aneurysm, which was followed by reconstruction using deceased donor iliac vessels. The graft was then successfully reimplanted. Based on this experience and after a review of the literature related to autologous saphenous vein graft aneurysms in renal transplant, we recommend that surveillance for this particular complication should be considered no later than 10 years after implant of an autologous saphenous vein graft when used as an arterial conduit.

Retrospective evaluation of the endovascular repair of the anastomotic pseudoaneurysm of the transplanted renal artery using the snorkel technique

OBJECTIVE

To evaluate the endovascular repair of the transplanted renal artery anastomotic pseudoaneurysm using the snorkel technique.

METHODS

From April 2012 to December 2017, we performed endovascular repair in six patients, who were diagnosed with transplanted renal artery anastomotic pseudoaneurysm, using the snorkel technique. The "snorkel" stent and the "parallel" stent were placed in the transplanted kidney and the external iliac artery, respectively. Another covered stent was implanted at the proximal end of the external iliac artery to match the diameter of the iliac artery.Result and conclusion: Of the six patients, three patients recovered. Two patients experienced pseudoaneurysm rupture due to infection, and one patient developed stent thrombosis; all three patients underwent graft nephrectomy. The endovascular treatment of transplanted renal artery anastomotic pseudoaneurysm with the snorkel technique is a feasible method but needs to comply with certain indications.

Endovascular Management of Mycotic Pseudoaneurysm After Pancreas Transplantation: Case Report and Literature Review

INTRODUCTION

Mycotic pseudoaneurysm is a rare complication of pancreas transplantation. Successful management relies on early diagnosis and expedient treatment comprising surgery and antibiotics. While the standard of care in recipients of pancreatic transplants is open repair of pseudoaneurysm with or without excision of the allograft, endovascular management has been reported. Endovascular repair is a less invasive treatment option with advantages of expedient control of hemorrhage, avoidance of adhesions with an open repair, and greater suitability for elderly and frail patients.

MATERIAL AND METHODS

We report a case of a 40-year-old recipient of a pancreas transplant who had a mycotic pseudoaneurysm managed with endovascular repair. A systematic search of PubMed-MEDLINE, Embase, and Cochrane Library was performed of all cases of mycotic aneurysms following pancreas or kidney transplantation managed with endovascular repair.

RESULTS

There were 14 cases of mycotic aneurysms in transplant recipients managed with endovascular repair in the literature. Of those who received an endovascular stent as the only initial management strategy, 6 (54.5%) required a subsequent graft excision. Four (28.6%) patients required excision of their stent due to continued sepsis. There was 1 death from unrelated causes.

CONCLUSIONS

Endovascular repair was a reasonable bridging technique to further definitive surgical treatment in our case. Endovascular management may be used with caution in high-risk patients. We advocate for prolonged antibiotic therapy combined with vigilant surveillance of the clinical response, and a low threshold for allograft excision in the event of clinical deterioration.

Renal transplant anastomotic pseudoaneurysms: Case report of open repair and endovascular management

Introduction

Anastomotic pseudoaneurysm is one of the rarest vascular complications after renal transplant surgery. Therapeutic options include open surgical repair or endovascular stenting.

Case presentation

Case 1 had pseudoaneurysm involving external iliac artery and was managed by jump graft to allograft using cadaveric donor iliac arteries and patch angioplasty repair of external iliac artery after excising pseudoaneurysm. Case 2 had undergone orthotopic renal transplant with spleno‐renal arterial anastomosis and developed a massive pseudoaneurysm proximal to spleno‐renal arterial anastomosis. This patient underwent endovascular stenting preserving allograft vascularity and graft function. Outcome in both patients was successful with normalization of renal function to baseline levels.

Conclusion

Treatment of renal transplant anastomotic pseudoaneurysms is difficult and associated with high rates of graft loss. Open surgery is the gold standard providing several possibilities for arterial reconstruction preserving graft and limb circulation. Endovascular treatment should be considered in high‐risk surgical patients with favorable anatomy.

Treatment of Visceral Transplant Pseudoaneurysms Using Physician-Modified Fenestrated Stent Grafts: Initial Experience

Pseudoaneurysms after visceral transplantation represent a significant risk to patients. We report the successful treatment of three transplant (pancreas, liver and kidney) artery anastomotic pseudoaneurysms using physician-modified fenestrated endovascular stent grafts. In all cases, surgical repair was considered high risk and would have compromised the arterial supply to the graft. The endovascular approach in all cases obviated the need for surgical intervention and maintained graft arterial supply.

Treatment of transplant renal artery pseudoaneurysm using expandable hydrogel coils: A case report and review of literature

Transplant renal artery (TRA) pseudoaneurysm can result in bleeding, infection, graft dysfunction and graft loss. We report the management of a renal transplant recipient who presented five months after renal transplantation with deterioration of renal function, who was found to have TRA pseudoaneurysm and TRA stenosis. Both were treated radiologically by using expandable hydrogel coils (EHC) in combination with stenting. Improvement in clinical, biochemical and radiological parameters were observed after the intervention. To our knowledge, this is the first report in the transplant literature on the use of EHC for the treatment of a TRA pseudoaneurysm.

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.

Presentation and management of mycotic pseudoaneurysm after kidney transplantation

Pseudoaneurysms (PAs) developing at the site of vascular anastomosis after organ transplantation are a rare but serious complication. We report a series of 3 cases of PA observed in a single center over a period of 18 years. The mode of presentation was acute bleeding in 2 cases. In the third patient, who underwent combined kidney and pancreas transplantation, the PA on the renal graft was discovered by chance. Graft removal associated with iliac artery ligation and extra-anatomic femoro-femoral bypass represents the standard treatment. However, interposition of a venous homograft may allow preservation of inferior limb perfusion and possibly graft salvage.

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.

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.

Mycotic pseudoaneurysm following a kidney transplant: a case report and review of the literature

Vascular complications represent a significant cause of morbidity and mortality following a kidney transplant. Pseudoaneurysms are rare, occurring in approximately 1% of cases. We present a 15-yr-old patient who received a kidney transplant in the right iliac fossa. Thirty-six days following the transplant, the patient was admitted to the hospital because of a marked increase in serum creatinine levels, arterial hypertension, scrotal edema, and lower right limb pain. The patient did not present fever or raised inflammatory markers. A pseudoaneurysm was diagnosed by means of a Doppler echography and a CT. By a selective arteriography of the right iliac artery, we placed a 8 x 5 cm stent to isolate the pseudoaneurysm, due to the high risk of an extensive defect occurring in the arterial wall. Forty-eight h later the patient underwent transplant nephrectomy. Seven days following surgery, the patient experienced febrile syndrome and therefore another CT was carried out which showed a large abscess around the stent. So we decided to perform another intervention in order to drain this abscess. Due to the extensive loss of the arterial wall where the prosthesis was largely exposed, we ligated the common iliac and external iliac arteries, removed the prosthesis and performed a femoro-femoral bypass with the usual subcutaneous positioning of the prosthesis (separate from surgical site). The stent and mural thrombus were sent for culture analysis and Candida albicans was observed. The diagnosis of a pseudoaneurysm in these types of patients continues to be considered as a surgical emergency by the majority of authors. Transplantectomy is the most frequently used treatment technique. Positioning a stent prior to transplantectomy avoids ligature of the iliac artery in the majority of cases.

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.