Renal artery aneurysm at the anastomosis after kidney transplantation

Life-Threatening Hematuria as Initial Presentation of a Complicated Transplant Renal Artery Pseudoaneurysm

In this case report, we describe the clinical course of a complicated transplant renal artery (TRA) pseudoaneurysm, clinically featured by gross and massive hematuria one month after a kidney transplant was performed on a 50 year-old male patient. TRA pseudoaneurysm is a rare but potentially life-threatening complication that may result in bleeding, infection, graft dysfunction/loss, lower limb ischemia/loss, hemorrhagic shock, and death. TRA pseudoaneurysm treatment remains challenging as it needs to be tailored to the patient characteristics including hemodynamic stability, graft function, anatomy, presentation, and pseudoaneurysm features. This publication discusses the clinical scenario of massive gross hematuria that derived from a retroperitoneal hematoma which originated from an actively bleeding TRA pseudoaneurysm. This case highlights the combined approach of endovascular stent placement and subsequent transplant nephrectomy as a last resort in the management of intractable bleeding from a complicated TRA pseudoaneurysm. To the best of our knowledge, this is the first published case report of an actively bleeding TRA anastomotic pseudoaneurysm that caused a massive retroperitoneal bleed that in turn evacuated via the bladder after disrupting the ureter-to-bladder anastomosis. A temporizing hemostatic arterial stent placed percutaneously allowed for a safer and controlled emergency transplant nephrectomy.

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.

Infective Artery Rupture of Renal Allografts: A Single-Center Retrospective Study in China

OBJECTIVE

This study investigated the composition of pathogenic microorganisms, clinical features, and therapeutic strategies of infective artery rupture of renal allografts in recipients receiving deceased donor (DD) kidneys.

METHODS

We retrospectively studied the clinical data of the DD kidney transplant recipients with donor-associated infection at Tongji Hospital, Wuhan, China from January 1, 2015 to December 31, 2018, related recipients and corresponding donors. We collected the entire results of pathogenic microorganisms cultured from these related ruptured kidneys and then analyzed their distribution and differences.

RESULTS

A total of 1440 kidney transplants from DD were performed in our center. The total incidence of infective artery rupture in kidney transplants was about 0.76% (11/1440), and the annual incidence ranged from 0.25% to 1.03%. The microbial culture results revealed that 11 recipients suffered from infective artery rupture and 3 recipients who accepted the kidney from same donor had the donor-associated pathogens, including 9 fungal strains (28.1%) and 23 bacterial strains (71.9%). There were 4 recipients infected with multi-drug-resistant Staphylococcus and Klebsiella pneumoniae from the above 11 recipients, of which, 10 recipients underwent graft loss, and one died of septic shock. The microbial cultures of the remaining 3 recipients who received appropriate anti-infective regimens turned negative eventually, and the patients were discharged successfully without significant complications.

CONCLUSION

Renal recipients with infections derived from DDs were at high risk of artery rupture, graft loss, or even death. Appropriate anti-infective treatment is essential to reduce the incidence of artery rupture and mortality.

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.

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.

Successful repair of kidney graft artery rupture secondary to infection using a preprocessed homologous "Y"-shaped iliac artery

Objectives

This retrospective study aims to describe novel ways of repair kidney allograft artery rupture secondary to infection using a preprocessed homologous “Y”‐shaped iliac artery.

Methods

Five patients' whose course was complicated by graft arterial rupture were included in the rupture group, and patients who received the kidney from the same donor were included in the control group. In the rupture group, the iliac artery used for revascularization was harvested from a DCD donor, pre‐treated with absolute diethyl ether, followed by absolute alcohol, and then preserved in 75% alcohol. A biopsy of the arterial graft was obtained and stained using hematoxylin and eosin (H&E). Once a patient was diagnosed with kidney allograft arterial rupture by ultrasound, emergency surgery was conducted and the preprocessed “Y”‐shaped iliac artery was used for bridging.

Results

Five patents were included in the rupture group. The “Y”‐shaped iliac artery grafts were successfully preprocessed, H&E staining and electron microscope observation revealed few visible nuclei, with karyorrhexis and karyolysis. There were no significant differences in the long‐term graft survival between two groups.

Conclusions

In conclusion, using preprocessed homologous “Y”‐shaped iliac artery provides a useful method to bridge the vascular defects from kidney graft artery rupture secondary to infection in renal allograft recipients.

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 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.

Mycotic Pseudoaneurysm After Kidney Transplantation: Two Case Reports

BACKGROUND

Vascular complications after kidney transplantation may cause allograft loss. Here, we describe 2 patients with extrarenal mycotic pseudoaneurysm after kidney transplantation.

PATIENTS

Patient 1 was a 54-year-old man who developed pseudoaneurysm 60 days after transplantation, and patient 2 was a 48-year-old woman who was diagnosed with a pseudoaneurysm 5 months after transplantation.

RESULTS

Patient 1 had a deceased-donor kidney transplant with end-to-side external iliac arterial anastomosis that was reconstructed 8 days after transplantation owing to rupture and major bleeding. At 60 days after transplantation, he had high serum creatinine level and Doppler ultrasonography showed a pseudoaneurysm of the arterial graft anastomosis and postanastomotic renal artery stenosis. Treatment included surgical excision of the pseudoaneurysm, vascular reconstruction, and fluconazole, with mycologic culture of the resected pseudoaneurysm showing Candida albicans. Patient 2 developed nondisabling intermittent claudication at 5 months after kidney transplantation, with a pseudoaneurysm subsequently observed on Doppler ultrasonography and computerized tomographic angiography. Treatment included renal artery thrombectomy and common iliac bypass to the hilar donor renal artery with inverted ipsilateral long saphenous vein. Operative samples showed C albicans, and she was treated with fluconazole. Both patients had satisfactory outcomes, and both kidney allografts were preserved.

CONCLUSIONS

Extrarenal mycotic pseudoaneurysms after kidney transplantation require a high index of suspicion for early diagnosis, and preservation of the kidney graft may be achieved with the use of surgical treatment and antifungal therapy.

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.

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.

Transplant renal artery false aneurysm: case report and literature review

This is a case report of a 59 years old male who had a commercial non-related living renal transplantation for his end stage renal insufficiency secondary to adult polycystic kidney disease. He suffered an immediate and early post-operative bleeding, which was managed conservatively. He was presented at Sultan Qaboos University Hospital four months after his transplant with abdominal pain, nausea, loss of appetite and a rise in serum creatinine levels. Ultrasonography and angiography have shown a 4 cm false aneurysm of the transplant renal artery at the anastomotic site with the external iliac artery. Surgical exploration with resection of the false aneurysm and reanastomosis of the donor renal artery to the external iliac artery was carried out successfully with preservation of the renal allograft. This is a rare case of an extra-renal false aneurysm at the anastomotic site of the transplant renal artery to the external iliac artery four months after renal allotransplantation. Literature review on the management and outcome of false aneurysms after renal transplant was carried out.

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.