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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 50-52

Pseudoaneurysm at anastomotic site in a case of renal transplant: A rare postsurgical complication


Department of Radiodiagnosis, Sher-I-kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Web Publication7-Dec-2017

Correspondence Address:
Mohd Ilyas
Department of Radiodiagnosis, Sher-I-kashmir Institute of Medical Sciences, Srinagar - 190 011, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ami.ami_40_17

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  Abstract 

A rare case of a large pseudoaneurysm at the anastomotic site of internal iliac artery with the graft renal artery in a case of renal transplant is presented with a vision of documenting this condition and making clinicians familiar with this rare postsurgical complication in patients of renal transplant.

Keywords: Computed tomography angiography, pseudoaneurysm, renal transplant


How to cite this article:
Ilyas M, Shah SA, Gojwari T, Ahmad Kazime MJ, Shafi F. Pseudoaneurysm at anastomotic site in a case of renal transplant: A rare postsurgical complication. Acta Med Int 2017;4:50-2

How to cite this URL:
Ilyas M, Shah SA, Gojwari T, Ahmad Kazime MJ, Shafi F. Pseudoaneurysm at anastomotic site in a case of renal transplant: A rare postsurgical complication. Acta Med Int [serial online] 2017 [cited 2019 Sep 19];4:50-2. Available from: http://www.actamedicainternational.com/text.asp?2017/4/2/50/220212


  Introduction Top


Renal transplant rejection is a common phenomenon in cases of allografts. The pseudoaneurysm formation at the site of anastomosis of donor renal artery and internal iliac artery is a rare postsurgical complication.[1]


  Case Report Top


A 24-year-old male patient who had allograft (from 1st cousin) renal transplant for end-stage renal disease secondary to familial focal segmental glomerulosclerosis 4 months back wherein the graft renal artery was anastomosed with the right internal iliac artery, presented to emergency surgical observation with complaints of the right iliac fossa pain radiating to the right thigh, nausea, and loss of appetite. The clinical examination revealed a bruit over the right iliac fossa. The biochemical investigations revealed deranged renal function tests (serum creatinine = 3.8 mg % and serum urea = 105 mg %). Gray-scale ultrasonography revealed normal sized graft kidney in the right iliac fossa with markedly increased cortical echogenicity with mildly altered corticomedullary differentiation, mildly dilated pyelocalyceal system, and a large hypoechoic lesion measuring 6.62 cm × 6.67 cm near the hilum of graft kidney [Figure 1]a and [Figure 1]b. The color-coded Doppler sonography revealed peripheral vascularity of the hypoechoic lesion with normal Doppler parameters of the segmental renal arteries [Figure 1]c and [Figure 1]d. The preliminary diagnosis of a thrombosed pseudoaneurysm of the transplanted renal artery was made, and the patient advised for computed tomographic angiography for definitive confirmation. After proper rehydration and one cycle of hemodialysis, the creatinine levels improved to 1.6 mg%. Contrast-enhanced renal angiography was performed using 64-slice Somatom sensation computed tomography (CT) machine (Siemens Healthcare, Germany) after injecting 90 ml of iodixanol (Visipaque 370, relatively safe in the presence of deranged renal function). The CT angiographic study revealed a large thrombosed pseudoaneurysm at the anastomotic site of internal iliac and graft renal artery displacing the right external iliac artery and right common iliac vein. The opacification of the right external iliac artery was normal. There was mild uptake of contrast by the graft kidney; however, no excretion of the contrast was seen in the delayed scans relating to decreased renal function. Furthermore, the atrophic and dysfunctional native kidneys were noted [Figure 2] and [Figure 3]. The graft kidney biopsy was also taken which revealed the features of humoral rejection. The condition did not improve despite the plasmapheresis. The attendants were explained the prognosis and advised for a nephrectomy with aneurysm resection/repair followed by a re-transplant.
Figure 1: Gray-scale (a and b) ultrasonography images of the graft kidney showing the increased cortical echogenicity and mildly altered corticomedullary differentiation along with the large hypoechoic round structure at the hilum with central hyperechogenicity (thrombosis). Color Doppler sonography (c and d) images of the same patient showing the normal segmental arterial waveform and thrombosed pseudoaneurysm

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Figure 2: Computed tomography angiographic images showing large mildly enhancing thrombosed pseudoaneurysm (Curved arrow- [a and b]) at the junction with graft renal artery (oblique leftward arrow-[a]), native contracted kidneys (c), and displacement of the right common iliac vein (d)

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Figure 3: Sagittal computed tomography angiographic images showing the thrombosed pseudoaneurysm (curved arrow-[a and b]) and its continuation with the right internal iliac artery (straight arrow-[a] with normal caliber and opacification of the right external iliac artery {asterisk-[a-d])

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  Discussion Top


Pseudoaneurysm at the site of arterial anastomosis is a very rare complication seen in <1% of the recipients.[1] The various caused attributed to this condition include mycotic infections, suture rupture, anastomotic leakage, and vessel wall ischemia.[2] The diagnosis is made by color Doppler sonography and CT angiography. The management includes aneurysm repair with transplantectomy in patients showing features of rejection on biopsies and repair by percutaneous administration of thrombotic agents, conventional open repair, or endovascular repair in cases where the renal function is preserved and there are no signs of rejection.[3] Endovascular treatment with the use of covered stents is another valuable therapeutic option but with a substantial risk of allograft sacrifice.


  Conclusion Top


Although rare, the pseudoaneurysm formation at the vascular anastomotic must be considered in differential diagnosis of posttransplant patients presenting with the right lower quadrant pain and audible bruit so that necessary investigations and treatment are planned at the earliest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Koo CK, Rodger S, Baxter GM. Extra-renal pseudoaneurysm: An uncommon complication following renal transplantation. Clin Radiol 1999;54:755-8.  Back to cited text no. 1
[PUBMED]    
2.
Renigers SA, Spigos DG. Pseudoaneurysm of the arterial anastomosis in a renal transplant. AJR Am J Roentgenol 1978;131:525-6.  Back to cited text no. 2
[PUBMED]    
3.
Poels JA, Riley PL. Extrarenal transplant artery pseudoaneurysm: A combined therapeutic approach. Cardiovasc Intervent Radiol 2008;31:404-6.  Back to cited text no. 3
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
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