Modality-specific occult intrarenal pseudoaneurysm in a renal allograft and the legacy of catheter angiography
Department of Radiology
Aged; Aneurysm, False; Aneurysm, Ruptured; Delayed Graft Function; Embolization, Therapeutic; Hematuria; Humans; Injections, Intralesional; Kidney Failure, Chronic; Kidney Transplantation; Male; Predictive Value of Tests; Renal Artery; Thrombin; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Color
Cardiovascular Diseases | Radiology | Surgery
A 69-year-old man with history of end-stage-renal disease (ESRD) underwent successful kidney transplantation from a cadaveric donor in November 2011. However, posttransplant recovery was complicated by delayed graft function and recurrent gross hematuria. Serial Doppler ultrasound (US) of the renal allograft demonstrated a pseudoaneurysm with interval increase in size. However, it could not be visualized with other modalities, including an initial angiogram (postoperative day 49) and a second angiogram (postoperative day 68), followed by surgical exploration (postoperative day 71), which demonstrated complete intra-aneurysmal thrombosis on intraoperative Doppler US. Unfortunately, the patient's hematuria continued and a repeat Doppler US 48 hours later demonstrated a persistent pseudoaneurysm. Therefore, on postoperative day 75, we performed targeted percutaneous intra-aneurysmal thrombin injection under dual image guidance, which showed complete intra-aneurysmal thrombosis on intraprocedural Doppler US. Hematuria recurred the next day. A third angiogram (postoperative day 77) finally illuminated the hidden pseudoaneurysm occult on the first and second angiographic studies (sensitivity [index case] 33%) and surgery. This allowed for successful coil embolization of a subsegmental feeding branch with an excellent outcome. We support a more aggressive management with serial angiography and embolization of the intrarenal symptomatic pseudoaneurysm rather than surgery in renal allograft recipients, with the benefits outweighing the risks.
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Citation: Ann Vasc Surg. 2013 Nov;27(8):1184.e7-11. doi: 10.1016/j.avsg.2013.04.004. Link to article on publisher's site
Annals of vascular surgery
Rastogi, Neeraj; Williams, Gethin; and Alencar, Herlen, "Modality-specific occult intrarenal pseudoaneurysm in a renal allograft and the legacy of catheter angiography" (2013). Radiology Publications and Presentations. 37.