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

Abstract

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.

Keywords

transplant renal artery pseudoaneurysm - graft-loss - delayed graft function - massive pulmonary embolism - ischemia - cardiac arrest - hemorrhagic shock - sepsis - hematuria

^* Both authors had equal contribution.

Publication History

Article published online:
16 September 2020

• References

• 1 Marie Y, Kumar A, Hinchliffe S. et al. Treatment of transplant renal artery pseudoaneurysm using expandable hydrogel coils: a case report and review of literature. World J Transplant 2018; 8 (06) 232-236
• 2 Che H, Men C, Yang M, Zhang J, Chen P, Yong J. Endovascular repair of a transplant renal artery anastomotic pseudoaneurysm using the snorkel technique. J Vasc Surg 2014; 60 (04) 1052-1055
• 3 Dimitroulis D, Bokos J, Zavos G. et al. Vascular complications in renal transplantation: a single-center experience in 1367 renal transplantations and review of the literature. Transplant Proc 2009; 41 (05) 1609-1614
• 4 Buimer MG, van Hamersvelt HW, Adam van der Vliet J. Anastomotic pseudoaneurysm after renal transplantation; a new hybrid approach with graft salvage. Transpl Int 2012; 25 (07) e86-e88
• 5 Al-Wahaibi KN, Aquil S, Al-Sukaiti R, Al-Riyami D, Al-Busaidi Q. Transplant renal artery false aneurysm: case report and literature review. Oman Med J 2010; 25 (04) 306-310
• 6 Voiculescu A, Brause M, Engelbrecht V, Sandmann W, Pfeiffer T, Grabensee B. Hemodynamically relevant hematuria several months after biopsy of a kidney graft: an unusual cause. Clin Nephrol 2003; 59 (03) 217-221
• 7 Luzzio CC, Waclawik AJ, Gallagher CL, Knechtle SJ. Iliac artery pseudoaneurysm following renal transplantation presenting as lumbosacral plexopathy. Transplantation 1999; 67 (07) 1077-1078
• 8 Madhav D, Kumar P, Mohan C, Mahesh U. ; Vijay; Anusha; Suneetha; Suryaprakash. Candida-associated pseudo-aneurysm of the transplant renal artery presenting as malignant hypertension and managed successfully without nephrectomy. Saudi J Kidney Dis Transpl 2015; 26 (05) 1000-1005
• 9 Santangelo ML, Bracale UM, Carlomagno N. et al. Kidney transplantation and large anastomotic pseudoaneurysm. Transplant management considerations. Ann Ital Chir 2013; 84 (03) 275-279
• 10 Akbar SA, Jafri SZ, Amendola MA, Madrazo BL, Salem R, Bis KG. Complications of renal transplantation. Radiographics 2005; 25 (05) 1335-1356
• 11 Asztalos L, Olvasztó S, Fedor R, Szabó L, Balázs G, Lukács G. Renal artery aneurysm at the anastomosis after kidney transplantation. Transplant Proc 2006; 38 (09) 2915-2918
• 12 Koo CK, Rodger S, Baxter GM. Extra-renal pseudoaneurysm: an uncommon complication following renal transplantation. Clin Radiol 1999; 54 (11) 755-758
• 13 Peel RK, Patel J, Woodrow G. Iliac artery false aneurysm following renal allograft: presentation with non-specific inflammatory response and treatment by endovascular stent graft. Nephrol Dial Transplant 2003; 18 (09) 1939-1940
• 14 Taghavi M, Shojaee Fard A, Mehrsai R, Shadman M. Late onset anastomotic pseudoaneurysm of renal allograft artery: case report, diagnosis, and treatment. Transplant Proc 2005; 37 (10) 4297-4299
• 15 Siu YP, Tong MK, Leung KT. et al. Renal artery pseudoaneurysm following renal transplantation and treatment by percutaneous thrombin injection. Hong Kong Med J 2006; 12 (01) 80-81
• 16 Giakoustidis A, Antoniadis N, Giakoustidis D. Vascular complications in kidney transplantation. In: Ortiz J, Andre J. eds. Understanding the Complexities of Kidney Transplantation. Rijeka, Croatia: IntechOpen; 2011: 547-564
• 17 Brandenburg VM, Frank RD, Riehl J. Color-coded duplex sonography study of arteriovenous fistulae and pseudoaneurysms complicating percutaneous renal allograft biopsy. Clin Nephrol 2002; 58 (06) 398-404
• 18 Zaragozano Guillén R, García Díez AI, Cobos Hernández MV, Yagüe Romeo D. [Postbiopsy giant pseudoaneurysm in renal transplant: treatment with embolization] (in Spanish). Actas Urol Esp 1998; 22 (03) 267-271
• 19 Previte SR, Murata GT, Olsson CA, Schmitt GW, Nabseth DC, Cho SI. Hematuria in renal transplant recipients. Ann Surg 1978; 187 (02) 219-222
• 20 Wang Z, Vathsala A, Tiong HY. Haematuria in postrenal transplant patients. BioMed Res Int 2015; 2015: 292034
• 21 Ladinsky GA, Goral S. Macroscopic hematuria in a kidney transplant recipient: a rare cause. Am J Kidney Dis 2006; 47 (01) e3-e7
• 22 Bergqvist D, Pärsson H, Sherif A. Arterio-ureteral fistula--a systematic review. Eur J Vasc Endovasc Surg 2001; 22 (03) 191-196