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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 16  |  Issue : 3  |  Page : 322-324

A rare case of graft lower polar artery aneurysm: Delayed presentation after 10 years - A case report


Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Date of Submission08-Aug-2021
Date of Acceptance18-Jan-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Dr. Ravindra Sabnis
Department of Urology, Muljibhai Patel Urological Hospital, Dr. V V Desai Road, Nadiad - 387 001, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_75_21

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  Abstract 


Graft artery aneurysms though rare, may have devastating consequences. We present a case of an aneurysm involving the lower polar artery anastomosed to external iliac artery using a gonadal vein graft. The patient presented with sudden onset graft fossa swelling, pain, and decreased urine output. Color Doppler and computed tomography angiography helped in diagnosis and management. Since the majority of the graft was well-perfused by the upper polar artery, the patient underwent excision of the lower polar artery aneurysm. The prompt diagnosis and management salvaged the graft. This aneurysm presented after 10 years of the underlying importance of long-term surveillance.

Keywords: Graft artery aneurysm, lower polar artery, renal allograft artery complication


How to cite this article:
Patil A, Ganpule A, Sabnis R, Desai M. A rare case of graft lower polar artery aneurysm: Delayed presentation after 10 years - A case report. Indian J Transplant 2022;16:322-4

How to cite this URL:
Patil A, Ganpule A, Sabnis R, Desai M. A rare case of graft lower polar artery aneurysm: Delayed presentation after 10 years - A case report. Indian J Transplant [serial online] 2022 [cited 2022 Nov 27];16:322-4. Available from: https://www.ijtonline.in/text.asp?2022/16/3/322/357619




  Introduction Top


Graft artery aneurysm, a rare complication after kidney transplant, may profoundly affect the patient and graft survival. It is generally due to fungal infection, but it could also be due to the involvement of vascular reconstruction performed. There is no consensus regarding the management of such aneurysms, and there are only case reports managing various aneurysms by endovascular technique or allograft nephrectomy.

We report a rare case of management of an aneurysm involving lower polar artery in a dual artery transplant presenting 10 years after kidney transplant. We highlight the presentation and insight into the salvage of the graft with selective excision of the lower polar artery aneurysm.


  Case Report Top


A 45-year-old hypertensive female underwent live-related renal transplantation with her cousin's sister as a donor with a dual renal artery in 2010. The upper polar artery was supplying 90% of the kidney and was anastomosed with internal iliac artery. The lower polar artery supplied the remaining 10% of graft which was anastomosed end to side to external iliac artery (EIA) using gonadal vein graft as the length of lower polar artery was not insufficient. The graft was functioning normally for the last 10 years with a serum creatinine of around 1 mg/dl.

Now, she presented with sudden onset of swelling in the right iliac fossa with pain and associated with decreased urine output for 1 day. On examination, the patient was vitally stable, and there was a palpable cystic swelling in the fossa. On evaluation with color Doppler ultrasound, she had around 7 cm sized anechoic collection with the turbulent color flow in it suggestive of graft artery aneurysm associated with mild hydronephrosis [Figure 1]. Her serum creatinine was 2.4 mg/dl, and hemoglobin was 9.8 g/dl. Her computed tomography (CT) angiography revealed a normal graft upper polar artery anastomosed with internal iliac artery. The graft lower polar artery revealed abnormal aneurysmal dilatation measuring 86 mm × 79 mm. The lumen of the aneurysm showed hypodense eccentric mural thrombus within it [Figure 2]. In view of her anuria and raised serum creatinine, she underwent one session of hemodialysis.
Figure 1: The left side of the figure shows B-mode ultrasound of the swelling. It shows graft kidney with anechoic collection with graft hydronephrosis. The color Doppler mode shows vascularity in the area suggestive of aneurysm

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Figure 2: Computed tomography angiography – the graft can be seen well perfused by upper polar artery, the aneurysm can be appreciated originating from lower polar artery with a very short segment. The aneurysm compresses the ureter leading to graft hydronephrosis

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Since the aneurysm involved the gonadal vein part of the lower polar artery, which was supplying a small portion of lower pole parenchyma, we decided to excise the aneurysm, with majority graft perfusion by the upper artery. We performed ultrasound-guided antegrade graft puncture and placed a 6 Fr ureteric catheter into the bladder along with percutaneous nephrostomy. On open exploration, we could identify ureter due to preplaced ureteric catheter. There was a lot of perigraft fibrosis. The aneurysm was confirmed by intraoperative Doppler and was separated from surrounding tissues. The junction of aneurysm and EIA was clamped with a Satinsky clamp, the aneurysm was excised, and the junction was repaired with 6-0 Prolene, as shown in [Figure 3]. The perfusion of graft was confirmed using intraoperative Doppler and femoral pulses were checked. In postoperative period, urine output slowly increased to 3 L/day, and she was discharged on day 5 with a serum creatinine of 0.9 mg/dl. The postoperative color Doppler showed good vascularity [Figure 4].
Figure 3: Intraoperative image – (a) A Satinsky clamp applies to the common stump between the lower polar artery aneurysm and external iliac artery. The aneurysm wall can be seen. (b) The excised aneurysm

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Figure 4: Postoperative color Doppler of the graft shows well-perfused graft by the upper polar artery and absence of aneurysm

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  Discussion Top


Graft artery aneurysm is a rare complication present in <1% cases.[1] Its etiology can be due to infection, especially mycotic, defective vascular anastomoses, or renal transplant biopsies.[2],[3] Mycotic aneurysm, which is most commonly seen, can involve any site of the artery and can be multiple. The defective vascular anastomoses are generally singular and involve the anastomotic site. Aneurysm due to injury to a renal artery due to renal biopsy may present at the site of injury. In our case, the cause of the aneurysm was the venous segment used for vascular reconstruction. These aneurysms generally present within weeks after transplantation,[4] while in our case, they presented after 10 years. Hence, long-term surveillance is important.

A swelling in the graft iliac fossa should be evaluated with ultrasound to diagnose underlying collection. An addition of color Doppler is of utmost importance to exclude aneurysm before percutaneous aspiration of the collection as accidental injury to artery aneurysm would be dangerous. There was no history of fever in our patient, and the presence of fever should raise a suspicion of a mycotic aneurysm. Although ultrasound diagnoses an aneurysm, CT angiography is very useful in management planning. It revealed proper arterial anatomy of the upper polar artery and aneurysm affecting the lower polar artery and compressing the ureter. It helped us know the size of the common stem between aneurysm and EIA and the amount of graft perfused by that artery.

Such aneurysms can be managed by endovascular management.[4] However, proper case selection is important as we deferred this modality because of the large size of the aneurysm and a very short length of vascular stem from the aneurysm to EIA. The coil that should be placed in the vascular stem to block the aneurysm would have slipped into the aneurysm, making it ineffective. This prompted us to perform an open surgical intervention.

We should always suspect perigraft fibrosis in case of graft exploration after a long time. Preoperative ureter catheterization with a ureteric catheter would help identify ureter and prevent iatrogenic injury, which would be disastrous. We sent the aneurysm wall for analysis, and there was no fungal involvement. The fungal involvement should always be ruled out as prompt antifungal therapy is important as the fungal invention may spread and involve other surrounding structures.

We used a gonadal vein graft to increase the length of the lower polar artery. This vein wall being thin may progressively lead to an aneurysm. Sometimes, the aneurysm silently increases in size and may suddenly burst leading to torrential bleed leading to an emergency. Majority of reports of aneurysms, especially mycotic, are managed by allograft nephrectomy.[5],[6] We highlight that graft can be salvaged by proper preoperative planning. The prompt diagnosis of the aneurysm and managing it is of utmost importance.


  Conclusion Top


Graft artery aneurysm should be suspected in case of graft fossa swelling. Graft aneurysm may present late in course underlying the importance of long-term graft surveillance. Every attempt should be made to salvage the graft.

Declaration of patient consent

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

PCN-percutaneous nephrostomy.

EIA– external iliac artery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Akgul E, Binokay F, Aikimbaev K, Aksungur EH. Extrarenal pseudoaneurysm of the arterial anastomosis in a renal transplant: Endovascular coil embolization with balloon remodeling technique. Ren Fail 2011;33:452-5.  Back to cited text no. 1
    
2.
Duwe KM, Newhouse JH, Fayter J, Stern L, Budorick NE. Conservative management of an extrarenal pseudoaneurysm after percutaneous needle biopsy of a renal allograft. J Ultrasound Med 2000;19:281-3.  Back to cited text no. 2
    
3.
Tobben PJ, Zajko AB, Sumkin JH, Bowen A, Fuhrman CR, Skolnick ML, et al. Pseudoaneurysms complicating organ transplantation: Roles of CT, duplex sonography, and angiography. Radiology 1988;169:65-70.  Back to cited text no. 3
    
4.
Fananapazir G, Hannsun G, Wright LA, Corwin MT, Troppmann C. Diagnosis and management of transplanted kidney extrarenal pseudoaneurysms: A series of four cases and a review of the literature. Cardiovasc Intervent Radiol 2016;39:1649-53.  Back to cited text no. 4
    
5.
Leonardou P, Gioldasi S, Zavos G, Pappas P. Mycotic pseudoaneurysms complicating renal transplantation: A case series and review of literature. J Med Case Rep 2012;6:59.  Back to cited text no. 5
    
6.
Ram Reddy C, Ram R, Swarnalatha G, Krishna LS, Prayaga A, Murthy PV, et al. “True” mycotic aneurysm of the anastomotic site of the renal allograft artery. Exp Clin Transplant 2012;10:398-402.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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