title: Modality-specific occult intrarenal pseudoaneurysm in a renal allograft and the legacy of catheter angiography.
abstract: 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.
authors: Department of Radiology, Division of Vascular and Interventional Radiology, University of Massachusetts Medical School, Worcester, MA. Electronic address: neerajrastogi@hotmail.com.
authors: Neeraj
authors: N
authors: Rastogi
authors: Gethin
authors: G
authors: Williams
authors: Herlen
authors: H
authors: Alencar
mesh_terms: D000368:Aged; D017541:Aneurysm, False / Q000000981:diagnostic imaging* / Q000209:etiology / Q000628:therapy; D017542:Aneurysm, Ruptured / Q000000981:diagnostic imaging / Q000209:etiology; D051799:Delayed Graft Function / Q000000981:diagnostic imaging / Q000209:etiology; D004621:Embolization, Therapeutic; D006417:Hematuria / Q000000981:diagnostic imaging / Q000209:etiology; D006801:Humans; D015552:Injections, Intralesional; D007676:Kidney Failure, Chronic / Q000601:surgery*; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D011237:Predictive Value of Tests; D011859:Radiography; D012077:Renal Artery / Q000000981:diagnostic imaging*; D013917:Thrombin / Q000008:administration & dosage; D013997:Time Factors; D016896:Treatment Outcome; D018615:Ultrasonography, Doppler, Color
chemical_list: D013917:Thrombin