Endovascular Repair of Anastomotic Site Pseudoaneurysms in a Transplant Renal Artery Using Flow-Diverter Stents

Pseudoaneurysms in anastomotic sites in the postrenal transplantation period are rare, with an incidence of <1% (1Poels J.A. Riley P.L. Extrarenal transplant artery pseudoaneurysm: a combined therapeutic approach.Cardiovasc Intervent Radiol. 2008; 31: 404-406Crossref PubMed Scopus (19) Google Scholar). The causes of anastomotic site pseudoaneurysms in transplant renal arteries may include intraoperative arterial wall injury, a faulty suturing technique, infection, or an immunologic factor (1Poels J.A. Riley P.L. Extrarenal transplant artery pseudoaneurysm: a combined therapeutic approach.Cardiovasc Intervent Radiol. 2008; 31: 404-406Crossref PubMed Scopus (19) Google Scholar). Although the majority of patients are asymptomatic, some may present with pain or ipsilateral limb swelling, anemia, fever, and posttransplant renal dysfunction (1Poels J.A. Riley P.L. Extrarenal transplant artery pseudoaneurysm: a combined therapeutic approach.Cardiovasc Intervent Radiol. 2008; 31: 404-406Crossref PubMed Scopus (19) Google Scholar). The therapeutic options in such situations include surgical repair, endovascular repair, and ultrasonography-guided percutaneous thrombin injection (2Bracale U.M. Santangelo M. Carbone F. et al.Anastomotic pseudoaneurysm complicating renal transplantation: treatment options.Eur J Vasc Endovasc Surg. 2010; 39: 565-568Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar). Here, we report the case of a posttransplant anastomotic site pseudoaneurysm successfully treated with a flow-diverter stent designed for intracranial use. The institutional review board granted permission for the publication of this case. Patient permission was also obtained for its publication. A 31-year-old woman with systemic hypertension and Stage V chronic renal failure received a renal allograft from her mother, which was implanted into her right iliac fossa. The single transplant renal artery was sutured end-to-side to the right external iliac artery. Two months after transplantation, she developed pyrexia and tenderness at the right iliac fossa. On evaluation, she had type 1 acute cellular rejection of grade 1A, with microvascular inflammation, which was treated with intravenous methylprednisolone. After treatment, she had no graft dysfunction, and her glomerular filtration rate was 129 mL/min/1.73 m2. One year after transplantation, she developed a high-grade fever and dysuria. On evaluation, her total leukocyte count was 30,500/μL, and she had urosepsis secondary to Escherichia coli. Ultrasonography showed a pseudoaneurysm at the anastomotic site. Computed tomography angiography revealed a pseudoaneurysm measuring 3 × 2.2 × 2.6 cm, which compressed the transplant renal artery (Fig 1), with associated occlusion of the external iliac and common femoral arteries, distal to the anastomotic site. The right superficial femoral artery was reconstituted by collaterals, and there were no symptoms of lower limb ischemia. Intravenous antibiotics and antipyretics were initiated. Once the infection was controlled, she underwent endovascular management of the pseudoaneurysm. A conventional angiogram showed an anastomotic site pseudoaneurysm in the grafted kidney (Fig 2a). The diameter of the right external iliac artery was 5 mm near the anastomotic site, and the diameter of the transplant renal artery was 4.3 mm, with an acute angle of 20° between the transplant renal artery and the external iliac artery. Subsequently, a 7-F crossover sheath (Cook Medical, Bjaeverskov, Denmark) was placed in the right external iliac artery through the left common femoral artery. A microcatheter (XT-27; Stryker Neurovascular, Fremont, California) was used to navigate over a microguidewire (Synchro 14; Stryker Neurovascular, Kalamazoo, Michigan) to the upper polar renal artery of the transplanted kidney. A flow-diverter stent (Surpass Evolve; Stryker Neurovascular) was placed across the neck of the pseudoaneurysm. A postprocedure angiogram showed contrast stasis within the pseudoaneurysm, the complete opening of the stent, and good distal flow (Fig 2b). Oral prasugrel (10 mg/d) and aspirin (150 mg/d) were prescribed to prevent in-stent thrombosis. Three-month follow-up computed tomography angiography showed the complete exclusion of the anastomotic site pseudoaneurysm with a patent stent, with no in-stent stenosis or thrombosis (Fig 3a, b).Figure 3(a) Maximum intensity projection reconstruction image obtained from 3-month follow-up computed tomography angiography showed an in-situ flow-diverter stent (arrow), with the complete exclusion of the anastomotic site pseudoaneurysm and normal filling of the transplant renal artery and its branches. (b) Axial computed tomography angiography showed a thrombosed pseudoaneurysm (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) The indications for active intervention for transplant renal artery pseudoaneurysms include symptomatic pseudoaneurysms, a size of 25 mm, or interval growth (2Bracale U.M. Santangelo M. Carbone F. et al.Anastomotic pseudoaneurysm complicating renal transplantation: treatment options.Eur J Vasc Endovasc Surg. 2010; 39: 565-568Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar). Although traditional open surgical excision was used to treat most of these cases, a substantially high number of graft losses was encountered with open surgery (1Poels J.A. Riley P.L. Extrarenal transplant artery pseudoaneurysm: a combined therapeutic approach.Cardiovasc Intervent Radiol. 2008; 31: 404-406Crossref PubMed Scopus (19) Google Scholar,2Bracale U.M. Santangelo M. Carbone F. et al.Anastomotic pseudoaneurysm complicating renal transplantation: treatment options.Eur J Vasc Endovasc Surg. 2010; 39: 565-568Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar). Depending on the anatomy, the endovascular treatment armamentarium includes stent grafts, coils, or percutaneous treatment with thrombotic agents. However, coils or percutaneous thrombin injection may be unsuitable for wide-necked pseudoaneurysms and may cause graft loss. Recently, several case studies reported that endovascular treatment with conventional stent grafts successfully preserved renal graft function in patients with favorable iliac vessel anatomy (2Bracale U.M. Santangelo M. Carbone F. et al.Anastomotic pseudoaneurysm complicating renal transplantation: treatment options.Eur J Vasc Endovasc Surg. 2010; 39: 565-568Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar,3Smeds M.R. Ofstein R. Peterson G.J. Peterson B.G. Jacobs D.L. Endovascular repair of a para-anastomotic pseudoaneurysm after renal autotransplantation: an alternative to open reconstruction.Ann Vasc Surg. 2013; 27 (110.e5–110.e1)Abstract Full Text Full Text PDF Scopus (19) Google Scholar), whereas limb circulation was maintained using chimney grafts or periscope techniques. To circumvent the problem associated with extreme acute angulation (20°) between the external iliac artery and the transplant renal artery at the anastomotic site, an intracranial flow-diverter stent was chosen over a conventional covered stent, with the former having the advantage of being more flexible, easily navigable, and equipped with a low-profile deployment system (4Rabuffi P. Bruni A. Antonuccio E.G. Ambrogi C. Vagnarelli S. Treatment of visceral artery aneurysms and pseudoaneurysms with the use of cerebral flow diverting stents: initial experience.CVIR Endovasc. 2020; 3: 1-8Crossref PubMed Scopus (8) Google Scholar). In the authors’ experience, intracranial flow-diverter stents are an excellent device in similar bends encountered in the cavernous segment of the internal carotid artery while treating aneurysms arising from that location. Moreover, flow-diverter stents can preserve lower limb blood flow better than conventional stent grafts (4Rabuffi P. Bruni A. Antonuccio E.G. Ambrogi C. Vagnarelli S. Treatment of visceral artery aneurysms and pseudoaneurysms with the use of cerebral flow diverting stents: initial experience.CVIR Endovasc. 2020; 3: 1-8Crossref PubMed Scopus (8) Google Scholar). An endovascular approach to the management of anastomotic site pseudoaneurysms in transplant renal arteries using intracranial flow-diverter stents might be a feasible method for tortuous anatomy, with the associated advantage of preserving lower limb blood flow. The availability of larger flow-diverter stents with a low-profile delivery system further expands the treatment options for anastomotic site pseudoaneurysms in transplant renal arteries. The authors thank Prof. Dr. Santhosh Joseph for constant encouragement and support. Demonstration of Respiratory Movements of Inferior Vena Cava Filters Using 4D-CTJournal of Vascular and Interventional RadiologyVol. 30Issue 9PreviewWe applied 4-dimensional computed tomography (4D-CT) to investigate the respiratory movement of inferior vena cava filters related to complications. Filters without complications demonstrated smooth craniocaudal movement (Video 1 [available online on the article’s Supplemental Material page at www.jvir.org]). The suprarenal filters showed relatively larger movements from the cranial posterior to the caudal anterior direction than the infrarenal filters (Video 2 [available online on the article’s Supplemental Material page at www.jvir.org]). Full-Text PDF Use of Fenestrated Stent Grafts for the Treatment of Anastomotic Pseudoaneurysms in Transplant Renal ArteriesJournal of Vascular and Interventional RadiologyVol. 34Issue 4PreviewAfter renal transplantation, the incidence of anastomotic pseudoaneurysms in the renal artery is 0.3% (1). Pseudoaneurysms may cause renal impairment, and rupture can lead to life-threatening hemorrhage (2). Standard stent graft placement potentially sacrifices the transplant vessel, thereby risking the renal transplant; avoiding sacrificing requires stent graft placement in a T configuration using a fenestration. However, no commercially available endovascular devices have been designed for this purpose. Full-Text PDF Clarification of Lumbar Puncture Risk Categorization in Consensus Guidelines for Periprocedural Management of Thrombotic and Bleeding RiskJournal of Vascular and Interventional RadiologyVol. 33Issue 9PreviewI would like to thank the authors of the article titled “Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations: Endorsed by the Canadian Association for Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe” for handling an extremely difficult topic, often with a dearth of literature (1). For radiologists performing lumbar punctures (LPs), I would like to seek clarification regarding LPs in these guidelines. Full-Text PDF