Pseudoaneurysm of superior epigastric artery branch: A rare complication following renal allograft biopsy treated by percutaneous thrombin injection

Raghunandan Prasad; J M Alex Babu; Hira Lal; Manas R Patel; Amit Gupta

doi:10.4103/ijot.ijot_13_18

CASE REPORT

Year : 2018 | Volume : 12 | Issue : 2 | Page : 143-145

Pseudoaneurysm of superior epigastric artery branch: A rare complication following renal allograft biopsy treated by percutaneous thrombin injection

Raghunandan Prasad¹, J M Alex Babu², Hira Lal¹, Manas R Patel², Amit Gupta²
¹ Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
² Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication

29-Jun-2018

Correspondence Address:
Dr. Raghunandan Prasad
Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_13_18

Abstract

Renal biopsy is often needed to diagnose posttransplant graft dysfunction. Although it is very safe due to availability of real-time imaging, complications do occur. We report a rare case of anterior abdominal wall vessel injury during allograft biopsy resulting in a large perigraft hematoma. It mimics a subcapsular hematoma due to intrarenal vessel injury leading to diagnostic confusion. We detected a partially thrombosed pseudoaneurysm 3 weeks after the biopsy which had feeders from superior and inferior epigastric artery confirmed by injecting contrast into the pseudoaneurysm. The pseudoaneurysm is due to injury to small branch of these arteries. We used a novel and a cost-effective therapeutic intervention to treat this pseudoaneurysm. We injected thrombin percutaneously into pseudoaneurysm which enables thrombosis of the feeder vessels preventing recurrence.

Keywords: Allograft, biopsy, epigastric artery, perigraft hematoma, pseudoaneurysm, thrombin

How to cite this article:
Prasad R, Babu J M, Lal H, Patel MR, Gupta A. Pseudoaneurysm of superior epigastric artery branch: A rare complication following renal allograft biopsy treated by percutaneous thrombin injection. Indian J Transplant 2018;12:143-5

How to cite this URL:
Prasad R, Babu J M, Lal H, Patel MR, Gupta A. Pseudoaneurysm of superior epigastric artery branch: A rare complication following renal allograft biopsy treated by percutaneous thrombin injection. Indian J Transplant [serial online] 2018 [cited 2021 Apr 10];12:143-5. Available from: https://www.ijtonline.in/text.asp?2018/12/2/143/235587

Introduction

Renal biopsy is essential in confirmation of diagnosis and treatment of kidney diseases, more so in cases of posttransplantation renal graft dysfunction.

Although very safe, sometime renal biopsy may be associated with various complications such as perinephric hematoma, pseudoaneurysm, and arteriovenous fistula formation resulting in hematuria.^[1] Very rarely extrarenal parietal and intercostals vessels may also get injured resulting in bleeding and hematoma formation.^[2],[3]

We report a rare complication of renal allograft biopsy in the form of injury to anterior abdominal wall vessels in the right iliac fossa resulting in a large perigraft hematoma. Initially, the source of this hematoma was considered postbiopsy renal vessels injury as this hematoma was mimicking as a subcapsular hematoma causing compression over upper pole cortex of graft kidney. Later on, a pseudoaneurysm was detected in the center of hematoma with feeders from anterior abdominal wall vessels. This pseudoaneurysm was treated by a novel intervention in the form of forceful and rapid injection of thrombin into pseudoaneurysm sac enabling reflux of thrombin into the feeder vessels resulting in thrombosis of the pseudoaneurysm sac as well as the feeder vessels.

Case Report

A 30-year-old male, a case of biopsy-proven hypertensive nephropathy, underwent renal transplantation without any intraoperative complications. His urine output was brisk. He had acute graft dysfunction on postoperative day 5. He underwent graft kidney biopsy on postoperative day 7, under ultrasound guidance, which revealed tacrolimus toxicity. The dose of tacrolimus was decreased.

There was a localized swelling of the wound. The patient was already having hematuria before biopsy. The intensity of hematuria increased, and there was a bloody discharge from the wound 3 days after the biopsy though there was no fall in hemoglobin or hematocrit. Ultrasound abdomen done 3 days after the biopsy revealed presence of a collection measuring 8.0 × 3.7 × 2.2 cm in size adjacent to upper and mid pole of the graft without any significance compression on it. Doppler revealed no evidence of pseudoaneurysm or arteriovenous fistula.

He was managed conservatively with bed rest. His repeat ultrasound 10 days after the biopsy revealed a decrease in the size of hematoma with no evidence of pseudoaneurysm or AVF. He underwent a repeat Doppler ultrasound of the graft 30 days after the biopsy. It revealed a partially thrombosed pseudoaneurysm measuring 3.7 × 2.6 cm in size with central anechoic sac measuring approximately 1 × 1 cm in size showing color flow [Figure 1]. The sac of the partially thrombosed pseudoaneurysm was getting supply from adjacent anterior abdominal wall vessels. As the pseudoaneurysm was superficially located in the anterior abdominal wall muscles, so ultrasound-guided compression of pseudoaneurysm was attempted. This too fails to obliterate the pseudoaneurysm. Finally, the patient was taken up for percutaneous thrombin injection into the sac. As the obliteration of pseudoaneurysm by percutaneous thrombin injection has a high recanalization rate, so we decided to adopt a new innovative and novel approach to inject thrombin in the sac. First, we secured access in the sac of pseudoaneurysm by puncturing the pseudoaneurysm percutaneously using 22G lumbar puncture needle under ultrasound guidance with its tip positioned near the neck of the pseudoaneurysm and making sure that needle track goes through the thick rim of the thrombus. Then, based on the volume of sac, approximately 1.5 ml of nonionic contrast was injected forcefully into the sac to make contrast reflux into the feeding arteries [Figure 2]. This maneuver was repeated three times to make an idea how much force is required to make contrast reflux into the feeding arteries. This maneuver beautifully opacified all the arterial feeders supplying the pseudoaneurysm. There was two feeding artery for the pseudoaneurysm coming from the branches of the superior and inferior epigastric arteries. Finally, 1.5 ml thrombin was injected into the sac in the same manner. This resulted in reflux of thrombin into the feeder vessels causing thrombosis of these feeder vessels and pseudoaneurysm sac [Figure 3] as documented on postprocedure ultrasound. One-week postprocedure follow-up, ultrasound Doppler reveals completely obliterated pseudoaneurysm with a residual hematoma.

Figure 1: Color Doppler image showing puseudoaneurysm sac of size 3.7 cm × 2.6 cm (indicated by box ) with central anechoic sac of size 1 cm × 1 cm showing color flow (indicated by white arrow)

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Figure 2: Digital substraction angiography image showing pseudoaneurysm (marked by black arrow) with feeder vessels (shown by white arrows), demonstrated by forceful injection of 1.5 ml nonionic contrast into the sac

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Figure 3: Digital subtraction angiography image showing reflux of thrombin into the feeder vessels. (marked by black arrows)

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Discussion

Renal allograft biopsy is essential in the diagnosis of posttransplant graft dysfunction or proteinuria. The predictors of complications include a presence of graft dysfunction, deranged coagulation, platelet dysfunction, the presence of medulla in the biopsy but not on the number of attempts or size of the tissue.

Color Doppler is the main diagnostic modality for the identification of pseudoaneurysm following biopsy. To-and-fro color signals in Doppler are characteristic of pseudoaneurysm. Pseudoaneurysms of arteries in the abdominal wall can occur during paracentesis,^[4] chest tube ^[3] insertion, and rarely following percutaneous biopsy.^[5] The arteries most commonly injured are the branches of the superior epigastric artery, inferior epigastric artery, or circumflex iliac artery.^[4],[5],[6] There are case reports of extrarenal pseudoaneurysm following renal allograft biopsy managed conservatively ^[7] or coil embolization.^[8] There are no prior case reports of thrombin injection of extrarenal pseudoaneurysm.

Ultrasound-guided compression of the pseudoaneurysm is the first line of treatment for pseudoaneurysm. It has a success rate up to 70%. The reasons for failure being pain due to prolonged compression and depth of the pseudoaneurysm.^[9]

In 1986, Cope and Ziet introduced percutaneous injection of thrombin as a treatment for pseudoaneurysm.^[10] The success rate for thrombin injection of pseudoaneurysms involving peripheral vessels is almost 90%.^[11] The reasons for the failure of thrombin injection are small pseudoaneurysms of size <2.5 cm, small neck, sonographically occult arteriotomy. Whenever there are multiple feeder vessels, the chances of failure of thrombin injection are high.^[12] It may necessitate vascular intervention in the form of coil embolization.

In their case report, Koshy et al. have reported a similar case of perinephric hematoma following allograft biopsy. There was a pseudoaneurysm arising from ascending branch of the deep circumflex iliac artery. Which was embolised using gel foam. Despite intervention, the patient continued to have a fall in hemoglobin. Hence DSA was repeated, which revealed the presence of multiple collaterals feeding the pseudoaneurysm. Hence, repeat DSA revealed the presence of multiple collaterals feeding the pseudoaneurysm. They cannulated the internal mammary artery through transfemoral route and feeders from superior epigastric artery were embolized using gelfoam.^[13]

There were two cases of postallograft biopsy bleed controlled by a novel method reported by Anant Kumar et al., where thrombin and gelatin matrix were directly injected into the biopsy tract to achieve hemostasis. These two cases had refractory bleeding from the biopsy tract requiring multiple transfusion not controlled by angioembolization also. They tried to achieve hemostasis by suturing the biopsy tract directly which failed. They were on the verge of planning for graft nephrectomy. Finally, they used gelatine-thrombin hemostatic matrix which controlled the bleeding.^[14] In our case, there was no fall in hemoglobin. There was a large hematoma with a partially thrombosed pseudoaneurysm associated with risk of rupture.

The nephrologist as well as the interventional radiologist should be aware that injury to the blood vessels in the abdominal wall can occur during allograft biopsy. When there is a perinephric hematoma following allograft biopsy and if no renal parenchymal pseudoaneurysm or arteriovenous fistula is being detected, one should always look for other possible sources of bleed also.

In our case, we did a small novel modification in the technique of injecting thrombin into the pseudoaneurysm sac percutaneously, to minimize the risk of pseudoaneurysm recanalization. The thrombin was injected forcefully which enabled the thrombosis of feeder vessels also, reducing the chances of recurrence. This method is successful, less invasive as well as cost-effective compared to coil or gelfoam embolization.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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