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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 247-249

Abdominal wall pseudoaneurysm after percutaneous renal allograft biopsy: A preventable complication? - a case report


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

Date of Submission06-Jun-2020
Date of Acceptance05-Aug-2020
Date of Web Publication30-Sep-2020

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


DOI: 10.4103/ijot.ijot_53_20

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  Abstract 


Percutaneous renal allograft biopsy (PRAB) complications have been extensively described in literature. We report an unusual case of a pseudoaneurysm in the anterior abdominal wall that developed after a PRAB in a 26-year-old male patient done for suspected posttransplant graft dysfunction. Surgical exploration and ligation of feeding vessel was done for this case. Such a distressing complication warrants extra care as it can lead to significant morbidity in the patient.

Keywords: Abdominal wall aneurysm, abdominal wall bleeding, pseudoaneurysm, renal allograft biopsy complication


How to cite this article:
Kareem Z, Patil A, Sabnis R, Desai M. Abdominal wall pseudoaneurysm after percutaneous renal allograft biopsy: A preventable complication? - a case report. Indian J Transplant 2020;14:247-9

How to cite this URL:
Kareem Z, Patil A, Sabnis R, Desai M. Abdominal wall pseudoaneurysm after percutaneous renal allograft biopsy: A preventable complication? - a case report. Indian J Transplant [serial online] 2020 [cited 2020 Oct 23];14:247-9. Available from: https://www.ijtonline.in/text.asp?2020/14/3/247/296897




  Introduction Top


Percutaneous renal allograft biopsy (PRAB) has been the gold standard to diagnose renal allograft rejection. However, it also leads to complications such as bleeding in a significant proportion of patients.[1] Here, we report a case of a pseudoaneurysm that developed in the anterior abdominal wall after PRAB in a patient, which was treated by surgical exploration and ligation of the feeder vessel.


  Case Report Top


A 26-year-old hypertensive male patient, having native kidney disease of undetermined etiology, had undergone live-related renal allograft surgery at our center 3 years back with no significant postoperative complications. He now presented to our nephrology clinic with progressive graft dysfunction and rising serum creatinine (3.10 mg %). The same patient had undergone a PRAB at our center 1 year back when he had presented with rising serum creatinine after suffering from an episode of acute gastroenteritis, which showed no rejection at the time. Keeping graft rejection in mind, he underwent PRAB under ultrasound (USG) guidance after confirming normal platelet count, bleeding, and coagulation parameters. His blood pressure before the procedure was 140/90 mm of Hg, and postprocedure blood pressure was 130/90 mm of Hg.

The patient developed a small tender swelling in the right iliac fossa few hours after the procedure. USG done at the time did not reveal any significant abnormality, and expectant management was carried out. However, over the next 3 days, he showed signs of serially dropping hemoglobin (drop of 2 g/dl) with increase in size of swelling over the abdominal wall. USG done at this time revealed the presence of a 2 cm × 2 cm sized collection in the intermuscular plane in the abdominal wall near the upper pole of the graft kidney, showing mixed vascularity on color Doppler imaging, with the presence of a feeder artery located medially between muscle and graft [Figure 1] and [Figure 2]. There was no perinephric collection seen.
Figure 1: Color Doppler showing the pseudoaneurysm, showing mixed vascularity, with the feeding vessel underneath

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Figure 2: Color Doppler showing graft kidney with no perinephric collection, and pseudoaneurysm with separate artery feeding it

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Initially, the patient was given expectant management with bed rest, compression of the swelling, monitoring the size of swelling, and two units of blood transfusions. However, in view of persistent drop in hemoglobin despite these measures, decision was taken to surgically explore and evacuate the hematoma and ligate the feeding vessel. Intraoperatively, there was a hematoma present between the external and internal oblique muscles [Figure 3], which was evacuated and arterial feeder vessel from the internal oblique muscular branch was identified and ligated. The patient recovered well postoperatively, and on follow-up after 3 months, there was no residual collection seen in the intermuscular plane.
Figure 3: Hematoma present between the external and internal oblique muscles seen intraoperatively

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  Discussion Top


PRAB is a commonly done procedure now to detect graft dysfunction. However, it is a procedure that is not bereft of complications, with formation of perinephric hematomas, arteriovenous fistulas, and hematuria being the major ones.[2] Predictors of complications post-PRAB such as hypertension, low platelet counts, and deranged coagulation parameters have been described in literature and should be thoroughly reviewed before performing the procedure,[2] with anticipation of complications in these cases.

Development of abdominal wall pseudoaneurysm following PRAB is a rare phenomenon. The vasculature of the anterior abdominal wall predominantly includes the superior and inferior epigastric arteries and their superficial branches [Figure 4]. These vessels are prone to get injured during procedures such as needle biopsies, laparoscopy, and percutaneous drain placements, and such injuries have been reported in literature,[3] with one even having fatal outcome.[4] Georgiadis et al. in their review described 16 cases of inferior epigastric artery pseudoaneurysms, most common etiology being iatrogenic (13/16), and they were all treated with different approaches ranging from open surgery to percutaneous approaches.[5]
Figure 4: The anatomy of the anterior abdominal wall vasculature

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Different techniques for the management of this complication have been described. Color Doppler USG is required for diagnosis, and in this case, it showed the pseudoaneurysm being supplied by the vessel underneath. Color Doppler USG is also helpful in differentiating the pseudoaneurysm from other differential diagnosis such as a true aneurysm or hematoma. A true aneurysm would demonstrate dilatation of all the three layers of the vessel, whereas in a pseudoaneurysm, there is an arterial wall deficiency, which leads to accumulation of blood in the nearby extraluminal region. Color Doppler USG in such a case would demonstrate the appearance of the communicating neck between the arterial vessel and pseudoaneurysmal sac with the classic “to-and-fro” waveform. A hematoma will not show any such movement on color doppler.

Percutaneous treatment options include USG-guided direct compression, injection of thrombin, glue injection, or embolization.[6] In this case, decision was taken to surgically explore the case as the hemoglobin was serially dropping. It is essential to be sure of the vessel location before exploration to reduce the duration of surgery, hence minimizing need for blood transfusions and further morbidity.

This complication is a rare phenomenon that all nephrologists and urologists should be aware of as PRAB is done routinely at all transplant centers. A thorough knowledge of the anterior wall vasculature before performing the PRAB is essential and will help to reduce the chances of pseudoaneurysm formation. Color Doppler is an essential tool and helps differentiate between a perinephric collection and pseudoaneurysm, and we recommend it should be done post-PRAB in all patients.


  Conclusion Top


Pseudoaneurysm in the anterior abdominal wall is a rare preventable complication of PRAB and should be considered in the differential diagnosis of post-PRAB abdominal swelling. Prompt suspicion and timely intervention can lead to reduced morbidity and mortality.

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.



 
  References Top

1.
Eiro M, Katoh T, Watanabe T. Risk factors for bleeding complications in percutaneous renal biopsy. Clin Exp Nephrol 2005;9:40-5.  Back to cited text no. 1
    
2.
Li CH, Traube LE, Lu DS, Raman SS, Danovitch GM, Gritsch HA, et al. Implementation and results of a percutaneous renal allograft biopsy protocol to reduce complication rate. J Am Coll Radiol 2016;13:549-53.  Back to cited text no. 2
    
3.
Ruiz-Tovar J, Rubio M, Conde S, Morales V, Martinez-Molina E. Inferior epigastric artery pseudoaneurysm: Complication of surgical drain insertion. ANZ J Surg 2008;78:1139.  Back to cited text no. 3
    
4.
Todd AW. Inadvertent puncture of the inferior epigastric artery during needle biopsy with fatal outcome. Clin Radiol 2001;56:989-90.  Back to cited text no. 4
    
5.
Georgiadis GS, Souftas VD, Papas TT, Lazarides MK, Prassopoulos P. Inferior epigastric artery false aneurysms: Review of the literature and case report. Eur J Vasc Endovasc Surg 2007;33:182-6.  Back to cited text no. 5
    
6.
Koshy CG, Chacko BR, Babu S, Basu G, Selvaraj D, John GT. An unusual case of abdominal wall bleeding after renal allograft biopsy. Indian J Nephrol 2011;21:62-5.  Back to cited text no. 6
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    Figures

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



 

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