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Mycotic pseudoaneurysms complicating renal transplantation: a case series and review of literature
© Leonardou et al; licensee BioMed Central Ltd. 2012
Received: 18 May 2011
Accepted: 14 February 2012
Published: 14 February 2012
Kidney transplantation can be complicated by infection and subsequent development of mycotic aneurysm, endangering the survival of the graft and the patient. Management of this condition in five cases is discussed, accompanied by a review of the relevant literature.
Five patients, three men 42-, 67- and 57-years-old and two women 55- and 21-years-old (mean age of 48 years), all Caucasians, developed a mycotic aneurysm in the region of the anastomosis between renal graft artery and iliac axes. Four patients presented with systemic fever and iliac fossa pain and one presented with hemorrhagic shock. Morphologic investigation by color doppler ultrasonography revealed a pseudoaneurysm at the anastomotic site. A combination of antibiotic therapy, surgery and interventional procedures was required as all kidney transplants had to be removed. No recurrence was recorded during the follow-up period.
A high index of suspicion is required for the timely diagnosis of a mycotic aneurysm; aggressive treatment with cover stents and/or surgical excision is necessary in order to prevent potentially fatal complications.
The incidence of mycotic aneurysm formation following renal transplantation is < 1%. A non-mycotic etiology for aneurysm formation in the same setting has also been recorded [1–3]. An aneurysm may be asymptomatic, being an incidental finding during imaging evaluation for other reasons, yet it can occasionally cause fever and anemia, iliac fossa discomfort, renal dysfunction and graft loss or even precipitate a lethal hemorrhage due to acute rupture . Early recognition of this entity based on a high index of suspicion and use of early diagnostic procedures is vital for its successful management. Therapeutic options include aneurysmectomy, proximal and distal ligation of the arterial trunk, medical treatment and percutaneous embolization, although the choice of prompt treatment strategy is still a subject of debate, requiring further delineation.
We report the cases of five patients suffering from this life-threatening complication and present the therapeutic procedures used and their long-term outcomes together with a literature review on this topic.
Cases two and three
One man, 67-years-old, and one woman, 55-years-old, both Caucasian, had previously received a transplant from cadaveric donors, and presented with fever and abdominal pain located at the left iliac fossa. Color doppler ultrasonography (CDU) examination revealed the presence of a hypoechoic mass at the hilus of the transplanted kidney with bidirectional or swirling blood flow within its lumen.
Infection of the artery at or around the site of anastomosis is an ominous complication commonly presenting as an anastomotic leak or local dissolution of the arterial wall . Mycotic aneurysm is a rare infectious complication, associated with high morbidity and mortality rates, while the prompt treatment modality remains a subject of debate. Small, asymptomatic pseudoaneurysms can be managed conservatively by regular monitoring, while early diagnosis and timely operation might be the most important factors in the survival of patients with mycotic pseudoaneurysms [6, 7]. However, an aneurysm infected with candida is reported to have been successfully managed by conservative pharmacological means during a period of 38 months follow-up .
Another point of interest is the need for nephrectomy in the majority of renal transplant patients presenting with pseudoaneurysm due to resistant rejection, function failure or infection. A review of the literature found reports of successful venous patch angioplasty and surgical reconstruction of a renal artery aneurysm that prevented aneurysm rupture and saved the graft [9, 10]. With regard to our fourth patient, although we decided on a two-stage procedure aiming to preserve the transplanted kidney, this was not feasible due to recurrence of the pseudoaneurysm.
Another aspect of significant consideration is the need for concomitant vascular reconstruction after surgical aneurysmectomy. As Bracale et al.  suggest, after investigation of 11 transplant recipients with mycotic aneurysm formation, vascular reconstruction is advisable since it prevents lower limb ischemia. Moreover, an above-knee amputation was reported in a 25-year-old woman who developed foot ischemia three months after external iliac ligation .
With regard to our cases, survival of the first patient was achieved due to a multi-disciplinary therapeutic approach involving medical and surgical interventions. There are published reports that support the efficacy of only one treatment modality (either pharmacological or interventional). On the other hand Liapis et al. , presented a study in which 11 out of 17 patients with mucorales infection who underwent surgery survived, while the remaining ones who did not have surgery died, thus reinforcing the view that medical therapy alone is not sufficient. We agree with Liapis et al. and remain sceptical of the proposed pathway of a single treatment modality [13, 14].
Taking into account the serious complications that can arise from mycotic aneurysm we feel that increased awareness and close monitoring are indispensable. The benefits derived from early diagnosis and treatment are indisputable. However, as a prompt therapeutic strategy has not been delineated yet, prospective studies are essential for thorough evaluation of treatment options.
Written informed consent was obtained from the patients for publication of these case reports and any accompanying images. Copies of the written consents are available for review by the Editor-in-Chief of this journal.
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