Case one
The first case is a 42-year-old Caucasian man, who was on hemodialysis after rejection of a kidney allograft of unknown etiology four years ago. Three months after nephrectomy, the patient was admitted to our hospital with diffuse pain in his right lower quadrant, acute ischemia of his right lower limb with the presence of petechiae and a systemic temperature of 38°C. Angiographic investigation revealed a pseudoaneurysm at the site of the previous arterial ligation and three balloon expandable cover stents were deployed during the same procedure to exclude the aneurysm (Figure 1). Following this interventional procedure, the patient was continuously febrile (38.5°C) and his blood examinations revealed leukocytosis. He then developed clinical signs of thromboembolism, which were confirmed by angiography (Figure 2). Subsequent treatment involved embolectomy and the histological examination of the thrombus identified mucorales hyphae. Histological examination also revealed mucorales infection of the stents. The patient underwent surgery for removal of both the mycotic aneurysm and the stents, and for construction of a suprapubic femoral-femoral by-pass. He also received amphotericin B for three months. No recurrence or any other major complication has been recorded during a follow-up period of eight years and he was able later on to undergo a kidney transplantation successfully.
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.
In both cases the blood cultures grew pseudomonas aeruoginosa. Both patients received ciprofloxacin intravenously for eight days and then orally for another three weeks. The subsequent angiographic investigation revealed a pseudoaneurysm formation (Figure 3). They were both treated with covered stent insertion followed later on by nephrectomy. They remain on hemodialysis without any reoccurrence of vascular infection evident on regular examination. The follow-up period ranges from 18 up to 36 months.
Case four
A 57-year-old Caucasian man developed a pseudoaneurysm three months after transplantectomy, at the site of the former transplant artery ligation. He presented with signs of right lower quadrant pain and tenderness, fever and weakness. CDU examination revealed a pseudoaneurysm. Klebsiella pneumoniae was isolated from blood cultures. He received intravenous antibiotic therapy (colistin) and a week later two balloon expandable covered stents were placed to exclude the aneurysmal sac from the external iliac artery (Figure 4). He was discharged home without complications and was living independently at his 14-month follow-up.
Case five
The fifth patient was a 21-year-old Caucasian woman, who had received a renal transplant from a living donor 15 months previously and subsequently developed a mycotic pseudoaneurysm. Apart from iliac fossa pain and fever, there were also signs of abdominal hemorrhage. CDU examination revealed the presence of an aneurysm at the anastomotic region and retroperitoneal blood collection. Blood cultures grew Candida which was treated with intravenous liposomal amphotericin. Percutaneous transluminal treatment was suggested and the pseudoaneurysm was initially packed with coils followed by placement of a covered stent, aiming to keep patent the transplant renal artery (Figures 5, 6, 7, 8). After a short, clinically stable, postoperative period, reappearance of a pseudoaneurysm was recorded (Figure 9); this was treated by insertion of a second covered stent (Figure 10) and renal transplant removal with successful surgical restoration of iliac arteries. Antifungal therapy with oral fluconazole had been continued for two months.