We report the case of a 57-year-old female who developed a large pseudoaneurysm of the right circumflex iliac artery 15 months after renal transplantation. Minimal invasive treatment was successfully performed with ultrasound-guided thrombin injection using the B-flow mod

Fornaro, J.

Jungius, K.-P

Marincek, B.

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Pseudoaneurysm in the iliac fossa after renaltransplantation—treatment withultrasound-guided thrombin injectionJ. Fornaro, B. Marincek, K.-P. JungiusInstitute of Diagnostic Radiology, University Hospital Zu¨rich, Zu¨rich, SwitzerlandAbstractWe report the case of a 57-year-old female who devel-oped a large pseudoaneurysm of the right circumﬂex iliacartery 15 months after renal transplantation. Minimalinvasive treatment was successfully performed withultrasound-guided thrombin injection using the B-ﬂowmode.Key words: Renal transplant—Pseudoaneurysm—Ultrasound-guided thrombin injection—B-ﬂowComplications following renal transplantation occur inabout 10% of patients [1, 2]. Medical causes are acutetubular necrosis, acute and chronic rejection of theallograft, and cyclosporine nephrotoxicity [1]. Surgicalcomplications include urologic problems (ureteralobstruction, hematoma, abscess, urinoma, lymphocele)and vascular problems (stenosis or thrombosis of therenal artery, arteriovenous fistula, thrombosis of the re-nal/iliac vein, and pseudoaneurysm) [2–4]. Pseudoaneu-rysms are typically at the anastomotic site or within theallograft [5, 6]. We report a patient presenting with apseudoaneurysm of the right circumflex iliac artery 15months after renal allotransplantation.Case reportA 57-year-old female presented with a pulsatile mass inher right lower abdomen. Renal transplantation in theright iliac fossa had been performed 15 months earlierbecause of terminal renal failure following IgAnephropathy. No adverse occurrences were reported.Renal allograft function was not compromised.B-mode ultrasonography (US) showed a hypoechoic,centrally anechoic lesion next to the upper pole of therenal allograft (Fig. 1a). The maximum diameter was 4.9cm. Color-coded Doppler sonography (CCDS) (Fig. 1b)and B-flow US (Fig. 1c) showed a pulsatile flow patternin the central anechoic part of the lesion. Diagnosis was apartially thrombosed pseudoaneurysm. The origin of thepseudoaneurysm could not be demonstrated by means ofUS. Subsequent magnetic resonance angiography al-lowed us to locate the pseudoaneurysm in the peripheralpart of the right circumflex iliac artery adjacent to theupper pole of the renal allograft (Fig. 1d).Minimal invasive treatment by means of percutane-ous ultrasound-guided thrombin injection (UGTI) wasperformed. After local disinfection a 21-G needle wasadvanced into the pseudoaneurysm under US guidancein B-ﬂow mode. Injection of nearly 1 ml thrombin(Beriplast; 500 IE) was performed under US guidanceafter adequate placement of the needle close to the neckof the pseudoaneurysm. B-ﬂow US showed within sec-onds the cessation of perfusion of the pseudoaneurysm,resulting in complete thrombosis (Fig. 2). No adversereactions occurred. Complete cessation was also con-firmed by CCDS. Follow-up sonography performed 1day and 4 weeks later did not show recurrence of per-fusion within the former pseudoaneurysm.DiscussionPseudoaneurysms represent one of the most frequentvascular complications with renal transplant. Neverthe-less, the incidence of pseudoaneurysms after renaltransplantation is lower than 1% [7]. Late vascularcomplications after renal transplantation are very rare;they usually result from infection or failure of the arterialanastomosis [8].When located at the anastomotic site pseusoaneu-rysms are commonly due to suture rupture, anastomoticleakage, or vessel wall ischemia [9]. Within the allograft,Correspondence to: K.-P. Jungius, Spitalzentrum Oberwallis, Departe-ment Radiologie, Ueberlandstrasse 14, 3900 Brig, Switzerland; email:karl-peter.jungius@rsv-gnw.chª Springer Science+Business Media, LLC 2006Published online: 15 July 2006AbdominalImagingAbdom Imaging (2007) 32:50–52DOI: 10.1007/s00261-006-9016-0pseudoaneurysms occur mostly of arcuate arteries fol-lowing needle biopsy or mycotic infection [9]. In ourcase one has to presume an intraoperative lesion of aperipheral branch of the arteria circumflexa iliaca pro-funda as the origin of the pseudoaneurysm.UGTI as a treatment option for pseudoaneurysmshas been reported to be an efﬁcient and secure procedure[10]. There are few cases where surgical repair is neces-sary, mainly when the pseudoaneurysm is not accessiblefor percutaneous treatment or when the pseudoaneurysmis complicated by infection. UGTI is efficient even in thepresence of anticoagulation with phenprocoumon orheparin.Complications of thrombin injection are rare [11, 12].When located in the proximal part of an extremity,arterial embolization distal to the pseudoaneurysm oc-curs in 0%–4% of cases [13, 14]. Other reported compli-cations are anaphylaxis [15] and generalized urticaria [16]after using bovine thrombin and infection of thethrombosed pseudoaneurysm with formation of abscess[13].B-ﬂow, a markedly improved echo amplitude imagingtechnique with a high spatial resolution, has been de-scribed as a suitable diagnostic method with someadvantages compared to CCDS in the treatment offemoral pseudoaneurysms, such as the absence of angledependency, the absence of Doppler artifacts, and theabsence of vessel wall overwriting [17]. For more than 2years B-flow has been the imaging modality of choice atour department when performing UGTI.In conclusion, even in an unusual location, UGTIseems to be a fast, safe, and reliable option for thetreatment of a pseudoaneurysm if performed in the reg-ular way. Clinical as well as US follow-up examinationFig. 2. B-flow ultrasonography. Percutaneous ultrasound-guided thrombin injection followed by immediate completethrombosis (long arrow) of the pseudoaneurysm. The needleis still within the no longer perfused hyperechoic area (shortarrow).Fig. 1. Pseudoaneurysm in theiliac fossa. a B-modeultrasonography. Mass lesion(arrow) with anechoic centralportion adjacent to the renaltransplant. (b) Color-codedDoppler sonography and (c)B-flow demonstrate perfusionwithin the pseudoaneurysm.(remark: Fig. 1a is result of theinitial examination; Fig. 1b and 1cwere taken immediately beforetreatment) d Magnetic resonanceangiography showing both therenal allograft (short arrow) andthe pseudoaneurysm (longarrow).J. Fornaro et al.: Pseudoaneurysm in the iliac fossa after renal transplant 51conﬁrmed successful therapeutic management in ourpatient.References1. Matas AJ, Payne WD, Sutherland DE, et al. (2001) 2,500 livingdonor kidney transplants: a single-center experience. Ann Surg234(2):149–1642. Gerbens D, Teyssou H, Manteau G, Ruiz R, Bureau M, Tessier JP(1980) Ultrasonography and surgical complications after kidneytransplants. J Radiol 61(6–7):405–4103. Yap R, Madrazo B, Oh HK, Dienst SG (1980) Perirenal fluidcollection after renal transplant. Am Surg 47(7):287–2904. Streeter EH, Little DM, Cranston DW, Morris PJ (2002) Theurological complications of renal transplantation: a series of 1535patients. BJU Int 90:627–6345. Grenier N, Douws C, Morel D, Ferriere JM, Le Guillou M, PotauxL, Broussin J (1991) Detection of vascular complications in renalallografts with color Doppler flow imaging. Radiology 178(1):217–2236. Koo CK, Rodger S, Baxter GM (1999) Extra-renal pseudoaneu-rysm: an uncommon complication following renal transplantation.Clin Radiol 54(11):755–7587. Donckier V, De Pauw L, Ferreira J, et al. (1995) False aneurysmafter transplant nephrectomy. Transplantation 60:3038. Luzzio CC, Waclawik AJ, Gallagher CL, Knechtle SJ (1999) Iliacartery pseudoaneurysm following renal transplantation presentingas lumbosacral plexopathy. Transplantation 67(7):1077–10789. Baxter GM (2001) Ultrasound of renal transplantation. Clin Radiol56(10):802–51810. Pezzullo JA, Dupuy DE, Cronan JJ (2000) Percutaneous injectionof thrombin for the treatment of pseudoaneurysms after catheter-ization: an alternative to sonographically guided compression. AJR175:103511. Owen RJT, Haslam PJ, Elliott ST, Rose JDG, Loose HW (2000)Percutaneous ablation of peripheral pseudoaneurysms usingthrombin: a simple and effective solution. Cardiovasc InterventRadiol 23:441–44612. Matson MB, Morgan RA, Belli AM (2001) Percutaneous treatmentof pseudoaneurysms using fibrin adhesive. Br J Radiol 74:690–69413. Paulson EK, Nelson RC, Mayes CE, et al. (2001) Sonographicallyguided thrombin injection of iatrogenic femoral pseudoaneurysms:further experience of a single institution. AJR 177:309–31614. Mohler ER III, Mitchell ME, Carpenter JP, et al. (2001) Thera-peutic thrombin injection of pseudoaneurysms: a multi-centerexperience. Vasc Med 6:241–24415. Pope M, Johnston KW (2000) Anaphylaxis after thrombin injec-tion of a femoral pseudoaneurysm: recommendations for preven-tion. J Vasc Surg 32:190–19116. Sheldon PJ, Oglevie SB, Kaplan LA (2000) Prolonged generalizedurticarial reaction after percutaneous thrombin injection for treat-ment of a femoral artery pseudoaneurysm. J Vasc Interv Radiol11:759–76117. Jung EM, Lutz R, Clevert DA, Rupp N (2001) B-flow: sono-graphic assessment and therapy for femoral artery pseudoaneu-rysm. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr173(9):805–80952 J. Fornaro et al.: Pseudoaneurysm in the iliac fossa after renal transplant

Pseudoaneurysm in the iliac fossa after renal transplantation—treatment with ultrasound-guided thrombin injection

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Pseudoaneurysm in the iliac fossa after renal transplantation—treatment with ultrasound-guided thrombin injection

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