CASE 52: Pseudoaneurysm with Massive Hematuria

Male in his 50s who developed massive hematuria (as documented in this figure) one month after having undergone a deceased donor kidney transplant onto the right external iliac vessels. The donor had 2 renal arteries, that were reconstructed together in the back table for a joint implantation. His post operative course had been remarkable for delayed graft function, an acute right lower extremity DVT, and sporadic hematuria (at the time attributed to anticoagulation for the DVT, and subsequently re-interpreted as herald bleeds).

Patient underwent an emergent IVC filter placement (arrow) and an angiogram.

A pseudo-aneurysm (black arrows) with an acute large extravasation of contrast (red arrows) was observed at the anastomosis (green arrows) of the 2 renal arteries (pink arrows) to the right external iliac artery (yellow arrows). Note also an area of diminished diameter within the external iliac artery (white arrow) probably representing an underlying plaque/dissection (later addressed in Figure 112-244).

A pseudo-aneurysm (black arrows) with an acute large extravasation of contrast (red arrows) was observed at the anastomosis (green arrows) of the 2 renal arteries (pink arrows) to the right external iliac artery (yellow arrows). Note also an area of diminished diameter within the external iliac artery (white arrow) probably representing an underlying plaque/dissection (later addressed in Figure 112-244).

The arterial hemorrhage (red arrows) was controlled by deploying a stent (purple arrows) over the pseudoaneurysm (black arrow) and the anastomosis (green arrow) of the transplant renal arteries to the external iliac artery (yellow arrows).

A repeat angiogram showed that the bleeding had been controlled. The deployed stent (purple arrows) occluded the flow to the pseudo aneurysm and to the kidney. Such approach stopped the massive hemorrhage and allowed for a controlled surgical intervention. There is adequate flow in the external iliac artery (yellow arrows).

After controlling the hemorrhage, the recipient was taken to the operating room. The transplant incision was re-opened and the retroperitoneum explored. A large hematoma was encountered and evacuated. The ureter had been detached from the bladder by the pressure of the hematoma, that in turn was filling the bladder, being evacuated via the urinary catheter, and presenting as massive hematuria.

There was no need to clamp the external iliac artery since the stent was occluding the inflow to the transplant renal arteries. To avoid stenosing the iliac vein, rather than taking down the ...