Table of Contents  
NOVEL TECHNIQUE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 91-92

Repair of large ruptured infected pseudoaneurysm of iliac artery with transposition of internal iliac artery after an allograft nephrectomy


Department of Vascular and Endovascular Surgery, Yashoda Hospitals, Somajiguda, Hyderabad, Telangana, India

Date of Submission26-Oct-2021
Date of Decision08-Nov-2021
Date of Acceptance01-Dec-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Devender Singh
Department of Vascular and Endovascular Surgery, Yashoda Hospitals, Somajiguda, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_115_21

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  Abstract 


Pseudoaneurysms following allograft nephrectomy are rare and associated with significant morbidity and mortality. Ruptured iliac artery pseudoaneurysm in a septic patient is a challenge to treat due to limited options. This case report highlights a novel technique of using ipsilateral internal iliac artery to repair an infected pseudoaneurysm of the iliac artery related to explanted renal transplant.

Keywords: Internal iliac artery, nephrectomy, pseudoaneurysm, renal transplant


How to cite this article:
Singh D, Aryala S. Repair of large ruptured infected pseudoaneurysm of iliac artery with transposition of internal iliac artery after an allograft nephrectomy. Indian J Vasc Endovasc Surg 2022;9:91-2

How to cite this URL:
Singh D, Aryala S. Repair of large ruptured infected pseudoaneurysm of iliac artery with transposition of internal iliac artery after an allograft nephrectomy. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:91-2. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/91/340496




  Case Study Top


A 26-year-old young male presented to the emergency in shock, with a history of pain and expanding mass in the abdomen for 2 weeks. There was a significant increase in the bloody discharge from the left flank incision for the last 2 days. This patient is a case of chronic kidney disease on regular hemodialysis. He underwent graft nephrectomy (left) 1 month back for rejection. On examination, there was a large swelling occupying left half of the abdomen, extending into the pelvis and groin. The dressing was soaked with blood-mixed purulent discharge with a foul smell from the previous incision site. An urgent computed tomography angiogram revealed a large ruptured infected pseudoaneurysm of 20 cm × 15 cm arising from the left external iliac artery [Figure 1] and [Figure 2]. After resuscitation with fluids, blood products, and hemodialysis, he was planned for the surgery. For the procedure, our reconstruction options were limited, as the patient was in septic shock with hostile abdomen with a large ruptured infected aneurysm involving the pubic and groin. Reconstruction with a vein or synthetic graft,either anatomic or extra anatomic, carries a significant risk of secondary infection and bleeding. The risk continued to be same even with endovascular techniques. Among available vascular conduits, an arterial graft seems to be more resistant to infections, so we planned to use left internal artery as a conduit for the reconstruction. After vascular control, the infected pseudoaneurysm was excised with the evacuation of infected hematoma. After identifying rent in the external iliac artery, the artery was transected at the healthy area and closed. Then, the internal iliac was dissected, transected distally after ligation, and transposed to the distal part of the external iliac artery with end-to-end anastomosis [Figure 3]. His culture grew Acinetobacter species, sensitive to only carbapenems. The patient was kept on long-term antibiotics and he made a smooth recovery in postoperative period with normal vascularity to the leg [Figure 4]. Hence, we highlight the successful use of our novel technique of transposing internal iliac artery for the reconstruction of the external iliac artery in a septic hostile abdomen.
Figure 1: Computed tomography scan showing a larger aneurysm of 20 cm × 15 cm at the left iliac artery bifurcation

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Figure 2: Computed tomography angiogram showing a pseudoaneurysm from the left external iliac artery

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Figure 3: Transposition of left internal iliac artery to reconstruct the distal external artery after excising and ligating proximal part

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Figure 4: Computed tomography angiogram showing the patent reconstructed left iliac artery

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Pseudoaneurysms following allograft nephrectomy are uncommon, having been reported in 0.9%–14% of cases, but are associated with poor outcomes.[1],[2],[3] The most important risk factor for the development of such complications is local infection or sepsis leading to anastomotic disruption with consequent pseudoaneurysm formation or rupture.[1],[2],[4] Ruptured large infected pseudoaneurysms should be considered for an open surgical approach with the excision, debridement, and reconstruction with a graft. A two-staged approach has also been advocated with initial iliac artery ligation followed by extra-anatomical revascularization; however, the risk of amputation stands high if the ischemic insult is more.[1],[2],[3],[5] Endovascular exclusion is currently the preferred option for the management of iliac artery pseudoaneurysm because it is a safe and with lower incidence of postoperative complications.[3] However, durability and long-term outcomes have not been reported, more so in sepsis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Akoh JA. Transplant nephrectomy. World J Transplant 2011;1:4-12.  Back to cited text no. 1
    
2.
Eng MM, Power RE, Hickey DP, Little DM. Vascular complications of allograft nephrectomy. Eur J Vasc Endovasc Surg 2006;32:212-6.  Back to cited text no. 2
    
3.
Chaer RA, Barbato JE, Lin SC, Zenati M, Kent KC, McKinsey JF. Isolated iliac artery aneurysms: A contemporary comparison of endovascular and open repair. J Vasc Surg 2008;47:708-13.  Back to cited text no. 3
    
4.
Bracale UM, Carbone F, del Guercio L, Viola D, D'Armiento FP, Maurea S, et al. External iliac artery pseudoaneurysm complicating renal transplantation. Interact Cardiovasc Thorac Surg 2009;8:654-60.  Back to cited text no. 4
    
5.
Pitoulias GA, Donas KP, Schulte S, Horsch S, Papadimitriou DK. Isolated iliac artery aneurysms: Endovascular versus open elective repair. J Vasc Surg 2007;46:648-54.  Back to cited text no. 5
    


    Figures

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



 

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