International Urology and Nephrology 28 (5), pp. 729- 732 (1996)

Surgical Repair of Aneurysm in the Transplanted Kidney Following a Percutaneous Needle Biopsy T. YAOISAWA, H. TOMA, K. TAKAHASHL K. OTA Department of Urology, Kidney Center, Tokyo Women's Medical College, Kawadacho, Shinjyuku-Ku, Tokyo, Japan (Accepted August 10, 1996)

Arterial aneurysm following a needle biopsy is a serious and troublesome complication in renal allograft. We report herein a case in which the large aneurysm developed at the interlobar arterial branch in the transplanted kidney after needle biopsy. We also present the successful surgical treatment of the aneurysm and discuss the management of this complication.

Introduction Needle (Trucut) biopsy is the standard investigation of allograft dysfunction after renal transplantation. The improvement of biopsy technique using ultrasound-guide and Biopty gun reduced the complication rate. Nevertheless, vascular complications remain potentially serious [1, 2]. We report the case of an aneurysm in the transplanted renal artery following percutaneous graft biopsy and the surgical treatment of the aneurysm.

Case report A 45-year-old man received a kidney graft from his younger sister. As the kidney produced urine immediately after the operation, the patient was free from haemodialysis postoperatively. The patient recovered uneventfully and renal function improved to a serum creatinine level of less than 1.3 mg/dl. He was immunosuppressed with cyclosporin and underwent an allograft needle (Trucut) biopsy to confirm cyclosporin nephrotoxicity on the 18th postoperative day. No symptom was seen and renal function remained stable after biopsy. However, massive haematuria and tamponade of the urinary bladder occurred on the 12th day after biopsy. The haematocrit level dropped from 32% to 16% and the serum ereatinine level increased to 3.2 mg/dl. We managed the patient with a blood transfusion and putting pressure upon the graft for haemostasis and investigated the allograft. Ultrasonogram showed an echo-lucent cavity within the kidney parenchyma. Renal arteriogram demonstrated an aneurysm at the interlobar arterial branch and the size of the aneurysm was 2.8 cm• 3.0 cm VSP, Utrecht Akad~miatKiad6, Budapest

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as measured by arteriography (Fig, I). The murmur became audible over the allograft and later an arteriogram revealed enlargement of the aneurysm along the 9 artery. Surgical treatment of the aneurysm was performed through a transperitoneal approach to the hilus of the allografl.The renal artery was explored and controlled and finally the largestextrarenal peripheral feeding artery of the aneurysm was successfully ligated,confirming the disappearance of the murmur by Doppler ultrasound. The infarcfing area was seen to be small from the surface. CT and scintigram after surgical intervention showed a small infarcting area in the parenchyma (Fig. 2). The patient recovered uneventfully and renal function remained the same as before biopsy. Blood pressure also remained normal.

Fig. I,Artcriogramshowing an ancurysm in the ~zansplantedkidney

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Fig. 2. Scintigramdemonstratinga small infarcting area after surgical intervention Discussion

Vascular complications such as arterial aneurysm or arterio-venous fistula following renal allografl biopsy are serious and troublesome problems [ 1]. The ultrasound-guided technique and the Biopty gun equipment reduced the rate of complications, however, even with careful procedure it is still associated with a definite complication rate [2]. Therefore, careful follow-up and adequate treatment for this complication are required after biopsy. In this case, it was necessary to repair or excise the aneurysm, because it became enlarged and turned symptomatic. Surgical treatment including extracorporeal bench work and transluminal embolization were considered for the management of the aneurysm [3]. Recently, transcatheter embolization has widely been used to treat vascular diseases and malignancies and this procedure seems to be a reasonable alternative to surgical treatment [4, 5, 6]. At In'st, we considered the indication of transcatheter embolization. However, because the feeding arterial branch of the aneurysm was too winding to introduce a catheter in this case, we selected surgical repair rather than embolization. Consequently, we could ligate the extrarenal peripheral feeding artery of the anInternational Urologyand Nephrology28, 1996

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eurysm with a small infarcting area of the graft by open surgery. The patient and his renal function recovered uneventfully after the surgical treatment. Although selective transcatheter embolization is a minimal-invasive procedure and has the advantage of instant control of bleeding [4, 5, 6], application o f this technique in the transplanted kidney is generally difficult because o f the intricate arterial route. Therefore, surgical treatment as well as embolization should be considered without delay if the aneurysm becomes symptomatic or enlarges.

References 1. Wilczek, H. E.: Percutaneous needle biopsy of the renal allograft. Transplantation, 50, 790 (1990). 2. Beckingham, I. J., Nicholson, M. L., Bell, P. R. F.: Analysis of factors associated with complications following renal transplant needle core biopsy. Br. s Urol., 73, 13 (1994). 3. Dunkow, P. D., Abraham, J. S., Johnson, R. W. G.: True aneurysm of the transplanted renal artery in a kidney transplant recipient. Nephrol. Dial. Transplant., 9, 1495 (1994). 4. Spigos, D. G., John, E. G., Chan, L., Jonasson, O.: Transcatheter control of renal hemorrhage following renal biopsy. J. Pediatr. Surg., 17, 321 (1982). 5. Moreau, J. F., Merland, J. J., Descamps, J. M.: Post-biopsy false arterial aneurysm of a transplanted kidney: Treatment by bucrylate transcatheter embolization. J. Urol., 128, 116(1982). 6. Horowitz, M. D., Russell, E., Abitbol, C., Kyriakides, G., Miller, J.: Massive hematuria following percutaneous biopsy of renal allograft. Arch. Surg., 119, 1430 (1984).

International Urologyand Nephrology 28, 1996