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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#58;</span></p><p class="elsevierStylePara">The most common complications following late kidney transplantectomy are intra- and postoperative haemorrhages and surgical wound infections&#46; Lesions produced in the iliac vessels have also been described&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">The incidence of pseudoaneurysms in the kidney transplantectomy bed is low&#44; with very few cases reported in the medical literature&#46;<span class="elsevierStyleSup">2-7</span> The treatment of these pseudoaneurysms using endovascular procedures is considered to be a relatively novel approach&#46;</p><p class="elsevierStylePara">We present the case of a 51-year-old patient with hypertension and terminal chronic renal failure due to mesangial IgA glomerulonephritis&#44; who sought emergency care due to diffuse abdominal pain with one week evolution&#44; and which had intensified and focalised in the right iliac fossa during the previous 24 hours&#44; accompanied by sweating&#44; nausea&#44; and vomiting&#46;</p><p class="elsevierStylePara">The patient had received a heterotopic kidney transplant in the right iliac fossa in 1998&#46; The graft failed due to the development of a non-Hodgkin&#8217;s lymphoma&#44; leading to a nephrectomy of the transplanted kidney in 1999&#44; with the patient returning to haemodialysis&#46; Three years later&#44; the patient received a second kidney transplant in the left iliac fossa&#44; for which the immunosuppression regimen consisted of prednisone&#44; mycophenolate mofetil&#44; and sirolimus&#46;</p><p class="elsevierStylePara">Upon arrival in the emergency department&#44; the patient suffered somnolence and haemodynamic instability&#46; A physical examination revealed a distended abdomen resembling peritonitis&#44; producing intense pain upon palpation in the right iliac fossa&#46;</p><p class="elsevierStylePara">Initial laboratory analyses revealed anaemia at 4 points lower than baseline haemoglobin values&#46; In addition&#44; an abdominal ultrasound revealed haemoperitoneum of an unknown origin&#46; The patient underwent an abdominal computerised tomography using contrast dye&#46; This test revealed the transplanted kidney in the left iliac fossa with a pseudoaneurysm of 4&#46;4x5x5&#46;2cm &#40;transverse&#44; antero-posterior&#44; and craniocaudal diameters&#41; whose neck was dependent to the right external iliac artery and abundant haemoperitoneum around the liver and spleen&#44; both paracolic gutters&#44; and the pelvis&#44; compatible with the signs of a ruptured pseudoaneurysm &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">In light of these findings&#44; we decided upon emergency repair of the pseudoaneurysm&#46; Under local anaesthesia and sedation&#44; we implanted a Viabahn<span class="elsevierStyleSup">&#174;</span> endo-prosthesis in the right common iliac artery&#44; extending it into the external iliac artery&#46; Angiographic control verified exclusion of the pseudoaneurysm with occlusion of the hypogastric artery&#46; The procedure was completed with the placement of a Visi-Pro<span class="elsevierStyleSup">&#174;</span> stent distally of the endo-prosthesis due to an intimal defect &#40;Figure 2&#41;&#46; The patient was discharged from the hospital 8 days later&#44; with no symptoms and recovered baseline renal function&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The formation of an iliac pseudoaneurysm in the surgical kidney transplantectomy bed is extremely rare&#46; Very few cases have been published in the medical literature&#44; with an estimated incidence &#60;1&#37;&#44; most commonly in patients with hypertension and dyslipidaemia&#46;<span class="elsevierStyleSup">8</span> Several different causes of iliac pseudoaneurysms have been described&#46; In the context of kidney transplantectomy&#44; it has been suggested that the origin lies in chronic rejection of residual blood vessels from the donated kidney that are present in the vascular stump&#44; which degenerate until forming a pseudoaneurysm&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">The clinical manifestations are correlated with the compression of neighbouring structures&#58; neurological or venous compression&#44; obstruction of the large intestine&#44; and ureteral obstruction&#46;<span class="elsevierStyleSup">9</span> The natural progression of pseudoaneurysms is rupture&#44; in which case the patient can enter into haemorrhagic shock accompanied by abdominal pain&#44; nausea&#44; vomiting&#44; genital&#47;urinary symptoms&#44; and fever &#40;especially in infectious pseudoaneurysms&#41;&#46;</p><p class="elsevierStylePara">The diagnosis tends to be late due to the location deep within the pelvis&#44; and may not be noticed until rupture&#46; The imaging test of choice is angio-CT scan&#44;<span class="elsevierStyleSup">10</span> which allows for visualising the origin of the pseudoaneurysm and the relationship with neighbouring structures as well as evaluating the possibility of endovascular treatment&#46; A Doppler-ultrasound is useful for establishing a diagnosis&#44; and angiography facilitates applying the treatment during the same procedure&#46;</p><p class="elsevierStylePara">The traditional treatment for an iliac pseudoaneurysm is open surgery through resection and insertion of a prosthesis&#46; The procedure is quite complex due to the location of the iliac arteries deep within the pelvis&#44; producing a 10&#37; mortality rate&#46;<span class="elsevierStyleSup">4</span> In ruptured iliac aneurysms that require emergency open surgical repair&#44; higher morbidity rates have been reported due to ureteral lesions&#44; postoperative haemorrhage&#44; and laparostomy&#46;<span class="elsevierStyleSup">11</span> Additional technical difficulties are inherent to residual pseudoaneurysms&#44; since the surgeon must dissect a fibrotic surgical field as a result of previous operations&#44; increasing the risk of injury&#46;</p><p class="elsevierStylePara">Endovascular treatment provides a quick&#44; safe&#44; and effective treatment alternative&#44; given the reduced invasiveness and no need for general anaesthesia&#44; with comparable results to those from traditional surgical approaches&#46;<span class="elsevierStyleSup">12</span> Even so&#44; the procedure requires assistance using costly imaging techniques that utilise radiation and contrast dye&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">To conclude&#44; in patients with a ruptured iliac pseudoaneurysm as a late complication of a kidney transplantectomy&#44; endovascular repair can be a valid&#44; effective&#44; and safe treatment alternative&#44; even for emergency cases&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11567&#95;16025&#95;35709&#95;en&#95;f1&#95;11567&#46;jpg" class="elsevierStyleCrossRefs"><img src="11567_16025_35709_en_f1_11567.jpg" alt="Abdominal computerised axial tomography"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Abdominal computerised axial tomography</p><p class="elsevierStylePara"><a href="grande&#47;11567&#95;16025&#95;35710&#95;en&#95;f2&#95;11567&#46;jpg" class="elsevierStyleCrossRefs"><img src="11567_16025_35710_en_f2_11567.jpg" alt="Angiography"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Angiography</p>"
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Kidney post-transplantectomy ruptured iliac pseudoaneurysm: emergency endovascular repair
Pseudoaneurisma ilíaco roto postrasplantectomía renal: reparación endovascular urgente
Marcela Acosta-Silvaa, Efrén Martel-Almeidaa, Serguei De Varona-Frolova, Guido Volo-Péreza
a Servicio de Angiología, Cirugía Vascular y Endovascular, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#58;</span></p><p class="elsevierStylePara">The most common complications following late kidney transplantectomy are intra- and postoperative haemorrhages and surgical wound infections&#46; Lesions produced in the iliac vessels have also been described&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">The incidence of pseudoaneurysms in the kidney transplantectomy bed is low&#44; with very few cases reported in the medical literature&#46;<span class="elsevierStyleSup">2-7</span> The treatment of these pseudoaneurysms using endovascular procedures is considered to be a relatively novel approach&#46;</p><p class="elsevierStylePara">We present the case of a 51-year-old patient with hypertension and terminal chronic renal failure due to mesangial IgA glomerulonephritis&#44; who sought emergency care due to diffuse abdominal pain with one week evolution&#44; and which had intensified and focalised in the right iliac fossa during the previous 24 hours&#44; accompanied by sweating&#44; nausea&#44; and vomiting&#46;</p><p class="elsevierStylePara">The patient had received a heterotopic kidney transplant in the right iliac fossa in 1998&#46; The graft failed due to the development of a non-Hodgkin&#8217;s lymphoma&#44; leading to a nephrectomy of the transplanted kidney in 1999&#44; with the patient returning to haemodialysis&#46; Three years later&#44; the patient received a second kidney transplant in the left iliac fossa&#44; for which the immunosuppression regimen consisted of prednisone&#44; mycophenolate mofetil&#44; and sirolimus&#46;</p><p class="elsevierStylePara">Upon arrival in the emergency department&#44; the patient suffered somnolence and haemodynamic instability&#46; A physical examination revealed a distended abdomen resembling peritonitis&#44; producing intense pain upon palpation in the right iliac fossa&#46;</p><p class="elsevierStylePara">Initial laboratory analyses revealed anaemia at 4 points lower than baseline haemoglobin values&#46; In addition&#44; an abdominal ultrasound revealed haemoperitoneum of an unknown origin&#46; The patient underwent an abdominal computerised tomography using contrast dye&#46; This test revealed the transplanted kidney in the left iliac fossa with a pseudoaneurysm of 4&#46;4x5x5&#46;2cm &#40;transverse&#44; antero-posterior&#44; and craniocaudal diameters&#41; whose neck was dependent to the right external iliac artery and abundant haemoperitoneum around the liver and spleen&#44; both paracolic gutters&#44; and the pelvis&#44; compatible with the signs of a ruptured pseudoaneurysm &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara">In light of these findings&#44; we decided upon emergency repair of the pseudoaneurysm&#46; Under local anaesthesia and sedation&#44; we implanted a Viabahn<span class="elsevierStyleSup">&#174;</span> endo-prosthesis in the right common iliac artery&#44; extending it into the external iliac artery&#46; Angiographic control verified exclusion of the pseudoaneurysm with occlusion of the hypogastric artery&#46; The procedure was completed with the placement of a Visi-Pro<span class="elsevierStyleSup">&#174;</span> stent distally of the endo-prosthesis due to an intimal defect &#40;Figure 2&#41;&#46; The patient was discharged from the hospital 8 days later&#44; with no symptoms and recovered baseline renal function&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The formation of an iliac pseudoaneurysm in the surgical kidney transplantectomy bed is extremely rare&#46; Very few cases have been published in the medical literature&#44; with an estimated incidence &#60;1&#37;&#44; most commonly in patients with hypertension and dyslipidaemia&#46;<span class="elsevierStyleSup">8</span> Several different causes of iliac pseudoaneurysms have been described&#46; In the context of kidney transplantectomy&#44; it has been suggested that the origin lies in chronic rejection of residual blood vessels from the donated kidney that are present in the vascular stump&#44; which degenerate until forming a pseudoaneurysm&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">The clinical manifestations are correlated with the compression of neighbouring structures&#58; neurological or venous compression&#44; obstruction of the large intestine&#44; and ureteral obstruction&#46;<span class="elsevierStyleSup">9</span> The natural progression of pseudoaneurysms is rupture&#44; in which case the patient can enter into haemorrhagic shock accompanied by abdominal pain&#44; nausea&#44; vomiting&#44; genital&#47;urinary symptoms&#44; and fever &#40;especially in infectious pseudoaneurysms&#41;&#46;</p><p class="elsevierStylePara">The diagnosis tends to be late due to the location deep within the pelvis&#44; and may not be noticed until rupture&#46; The imaging test of choice is angio-CT scan&#44;<span class="elsevierStyleSup">10</span> which allows for visualising the origin of the pseudoaneurysm and the relationship with neighbouring structures as well as evaluating the possibility of endovascular treatment&#46; A Doppler-ultrasound is useful for establishing a diagnosis&#44; and angiography facilitates applying the treatment during the same procedure&#46;</p><p class="elsevierStylePara">The traditional treatment for an iliac pseudoaneurysm is open surgery through resection and insertion of a prosthesis&#46; The procedure is quite complex due to the location of the iliac arteries deep within the pelvis&#44; producing a 10&#37; mortality rate&#46;<span class="elsevierStyleSup">4</span> In ruptured iliac aneurysms that require emergency open surgical repair&#44; higher morbidity rates have been reported due to ureteral lesions&#44; postoperative haemorrhage&#44; and laparostomy&#46;<span class="elsevierStyleSup">11</span> Additional technical difficulties are inherent to residual pseudoaneurysms&#44; since the surgeon must dissect a fibrotic surgical field as a result of previous operations&#44; increasing the risk of injury&#46;</p><p class="elsevierStylePara">Endovascular treatment provides a quick&#44; safe&#44; and effective treatment alternative&#44; given the reduced invasiveness and no need for general anaesthesia&#44; with comparable results to those from traditional surgical approaches&#46;<span class="elsevierStyleSup">12</span> Even so&#44; the procedure requires assistance using costly imaging techniques that utilise radiation and contrast dye&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">To conclude&#44; in patients with a ruptured iliac pseudoaneurysm as a late complication of a kidney transplantectomy&#44; endovascular repair can be a valid&#44; effective&#44; and safe treatment alternative&#44; even for emergency cases&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11567&#95;16025&#95;35709&#95;en&#95;f1&#95;11567&#46;jpg" class="elsevierStyleCrossRefs"><img src="11567_16025_35709_en_f1_11567.jpg" alt="Abdominal computerised axial tomography"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Abdominal computerised axial tomography</p><p class="elsevierStylePara"><a href="grande&#47;11567&#95;16025&#95;35710&#95;en&#95;f2&#95;11567&#46;jpg" class="elsevierStyleCrossRefs"><img src="11567_16025_35710_en_f2_11567.jpg" alt="Angiography"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Angiography</p>"
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Article information
ISSN: 20132514
Original language: English
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Idiomas
Nefrología (English Edition)