Infectious anastomotic pseudoaneurysm complicating renal allograft: case report and review of literature

Infectious anastomotic pseudoaneurysm complicating renal transplant is rare, but probably under-reported with <30 cases worldwide. We report a 45-year-old man with hypertension, diabetes mellitus and end stage renal failure, who had a renal transplant anastomosed to the right external iliac artery and vein. Postoperatively, he made a slow recovery with malaise and persistent vague right iliac fossa discomfort. Ultrasound scan 1 month postoperatively showed perinephric collection, and fluid culture grew Enterococcus faecium and Pseudomonas aeruginosa. He was started on vancomycin, daptomycin and colistin. MAG-3 scan also showed suboptimal function in the renal allograft. His symptoms persisted with fever, and blood culture yielded P. aeruginosa. Repeated ultrasound scan, and subsequent computed tomography scan a few weeks later, showed perinephric collection and a large, 3.8×3.5 cm pseudoaneurysm posteromedial to the graft kidney. He underwent emergency graft excision, together with resection of the pseudoaneurysm with in situ reversed great saphenous vein interposition graft, and made a good recovery on hemodialysis. The aneurysm wall grew P. aeruginosa, and he was put on imipenem and cilastatin (tienam), colistin, ciprofloxacin and daptomycin. To our knowledge, this is one of very few cases in the world’s literature in which a P. aeruginosa infectious anastomotic pseudoaneurysm developed after a renal allograft.