MYCOTIC ANEURYSM AND RENAL

TRANSPLANTATION

G. BENOIT, M.D. B. CHARPENTIER, M.D. I? ICARD, M.D. A. JARDIN, M.D. A. LEBALEUR, M.D. D. FRIES, M.D.

From the Department of Urology, Hopital Universitaire de Bicetre, and Department of Nephrology, Hopital Paul Brousse, Bicetre, France

ABSTRACT-A case of mycotic aneurysm secondary to suppuration of a renal transplant is re- ported. This aneurysm was responsible for &hernia of the leg and was treated successfully by ligation and venous bypass grafting.

Mycotic aneurysms are an infectious complica- tion of renal transplantation. We report on a case of mycotic aneurysm treated by ligation and venous interposition, and discuss the methods of prevention and treatment of this complication.

Case Report

A twenty-year-old woman presented with chronic renal failure due to Berger disease. She underwent renal transplantation with a ca- daver kidney with two HLA compatibilities on July 30, 1984. The renal artery was anasto- mosed to the external iliac artery with an aortic patch graft. The renal vein was anastomosed to the external iliac vein, and the ureter was anas- tomosed into the bladder. Immunosuppression was administered by a combination of Cyclosporin-Imurel-Prednisolone. l Prophylac- tic antibiotic therapy, consisting of ampicillin, oxacillin, and gentamicin, was administered before, during, and after the operation.2

On the second postoperative day, the pa- tient’s erythrocyte count fell as a result of rup- ture of the graft, requiring transfusion with four units of packed cells. The patient was

monitored and was reoperated on the tenth day for removal of a clot from the renal area. Ex- ploration revealed rupture of the convexity which was adherent.

Diuresis was restored and reached 2 L on the seventeenth day. On the following day, the pa- tient was febrile with a leukocytosis of 20,000 and complained of pain in the graft site. The patient was again surgically explored, revealing a purulent collection. The graft was removed with separate ligation of the artery and the vein, leaving the venous and arterial patch grafts in place. Culture grew Escherichia coli. The abdominal wall was left open. Combina- tion antibiotic therapy consisting of cefotaxim, gentamicin, and metronidazole was adminis- tered. The wound healed well.

Three months after the operation, the patient presented with intermittent claudication of the right leg. On clinical examination, a pulsatile mass was palpated in the right iliac fossa. Angi- ography revealed a large aneurysm of the ex- ternal iliac artery with patency of the hypogas- tric artery (Fig. 1A). The patient was afebrile and bacteriologic studies were negative. The patient was reexplored via a midline incision to exclude the false aneurysm by proximal and

UROLOGY i JANUARY 1988 I VOLUME XxX1, NUMBER 1 63

4) Angiography of mycotic aneurysm developing at expense of ex- ternal iliac artery (arrows). (B) Digital angiography of venous bypass graft (ar-

A rows) between common iliac artery and common femoral artery.

distal ligation of the external iliac artery A saphenous vein bypass graft was interposed be- tween the common iliac and common femoral arteries.

The postoperative course was uneventful. The patient no longer suffers from intermittent claudication. Results of follow-up angiography in January, 1986, were satisfactory (Fig. 1B).

Comment The term mycotic aneurysm was proposed by

Osler in 1885 to describe aneurysms complicat- ing bacterial endocarditis.’ Mycotic aneurysms are a rare complication in urology. They are due to bacterial colonization of the renal arte- ries, essentially intra-parenchymal, secondary (80% of cases) to bacterial endocarditis.

In renal transplantation, mycotic aneurysms may develop following suppuration of the graft site. In a series of 640 renal transplants, Ky- riakides, Simmons, and Najarian4 found 28 cases of suppuration of the graft site, resulting in 8 mycotic aneurysms. Squifflet et ~1.~ re- ported 1 case in 1983 and reviewed 12 cases in the literature. In our series of 623 renal trans- plants performed between 1980 and 1986, we have encountered 5 cases of suppuration of the graft site, responsible for one mycotic aneu- rysm. The risk of mycotic aneurysm was in- creased by the fact that we left the aortic patch

graft exposed to the base of the wound. Ky- riakides et ~1.~ reported the persistence of for- eign arterial material as the origin of 6 of his 7 cases of mycotic aneurysm.

Several approaches may be proposed to pre- vent this complication.

1. Ligation of the arterial trunk proximal and distal to the anastomosis is associated with a low risk of ischemia. Johnson, Ledgerwood, and Lucas,6 in a series of mycotic aneurysms in heroin addicts injecting the drug intra- arterially, ligated the arterial trunk in 40 cases and induced ischemia in 9 cases, requiring by- pass grafts.

2. Replace the foreign arterial patch graft by a venous patch. However, this does not decrease the risk of mycotic aneurysm. In a series of 16 mycotic aneurysms, including one following re- nal transplantation, Anderson, Bucher, and Ballinge? successfully excluded five aneurysms and repaired nine with a vein graft or Dacron graft, with 7 failures. This repair is therefore only possible when performed at a distance by means of an autologous vein not in contact with the site of infection.

The risk of hemorrhage due to rupture of a mycotic aneurysm is considerable. Kyriakides et ~1.~ reported 4 cases of rupture in his 7 cases of mycotic aneurysm, one of which was fatal. However, the presence of arterial rupture does

64 UROLOGY I JANUARY 1988 / VOLUME XxX1, NUMBER 1

not always indicate the presence of a mycotic aneurysm. In a series of 665 renal transplants, Owens et ~1.’ reported 11 cases of hemorrhage, only 2 of which were due to rupture of a my-

it is preferable to use autologous vein rather than a prosthetic graft.

78 Rue du G&&al Leclerc

cotic aneurysm, but perirenal suppuration was 94275 LeKremlin Bicitre Cedex, France

present in all 11 cases. In a series of 387 renal (DR. BENOIT)

transplants, Vegeto et al.* reported 7 cases of References

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perirenal suppuration was present in all 7 cases. tion r&ale, Semin Urol Niphrol 12: 67 (1986).

These findings confirm the vascular risks of 2. Tillegard A: Renal wound transplant infection: the value of

prophylactic antibiotics, Stand J Urol Nephrol 18: 215 (1984). suppuration of the graft site, early rupture with 3. Anderson CB, Bucher HR, and Ballinger WF: Mycotic an-

massive hemorrhage, and mycotic aneurysm eurysms, Arch Surg 109: 712 (1974).

with secondary rupture. We conclude that my- 4. Kyriakides GK, Simmons RL, and Najarian JJ: Mycotic an-

eurysm in transplant patients, ibid 111: 472 (1976). cotic aneurysms should be treated as an emer- 5. Squifflet JP, et aE: Mycotic aneurysm of renal graft artery,

gency. The treatment consists of proximal and diagnosis by ultrasonography, Urology 22: 212 (1983).

distal ligation of the arterial trunk. This liga- 6. Johnson JR, Ledgerwood AM, and Lucas CE: Mycotic an-

eurysm. New concepts in therapy, Arch Surg 118: 577 (1983). tion is generally well tolerated. A bypass graft, 7. Owens ML, et al: Major arterial hemorrhage after renal

away from the septic site, should be performed transplantation, Transplantation 27: 285 (1979).

in the presence of distal ischemia. In such cases, 8. Vegeto A, et al: Spontaneous rupture of the renal artery in

kidney transplantation, Transplant Proc 11: 1276 (1979).

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