EVOLUTION OF ARTERIOVENOUS FISTULA BETWEEN RENAL ARTERY AND VEIN IN RENAL ALLOGRAFT AFTER PERCUTANEOUS NEPHROSTOMY IN A RENAL TRANSPLANT RECIPIENT

Komplikacije poput arteriovenske fistule, pseudoaneurizme ili perirenalnog hematoma nastaju u transplantiranom ili nativnom bubregu nakon intervencijskih zahvata, najčešće nakon perkutanih biopsija ili perkutane nefrostomije. Prikazujemo 50-godišnjeg bolesnika s arteriovenskom fistulom (AVF) glavnog stabla renalne arterije i vene transplantiranog bubrega nastalom nakon perkutane nefrostomije alografta zbog opstruktivne uropatije. Selektivnom angiografijom transplantiranog bubrega dijagnosticirana je AVF jedne od dviju renalnih arterija i renalne vene presatka, te posljedična pseudoaneurizma renalne vene presatka. Zbog visokog rizika gubitka transplantiranog bubrega kirurškim zahvatom AVF-e, u cilju očuvanja funkcije bubrežnog presatka AVF i venska pseudoaneurizma su pažljivo praćene tijekom sedam godina, a bubrežna funkcija je čitavo vrijeme praćenja bila stabilna. U tom razdoblju bolesnik je kirurški liječen suptotalnom paratireoidektomijom zbog sekundarnog hiperparatireoidizma, a zbog vaskularnih komplikacija su učinjene amputacije II-IV prsta desne šake, lijeve potkoljenice i natkoljenična amputacija desno. Intervencijski radiološki zahvat postavljanja stent-presatka u vanjsku ilijačnu arteriju učinjen je zbog naglog rasta i visokog rizika rupture pseudoaneurizme renalne vene alografta, sedam godina nakon transplantacije. Navedeni zahvat imao je za posljedicu isključivanje transplantiranog organa iz cirkulacije, okluziju AVF i trombozu venske pseudoaneurizme, bez potrebe kirurškog zahvata visoko rizičnog bolesnika. Prema našem mišljenju, liječenje AVF transplantiranog bubrega u cilju očuvanja bubrežne funkcije treba biti rezervirano za simptomatske AVF i one s prijetećom rupturom pseudoaneurizme.Percutaneous urologic intervention has been accepted as a standard method to identify the etiology of graft dysfunction, or for treatment of urinary obstruction. Although ultrasound-guided procedure is a relatively safe method, arteriovenous fistula (AVF) is an important complication that is sometimes encountered. In this report, we present a renal transplant patient in whom an AVF and renal vein pseudoaneurysm after percutaneous nephrostomy were diagnosed. Surgical approach was not indicated for preservation of renal function. A 50-year-old man was admitted with obstructive uropathy 11 months after cadaveric renal transplantation. Percutaneous nephrostomy was performed under ultrasound guidance. Doppler sonography and angiography revealed an AVF between the main renal artery for lower pole of the graft and renal vein, with formation of a venous pseudoaneurysm. Careful monitoring during the next 7 years after iatrogenic AVF and venous pseudoaneurysm formation resulted in preservation of renal graft function and improvement of the patient’s quality of life. Radiological interventional procedure with vascular graft-stent placement was indicated because of rapid pseudoaneurysm enlargement and high risk of its rupture. Interventional endovascular graft-stent placement is a safe procedure for exclusion of renal allograft and AVF from circulation without indication for open surgery in high-risk transplanted patients. According to our opinion, radiological interventional or surgical procedure in transplanted patients with AVF and pseudoaneurysm should be considered as the treatment of choice only in patients who have clinical symptoms or rapid growth of AVF with a high risk of pseudoaneurysm rupture