Rectus Abdominis Flap Coverage of Exposed Endograft for Treatment of Symptomatic Pseudoaneurysm After Transplant Nephrectomy
Cindy Huynh, Michaela Kollisch-Singule, Prashant Upadhyaya, Michael J. Costanza.
SUNY Upstate Medical University, Syracuse, NY, USA.
Combined open surgery and endovascular stent graft repair is an effective approach to the management of transplant nephrectomy-related pseudoaneurysms. This method allows for treatment of the pseudoaneurysm, debridement of nonviable tissue, and relief from mass effect. However, the remaining tissue may be inadequate for coverage of the endograft, leaving it at risk for infection, hemorrhage, and stenosis. Rotational muscle flaps can protect the endograft by providing local tissue coverage, increasing the likelihood of healing and reducing the development of complications. We present a patient with an external iliac artery pseudoaneurysm after transplant nephrectomy who underwent endovascular repair and subsequent rectus abdominis flap creation for coverage of exposed endograft.
A 27-year-old man with history of IgA nephropathy, end-stage renal disease, and transplant nephrectomy after fungal infection involving the allograft, presented seven months later with dysuria. Physical exam revealed a palpable abdominal mass in the right lower quadrant. CT imaging showed a 10.3 x 7.8 x 11.4 cm pseudoaneurysm originating from the right external iliac artery (Figure 1).
Arterial access was obtained via right femoral artery cutdown. Three covered stents, 9mmx59mm proximally, 8mmx59mm, and 7mmx59mm distally, were placed through a 7 French sheath and postdilated, with completion arteriogram demonstrating exclusion of the pseudoaneurysm (Figure 2). Operative evacuation of infected debris and clots left the stents exposed (Figure 3). Soft tissue coverage of the endograft was achieved through harvest of a superior epigastric artery-based right rectus abdominis muscle flap after indocyanine green fluorescence angiography (SPY Elite™) confirmed viability.
Local tissue coverage with a rotational muscle flap for exposed endograft is a safe and feasible option for treatment of transplant nephrectomy-related pseudoaneurysms. The optimal management of these complex patients may require an individualized approach combining endovascular and open surgical techniques to reduce potential morbidity and mortality.
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