High-output cardiac failure from postbiopsy arteriovenous fistula.

A 56-year-old kidney transplant recipient (transplantation 15 years prior for end-stage kidney failure from presumed arterionephrosclerosis, with no major complications, with estimated glomerular filtration rate of 30 ml/min per 1.73 m2) was admitted for worsening dyspnea, and orthopnea. She noted a beating mass, at the site of the kidney transplant. Ten years earlier, the patient was noted to have developed a postbiopsy arteriovenous fistula in the inferior pole of the allograft that was subsequently monitored for only 2 years. An arterial-computed tomography scan with injection of iodinated contrast medium directly in the external iliac artery was performed. We were able to visualize a first aneurysm of the post-anastomotic part of the graft artery (96 × 96 × 87 mm), a dilatation of the whole graft arterial system, and a second aneurysm of the graft vein (30 × 29 × 12 mm; Figure 1). The aneurysms were associated with the compression of the upper ureter. Angiographic intervention was not deemed feasible because of the wide neck of the giant aneurysm. In view of heart failure symptoms and the potential for rupture, the decision was made to perform kidney graft removal (despite good kidney function) and vascular reconstruction with a complex bypass. The microbiology and pathology analysis did not reveal any infectious or inflammatory cause for these vascular complications. This case shows the potentially adverse natural history of kidney arteriovenous fistulae and illustrates the importance of monitoring and managing this complication of native and transplanted kidney biopsies. The patient provided oral consent for the publication of this case and radiological images.