vascular injury during biopsy of renal allograft is not uncommon and poses a unique problem because of single functioning kidney that already is compromised . at times transcatheter embolization is preferred over surgical interventions as this is less invasive and preserves the remaining functional renal tissue . transcatheter embolization involves use of microcatheters , and coils or particulate agents as embolic agents . however , the embolization process entails use of iodinated contrast that further compromises the renal function . also , transcatheter embolization at times may be technically challenging due to unfavorable anatomy . an alternative to transcatheter embolization is direct percutaneous access with a thin needle and injection of liquid or particulate embolic agents to occlude the aneurysm . superficial location of graft kidney is of advantage for ultrasound ( usg ) and doppler evaluation and usg - guided needle placement into the pseudoaneurysm can easily be done . percutaneous embolization is quick and effective with minimal damage to the remaining functioning kidney and also without the added risk of contrast nephropathy . a 44-year - old renal allograft recipient from his wife presented with delayed graft dysfunction and underwent graft kidney biopsy . he had received no induction agent and was on tacrolimus , mycophenolate mofetil and steroids . the kidney biopsy was suggestive of acute cellular rejection-1b ( acr ) and was subsequently treated with pulse methylprednisolone . patient responded to above therapy and was discharged with serum creatinine of 1.2 mg / dl . at 7 months post - transplant , patient had recurrence of graft dysfunction ( serum creatinine 3.4 mg / dl and graft sonography examination was within normal limits ) . patient underwent another graft kidney biopsy , which was suggestive of acute humoral rejection ( ahr ) and subsequently , patient was treated with pulse glucocorticoids and serum creatinine came back to baseline ( 1.2 mg / dl ) . at 10 months post - transplant , patient again developed graft dysfunction ( serum creatinine 5.5 mg / dl ) and underwent third graft kidney biopsy and was diagnosed as acr+ahr . patient was offered second line therapy , but he refused the treatment due to financial constraints . two weeks post - graft kidney biopsy patient had severe pain at the graft site with acute onset anuria ( serum creatinine 4.5 mg / dl ) . an usg examination was performed at the admission that showed massive hydronephrosis ( hdn ) of graft kidney ( caliceal dilatation 2.5 cm ) . patient was planned for percutaneous nephrostomy ( pcn ) of graft kidney , but while shifting to the intervention suite the patient passed about 200 ml of fresh blood mixed with blood clots per - urethra and the pelvicaliceal system decompressed with relief of pain . the procedure was terminated in view of relief of obstruction , but 36 h later patient again developed severe pain and repeat usg showed massive hdn of graft kidney filled with blood clots . computerized tomography ( ct ) angiography study was performed , that confirmed the presence of hdn and a pseudoaneurysm arising from interlobar artery in the graft kidney [ figure 1 ] . patient hdn again subsided spontaneously with passing of about 150 ml of blood clots . in view of imaging findings , recurrent graft hdn and passage of blood clots per - urethra , a diagnosis of intermittent bleeding from the pseudoaneurysm causing ureteric obstruction due to blood clots was made . patient was taken up for obliteration of the pseudoaneurysm by percutaneous glue injection as the doppler examination clearly showed the pseudoaneurysm , which appeared to be easily accessible with the percutaneous route [ figure 2 ] . axial ( a ) and volume rendered ( b ) computerized tomography angiographic images show a lobulated pseudoaneurysm ( arrow ) arising from interlobar artery in graft kidney . note the dilated pelvicaliceal system of renal graft in figure 1a color - doppler image ( a ) clearly demonstrates the pseudoaneurysm ( arrow ) . ultrasound image ( b ) shows spinal needle tip ( arrow ) within the pseudoaneurysm a volume of 0.5 ml 1:1 mixture of n - butylcyanoacrylate ( nectaryl , dr.reddylaboratories , india ) and iodophendylate oil ( lipiodol , laboratories guerbet , france ) was injected into the aneurysm through a 22 g spinal needle ( vygonsa , ecouen , france ) . placement of needle into aneurismal sac was usg guided and subsequent doppler usg showed complete obliteration of blood flow in the pseudoaneurysm after the glue injection [ figures 2 and 3 ] . post - embolization was uneventful and the urine output ( blood tinged ) was 1 l/24 h through pcn and nil per - urethra . subsequently within a couple of days , the blood clots largely cleared from the ureter and the pelvicalyceal system and patient continued to pass 1l clear urine per - urethra . ureteric patency was confirmed with contrast injection through the pcn catheter and ct nephrostogram [ figure 4 ] . the patient did not experience any further bouts of hematuria and was discharged 10 days after the procedure . ultrasound image ( a ) shows glue cast as echogenic contents ( arrow ) within the aneurysm sac . color doppler image ( b ) shows no flow within the aneurysm after embolization axial ( a ) non - contrast computerized tomography ( ct ) shows radio - opaque glue cast ( shortarrow ) within the pseudoaneurysm . part of the percutaneous nephrostomy catheter ( longarrow ) is seen within the pelvicaliceal system . the incidence of complication after percutaneous renal biopsy has decreased after usg guidance and smaller gauge biopsy needles . renal allograft biopsies are known to have a higher incidence of gross hematuria , hematoma formation and arteriovenous fistulae . hematuria requiring hospitalization and some sort of active management is seen in about 2.8% cases of graft biopsies . renal pseudoaneurysm is a rare complication of renal biopsy , but is of great significance due to risk of rupture . surgery may be indicated when hemostasis and repair of the arterial wall defect are required . usg - guided percutaneous injection of gelfoam ( pharmacia and upjohn company , ny , usa ) , cyanoacrylate or other thrombogenic material into aneurismal sac is an option for cases with unfavorable vascular anatomy or patients who have contraindications for intravenous contrast agents . percutaneous thrombin injection was used for treatment of pseudoaneurysm ( including renal ) from 1986 . however , thrombin injection may be complicated with reperfusion within the pseudoaneurysm , thromboembolic episodes and allergic reactions . polymerization of cyanoacrylate monomers forms a glue cast and efficiently occludes the pseudoaneurysm without side effects that are experienced with thrombin . this has been successfully used for many years for endoluminal treatment of extra and intracranial vascular malformations . the largest series of percutaneous embolization into renal pseudoaneurysm included 14 patients who were treated with direct injection of gelfoam into aneurismal sac under usg guidance . the authors of the above study suggested that percutaneous embolization could potentially replace angioembolization as first - line treatment for renal pseudoaneurysms . we had earlier reported successful percutaneous cyanoacrylate glue injection into renal pseudoaneurysm after failed thrombin injection to control hematuria after percutaneous nephrolithotomy . our patient had severe pain abdomen secondary to bleed from renal pseudoaneurysm causing recurrent ureteric obstruction by blood clots . in this case the choice of percutaneous glue injection was influenced by the direct easy access of the pseudoanurysm , successful percutaneous embolization of previous cases and also cost - effectiveness as compared with transcatheter coil angioembolization . we report the first successful case of percutaneous acrylic glue embolization of pseudoaneurysm in a renal allograft . percutaneous therapy should be considered as a quick and effective alternative method to transcatheter coil embolization for management of pseudoaneurysm in a renal allograft .
we report a 44-year - old male , renal allograft recipient of 1-year duration who had two episodes of steroid responsive acute rejection . 
 he presented with graft dysfunction for which a graft biopsy was performed and was suggestive of mixed rejection . at 2 weeks post - biopsy , 
 patient developed severe pain over the graft site with anuria and graft hydronephrosis ( hdn ) . 
 the hdn and anuria intermittently settled with the passage of blood clots per - urethra . 
 contrast enhanced computerized tomography was suggestive of pseudoaneurysm in the graft kidney . 
 the case was successfully managed with ultrasound guided percutaneous cyanoacrylate glue injection into the pseudoaneurysm .