Explant and Bypass for Polymicrobial Mycotic Pseudoaneurysm Following Renal Transplant

Abstract

Mycotic pseudoaneurysms in renal transplant patients are rare but serious complications associated with significant morbidity, graft loss, and mortality. They present a critical management challenge between endovascular salvage and definitive surgical explant. While contemporary reports suggest endovascular techniques can successfully treat this condition, their role as definitive treatment in fungal fields is controversial. We report a case where repeated endovascular stent treatment of a polymicrobial fungal and bacterial pseudoaneurysm perpetuated biofilm formation and polymicrobial colonization, enabling ongoing infection and ultimately requiring explant and femoral-femoral bypass for definitive source control and revascularization. This case highlights an important decision threshold: in the setting of angioinvasive molds, endovascular salvage is often futile, with recent series showing a high failure rate for allograft preservation. Recognition of persistent pain and recurrent fluid collections following endovascular therapy should trigger early surgical source control with infection-resistant conduits, such as autologous or cryopreserved allografts, rather than endovascular temporization.