Pseudoaneurysm of left colic artery after Tenckhoff catheter removal, with unrecognized fungal peritonitis

A 42-year-old continuous ambulatory peritoneal dialysis patient had presented to us with symptoms and signs of peritonitis, complicated by intestinal obstruction. On fourth day after admission, the Tenckhoff catheter was removed, as there was no response to intraperitoneal antibiotic. He developed hypotension during one of the hemodialysis sessions and was found to have low hemoglobin of 4 g/dL. Computed tomography revealed high-density fluid suggestive of fresh blood and clots in the peritoneal cavity. Conventional visceral angiogram with selective inferior mesenteric arterial cannulation revealed pseudoaneurysm arising from the descending branch of the left colic artery. An effort to embolize the pseudoaneurysm failed on 2 occasions. At laparotomy the pseudoaneurysm of the left colic artery was identified after evacuation of blood clots. The pseudoaneurysm was then excised and a lateral rent in the descending branch of left colic artery was repaired. The pus showed septate hyphae on potassium hydroxide mount. He was treated with injections of amphotericin B and oral voriconazole as the culture showed growth of Aspergillus flavus. The early fibrinous, ''easy'' flimsy adhesions formed during the initial intestinal obstruction phase might have resulted in formation of the pseudoaneurysm when the Tenckhoff catheter was removed with traction. The removal of the Tenckhoff catheter, drop in hemoglobin and distension of the abdomen were temporally so closely related that the pseudoaneurysm as a result of the traction removal of the catheter was undeniable. A controlled trial would provide firm evidence either in favor or against formal dissection for the removal of Tenckhoff catheters.