A 64-year-old man who had undergone a renal transplant 9 years earlier, was admitted to our hospital because of an asymptomatic, large, abdominal aortic aneurysm. During an introduction of a guide wire to the left common femoral artery dissection of iliac artery occurred with occlusion of graft renal artery. And endarterectomy of the common, external, and internal iliac arteries was performed, with no sufficient kidney inflow. A bypass was performed between the common iliac and the left common femoral artery with a kidney artery reanastomosis to the prosthesis. After 4 months of endovascular treatment of the aortic aneurysm, the patient’s renal function remained unchanged.
Kidney transplant is the criterion standard for treating end-stage renal disease. Despite the fact that the procedure is well established with a high success rate, vascular complications still occur.1 Prolonged hemodialysis, the expansion of transplant recipients age and other risk factors (eg, nicotinism, arterial hypertension, diabetes, and metabolic disturbances) may lead to deterioration of atherosclerotic lesions. Abdominal aortic aneurysms (AAA) are most common in the infrarenal aorta, are mostly asymptomatic, and are found incidentally. The prevalence range is between 1.7% to 6% in older men (> 65 y, with male-to-female ratio 3.5-6:1).2 The incidence of AAA increases with age, occurring in 25 per 100 000 men aged 50 year and older, and rising to 78 per 100 000 in those older than 70 years.3 Compared with the general population, AAAs may be more common, and may have a more aggressive natural history in kidney transplant recipients.4
Conventional management of AAA is by open repair and is associated with a mortality rate of 1% to 6%.5,6 Open abdominal surgery for treating AAA is connected with a high risk of kidney ischemia owing to aortic clamping, and requires ischemia-protecting procedures for the graft (eg, temporary axillofemoral bypass, aortoiliac shunt, aortofemoral shunt, aortofemoral bypass, femorofemoral bypass with extracorporal circulation, and cold perfusion of the graft.)7.8 In 1991, when Parodi and associates9 reported the first endovascular aneurysm repair (EVAR) by implanting stent grafts without aortic clamping, the procedure has become the preferable way in case of abdominal aneurysm treatment. Endovascular aneurysm repair may be associated with respiratory, cardiac, renal, neurologic, and hemorrhagic complications, as well as with endoleak, stent migration, and stent wire fracture.10 Other complications also have been reported such as graft infection, ischemic colitis, aortoenteric fistulas, and spinal cord ischemia.11-13 Vascular complications constitute most of the complications, and are related to technical problems or vascular compromise.
We report a possible complication of endovascular AAA repair with the external iliac artery acute dissection during catheterization. Dissection is characterized by a rapid development of an intimal flap separating the true lumen from the false one.14-16 The dissection spreads in an antegrade manner causing transplanted kidney artery occlusion and ischemia. Immediate intervention (< 60 min) results in restoring graft function and eventual positive outcome of aneurysm treatment. The 64-year-old man had undergone a renal transplant 9 years earlier, and was admitted to our hospital because of an asymptomatic AAA and left internal iliac artery aneurysms.
Enhanced computed tomography angiography revealed irregular atherosclerotic deposits in the aorta and an AAA measuring 59 mm and 30 mm in the left internal iliac aneurysm (Figure 1). Both the artery and the vein of the transplanted kidney were anastomosed to the left external iliac artery and vein. The patient’s renal function was good, with a glomerular filtration rate around 40 mL/min. The patient’s medical history was significant for hypertension and ischemic heart disease. Immuno-suppression at the time of admission to hospital consisted of tacrolimus, mycophenolate mofetil, and prednisone.
When the guide wire was introduced to the left common femoral artery (right external iliac artery was calcified and narrowed to more than 50%), dissection of the iliac artery occurred with the occlusion of the graft renal artery (Figure 2). Endarterectomy of the common, external, and internal iliac artery was performed, with no sufficient kidney inflow. Bypass between the common iliac and the left common femoral artery was performed with a kidney artery implantation to the prosthesis. Ischemic time of the transplanted kidney was estimated to be about 45 minutes. Before reanastomosis, perfusion of the graft was performed using 250 mL of cold Ringer’s lactate (4°C). Correct flow to the graft and left common femoral artery was obtained. Restoration of transplanted kidney function occurred in a 2-week period with the need of 1 hemodialysis. Glomerular filtration rate of the transplanted kidney at the time of discharge was 40 mL/min.
Several weeks after discharge, the patient was readmitted to our hospital owing to severe abdominal pain and diarrhoea. Clostridium difficile, Salmonella, and Shigella infections were excluded, and the decision to cease mycophenolate mofetil treatment was made. Antibiotics (eg, rifaximin, fluconazole, piperacillin/tazobactam sodium) were administered to the patient. A computed tomographic scan revealed infiltration and thickening of the sigmoid wall up to 8 mm, and an irregular hypodense area of 70 × 50 mm. During surgery, ischemic colitis was discovered, which entailed the need to perform a sigmoid resection and a temporary Hartmann procedure. There was no influence of surgery on the kidney function.
After 2 months, endovascular treatment of an aortic aneurysm was performed with bifurcated stent graft Cook Zenith (Cook Medical Inc., Bloomington, Indiana, USA) (Figure 3). The main device was introduced through the right common femoral artery. The proximal landing zone was under the superior mesenteric artery branch covering arteries of the insufficient kidneys (30 mm × 111 mm). The right side of the distal landing zone was the right external iliac artery (13 mm × 56 mm limb extender), and the left side was the common iliac and prosthesis (16 mm × 76 mm, as contralateral extension). During EVAR, 5000 units of heparin was injected intravenously to prevent graft thrombosis. Overall, the procedure was performed with no major complications and immediately afterward, both lower extremity pulses were in good condition. Commonly used Doppler indices: the resistive (0.72) and the pulsatility index (1.67) were within the normal range. The patient was discharged from hospital with unchanged renal function (GFR 40 mL/min and creatinine concentration of 106.08 μmol/L (1.2 mg/dL).
This case shows that special care is required where the transplant artery originates to prevent dissection during insertion of a guide wire or other device. In case of a narrow access route at the transplanted kidney side, the main body with a larger delivery sheath must be inserted through the contralateral artery.
Endovascular aneurysm repair for AAAs of renal transplant recipients is an available treatment, if the assessment of the size and planning of the deployment method are properly performed. However, EVAR may be connected with some additional problems, such as renal dysfunction owing to the iodine contrast medium, the transplanted kidney ischaemia owing to stent graft insertion through a narrow access route, as well as occlusion of the transplanted renal artery. Iodine contrast medium may cause complete renal failure requiring hemodialysis. Nevertheless, there are many reports of N-acetylcysteine used to prevent contrast-induced nephropathy.17-19 Because the dissection occurred, and it was impossible to deploy a bare stent in the true lumen to avoid low flow to the transplanted kidney, the only immediate rescue surgery with the reimplantation of renal artery to the prosthesis made it possible to avoid graft lost. Expansion of renal transplants to older (> 65 y) and atherosclerotic patients, as well as the growing long-term success rate of transplants, will result in more patients requiring endovascular or open surgical treatment.
Volume : 14
Issue : 4
Pages : 450 - 453
DOI : 10.6002/ect.2014.0133
From the 1Department of Transplantology, General and Vascular
Surgery; and the 2Department of Radiology, Clinical Hospital of
Poznan University of Medical Sciences, Poland
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare.
Corresponding author: Marek Karczewski, Department of Transplantology, General and Vascular Surgery, Poznan University of Medical Sciences, ul. Grunwaldzka 16/18, 60-780 Poznan, Poland
Phone: +486 1854 7900
Fax: +486 1854 7901
Figure 1. Preoperative Computed Tomography Angiography
Figure 2. Dissection of the External Femoral and the Iliac Artery With the Occlusion of the Transplanted Kidney Artery
Figure 3. Endovascular Abdominal Aortic Aneurysm Repair in the Patient With a Renal Transplant