Renal transplantation after endovascular repair of abdominal aortic aneurysm

Management of Aortoiliac Aneurysms with Atypical Renal Artery Anatomy

BACKGROUND

Renal artery anomalies occur at a rate of 1-2% and present a challenge to vascular surgeons performing aortic surgery. We describe adjuncts used to manage such anatomic variants.

METHODS

A single surgeon registry of all abdominal aortic aneurysms repaired in an academic center was retrospectively reviewed. Patients with prior renal transplants, congenital pelvic kidneys, or horseshoe kidneys were included. Open repair was reserved for patients with no endovascular or hybrid repair options.

RESULTS

Over an 8-year period, 18 patients were identified (renal transplant n = 9, horseshoe kidney n = 3, congenital pelvic kidney n = 6). All transplant patients were treated with endovascular repair. Four required cross-femoral bypasses, 1 for retrograde allograft perfusion after aorto-uni-iliac (AUI) procedure to the contralateral external iliac artery and 3 for contralateral limb perfusion after endograft extension into iliac artery ipsilateral to allograft. Three transplant patients required carotid access due to severe iliofemoral occlusive disease or allograft origin off the internal iliac artery. Two horseshoe kidney patients underwent open repair with direct reimplantation of accessory renal arteries, whereas 1 underwent endovascular repair with exclusion of an isthmus branch. Of the congenital single/pelvic kidney cohort, 2 underwent open repair with renal reimplantation, 2 underwent endovascular aneurysm repair, 1 was treated with AUI and cross-femoral bypass, and one was treated with a staged iliorenal bypass and subsequent fenestrated endovascular repair. Intravascular ultrasound was used to minimize contrast use in patients with chronic renal insufficiency (Cr > 1.5 mg/dL, n = 6). Over a mean follow-up of 31 months (range, 1-110), there were no aortic deaths or reintervention, no decline in renal function (measured by serum creatinine and glomerular filtration rate), and 100% patency of the preserved renal arteries.

CONCLUSIONS

Atypical renal anatomy should not preclude repair of aortic aneurysms. Repair of such aneurysms is safe and achieves good long-term outcomes with the use of the described techniques.

Outcomes of Endovascular Aortic Aneurysm Repair in Kidney Transplant Recipients: Results From a National Quality Initiative

Contrast-induced nephropathy after endovascular aortic aneurysm repair (EVAR) in kidney transplant recipients (KTRs) can have devastating consequences. The Vascular Quality Initiative (VQI) database was queried to select all KTRs who underwent EVAR between January 2003 and December 2014. Our primary outcome was renal dysfunction, defined as acute kidney injury (AKI; elevation of serum creatinine >0.5 mg/dL from baseline) or new postoperative hemodialysis requirement. Within the EVAR VQI dataset, 40 patients were KTRs (40 of 17 213, or 0.2%). Renal dysfunction occurred in five of 40 patients in the KTR group in comparison to 779 of 17 173 patients in the nontransplanted group (12.5% versus 4.5%, p < 0.01). Emergent EVAR was required in 2 (5%) patients, one of whom required dialysis after surgery and subsequently died. One-year survival after EVAR was similar in the two groups (92.9% versus 93.1%, p = 0.73). KTRs who developed renal dysfunction had significantly lower preoperative estimated glomerular filtration rates (eGFRs) (29.5 versus 54.7, p = 0.007) and a significantly higher iodine:eGFR ratio (0.78 versus 0.39, p = 0.02) despite receiving a similar volume of contrast (70.0 versus 68.8, p = 0.97). Renal dysfunction is 3 times more frequent in KTRs treated with EVAR, though overall survival did not differ between the groups. Decreased preoperative eGFR and a higher iodine:eGFR ratio are associated with postoperative renal dysfunction.

Renal Transplantation After Thoracic Endovascular Repair of Type B Aortic Dissection--A Case Report

Because of the strong association between uremia and atherosclerosis, incidence of aortic aneurysms is increasing among renal failure patients awaiting renal transplantation (RT). Successful RTs have been performed in these patients after surgical repair of the aneurysms. Since Parodi et al introduced endovascular aortic aneurysm repair (EVAR) in patients with high risk for conventional surgery, a new era has begun. The 1st successful RT after EVAR was published in 2001. Herein we report the 1st successful RT after thoracic EVAR (TEVAR) reported to date. We performed RT in a 54-year-old man with end-stage renal failure due to diabetic nephropathy, who had undergone TEVAR for type B aortic dissection (TBAD) 6 months earlier. The postoperative period was uneventful and the patient was discharged from the hospital at postoperative day 6 with a serum creatinine of 0.9 mg/dL. At follow-up examination at postoperative 6 months, graft function was stable. Because of its advantages over open surgery, including low mortality and morbidity, TEVAR is becoming more common among renal failure patients with thoracic aortic aneurysms and TBAD. Our case shows that successful RT can be performed in renal failure patients who have undergone TEVAR.

Renal transplantation after endovascular aortic aneurysm repair: case report and literature review

An increased number of aortic aneurysms are expected to be diagnosed in chronic renal failure patients awaiting kidney transplantation because of its strong association with atherosclerosis. The development of endovascular aortic aneurysm repair in the 1990s, which is characterized by low morbidity as well as shorter operative time and length of hospital stay, is particularly suited to these patients who are at high risk for conventional surgery. Herein we describe a case of a 58-year-old, man who was diagnosed with a 5.5-cm aortic aneurysm in 2001 and treated with a Gore Excluder (WL Gore and Assoc, Flagstaff, Ariz) aorto-iliac stent-graft. In 2004, he underwent uneventful deceased donor kidney transplantation in the right iliac fossa. With a follow-up of 6 and 9 years, respectively, there is no evidence of an endoleak. The renal function remains normal. This promising new surgical technique has been the subject of only a few published cases. At our center, endovascular aortic aneurysm repair is the first-intention treatment for these patients, as long as it is possible to preserve the iliac arteries for the renal anastomoses and the anatomic conditions are suitable for stent-graft deployment.

Endovascular repair of an aorto-iliac aneurysm succeeded by kidney transplantation

We present the case of aorto-iliac aneurysm in a patient with chronic renal failure requiring dialysis who were treated with an endovascular stent graft and, later on, submitted to kidney transplantation. A 53-year-old male with renal failure requiring dialysis presented with an asymptomatic abdominal aorto-iliac aneurysm measuring 5.0cm of diameter. He was treated with endovascular repair technique, being used an endoprosthesis Excluder®. After four months, he was successfully submitted to kidney transplantation (dead donor), with anastomosis of the graft renal artery in the external iliac artery distal to the endoprosthesis. The magnetic resonance imaging, carried out 30 days after the procedure, showed a good positioning of the endoprosthesis and adequate perfusion of the renal graft. In the follow-up, the patient presented improvement of nitrogenous waste, good positioning of the endoprosthesis without migration or endoleak. The endovascular repair of aorto-iliac aneurysm in a patient with end-stage renal failure under hemodialysis treatment showed to be feasible, safe and efficient, as it did not prevent the success of the posterior kidney transplantation.

Kidney transplantation in a patient with aortic bi-iliac endovascular graft case report and literature review

Arterial hypertension is a leading cause of both vascular diseases and chronic renal failure. With the increasing incidence of patients suffering from hypertension, an increasing number of patients with hypertensive vascular disease are reported, namely aortoiliac atherosclerosis and aneurysms, needing kidney transplantation (KT). Staged or simultaneous surgical repair of aortoiliac lesions with KT have long been described and studied. In this report, we discuss the case of a patient with infra-renal abdominal aortic aneurysm, having an endovascular bifurcated aortic bi-iliac stent (EVBAIS) introduced, who underwent a KT 3 months after his vascular surgery without any post-operative complication. This case, as well as other previous studies supports the fact that the presence of an EVBAIS does not contraindicate KT.