Late rupture of a saphenous vein aortorenal graft

Vein Graft Aneurysm after Aorto-Renal Bypass for Childhood Renovascular Hypertension Due to Fibromuscular Dysplasia

Renovascular hypertension (RVHT) is a major cause of surgically correctable secondary hypertension. Refractory hypertension despite multiple antihypertensive drugs requires angioplasty, surgical revascularization, or even nephrectomy. Herein, we report a pediatric patient who had been treated with angioplasty, nephrectomy, and aortorenal bypass surgery for RVHT due to fibromuscular dysplasia and re-do endoaneurysmal graft replacement for a vein graft aneurysm. This case highlights the various treatment modalities for RVHT and the recurrent nature of the disease with a rare presentation of a vein graft aneurysm after aortorenal bypass.

The use of polytetrafluoroethylene graft for damaged renal artery in ABO-incompatible living donor kidney transplantation: a case report

Short donor renal vessels during donor nephrectomy represent a technical challenge. The allograft of vessels from deceased donors can be an option for reconstruction; however, cryopreserved vessels are not routinely prepared for living donor kidney transplantation (LDKT). We report a reconstruction of the damaged short renal artery (RA) in LDKT using a polytetrafluoroethylene (PTFE) graft. A 45-year-old male patient underwent ABO-incompatible LDKT from his wife. After donor nephrectomy, we detected a hematoma surrounding the proximal RA of the allograft. The injured segment of the RA was transected, and the short RA was connected to the right external artery of the recipient; however, the blood flow was interrupted by the graft location. Once the arterial anastomosis was removed, the graft was flushed with cold saline, and a PTFE graft was used for the reconstruction of the short RA. Immediate blood flow to the renal graft was excellent without sign of parenchymal infarction until fascial closure. Renal graft Doppler on postoperative day 7 and 3 months showed good blood flow. In this patient, the use of PTFE graft presented no additional morbidity to the kidney transplantation, and no postoperative complications related to its use were noted.

Arterial reconstruction using the donor's gonadal vein in living renal transplantation with multiple renal arteries: a case report and a literature review

Background

Arterial reconstruction is one of the paramount procedures in kidney transplantation (KT) and greatly important if the procured kidney has multiple renal arteries (MRA). Despite various established techniques for arterial reconstruction, sometimes, the surgeon finds performing arterial anastomoses challenging in case of MRA. In our case, the donor’s gonadal vein and recipient’s internal iliac artery graft were used for arterial anastomoses, and 3 years after KT, the allograft did not present vascular complications.

Case presentation

A 34-year-old man underwent ABO-incompatible preemptive living KT. The allograft had three renal arteries and four renal veins. After donor nephrectomy, arterial reconstruction was performed on a back table. These arteries were reconstructed into one piece using the recipient’s internal iliac artery graft. The two arteries at the middle of the renal hilum were reconstructed using the conjoined method. As the superior renal artery was too short to anastomose, the donor’s gonadal vein was used for extension. The internal iliac artery graft was anastomosed to the original internal iliac artery. Intraoperative Doppler ultrasonography revealed that the blood flow in each renal artery was adequate, resulting in sufficient blood flow throughout the allograft. The allograft function was maintained with a serum creatinine level of approximately 0.9 mg/dL without vascular complications 3 years after KT.

Conclusions

The donor’s gonadal vein can be a candidate for extension of the renal artery in the allograft with MRA. Further follow-up is needed for the assessment of long-term outcomes.

Risk of rupture of an aortorenal vein graft aneurysm after the surgical repair of Takayasu arteritis-induced right renal artery stenosis: A case report and a literature review

INTRODUCTION

Takayasu arteritis (TA) is a chronic and nonspecific inflammatory disease mainly affecting the aorta and its major branches, resulting in the stenosis or occlusion of target arteries. Approximately 50% to 60% of patients with TA likely have renal artery stenosis (RAS), which results in refractory hypertension (HTN) and renal dysfunction. Aortorenal bypass with saphenous vein graft (SVG) is the classical procedure to relieve patients' symptoms. Graft restenosis is the most common complication during long-term follow-up. However, aortorenal vein graft aneurysm (AVGA) is uncommonly reported, and symptomatic or ruptured AVGA that needs reoperation is even rarer. Long-term follow-up results after AVGA reoperation also remain scare. Here, we introduced the long-term result of a symptomatic AVGA under the reoperation of polytetrafluoroethylene (PTFE) graft replacement and provided a literature review of AVGA reoperation after surgical bypass for RAS.

CLINICAL FINDING

An 18-year-old male complained about mild to severe right lumbar pain for 5 days. He underwent right aortorenal bypass with SVG for TA-induced right renal artery stenosis to relieve refractory HTN and renal dysfunction 2 years ago. However, this patient did not proceed with a follow-up after the procedure. Physical examination showed normal vital signs, and an obvious percussion tenderness over the right kidney region was detected. The updated computed tomography angiography (CTA) revealed a right AVGA with a maximum diameter of 26 mm. No restenosis of the proximal and distal anastomoses was detected.

DIAGNOSIS

The patient was diagnosed to have right aortorenal vein graft aneurysm at the risk of rupture and Takayasu arteritis.

INTERVENTIONS

The AVGA was resected with a 6 mm PTFE graft replacement. An end-to-side proximal anastomosis to the orifice of the original anastomosis on the abdominal aorta and an end-to-end distal anastomosis to the distal normal renal artery were made.

OUTCOMES

The patient had an uneventful postoperative clinical course and was discharged from the hospital 5 days after the operation. The 4-year updated CTA revealed no restenosis or aneurysmal degeneration of the prosthetic graft.

CONCLUSION

Symptomatic AVGA that needs reoperation is rare. Prosthetic graft replacement is an effective way to eliminate the risk of potential rupture. A 4-year satisfactory result indicative of a prosthetic graft can be the first choice for aortorenal bypass in RAS without active biological inflammation.

Endovascular Exclusion of Saphenous Vein Graft Aneurysms Complicating Abdominal Aortic Aneurysm Repair

A 64-year-old man was referred for vascular evaluation before renal transplantation for ischemic nephropathy. In the past he had undergone bilateral renal artery revascularizations using saphenous vein. At the time of transplant evaluation, he was found to have bilateral aneurysms of the saphenous veins used to bypass his renal artery stenoses. He underwent successful endovascular exclusion of the aneurysms with 2 endovascular AneuRx extension cuffs. This case highlights both the versatility of endovascular treatments as well as the importance of a comprehensive vascular examination.

Treatment of venous aortorenal bypass graft aneurysm using a stent-graft

We present the case of a 77-year-old male patient who had undergone a bilateral venous aortorenal bypass graft 30 years previously. Thirteen years previously, the patient was shown to have a decrease in renal function, with mild shrinking of both kidneys; additionally, a stenosis was found in the left proximal anastomosis. At the most recent follow-up visit (1 year previously), ultrasound revealed an aneurysm (42 mm in diameter) of the left renal bypass graft; the finding was confirmed by CT angiography. A significant ostial stenosis of the left renal bypass graft was also confirmed. It was decided to place a self-expandable stent-graft into the aneurysm while also attempting to dilate the stenosis. Proximal endoleak after stent-graft placement necessitated the implantation of another, balloon-expandable stent-graft into the bypass graft ostium. Postprocedural angiography and follow-up by CT angiography at 3 months confirmed good patency of the stent-grafts and complete thrombosis of the aneurysmal sac, with preserved kidney perfusion. Renal function remained unaltered, while the hypertension is better controlled.

Saphenous vein graft aneurysm with graft-enteric fistula after renal artery bypass

A 65-year-old female presented with upper gastrointestinal hemorrhage thirty years following an aorta-to-right renal artery bypass constructed with saphenous vein. Upper endoscopy demonstrated a duodenal ulcer, and a CAT scan demonstrated aneurysmal degeneration of her renal artery bypass with duodenal impingement. Laparotomy demonstrated erosion of the aneurysm through the posterior wall of the duodenum; extra-anatomic renovascular reconstruction and primary duodenal repair was performed. Although aneurysmal degeneration of intraabdominal saphenous vein grafts is well described and rupture likewise reported, this report represents the first description of an intraabdominal autogenous vein graft aneurysm presenting with gastrointestinal erosion and fistula.

Spontaneous Vein Graft Rupture after Infrainguinal Vascular Reconstruction: Report of Three Cases

We report three cases of spontaneous vein graft rupture within 2 weeks of infrainguinal vein bypass for limb salvage. Two of the three ruptures were in the distal vein graft and the last just beyond the proximal anastomosis. All were longitudinal slits in the vein with no proximity to branches or valves. Endovascular treatment failed in one patient. Surgical correction with graft salvage was possible in all three cases. This may be an ischemic injury analogous to carotid vein patch rupture, nonapparent trauma to the vein, or simply mechanical stress causing vein rupture with arterial flow.

Use of external iliac artery in renal revascularization surgery: long-term angiographic assessment

PURPOSE

The external iliac artery has physical characteristics, in particular, caliber and length, similar to those of the renal artery and would thus seem to be an ideal substitute for it. However, there are no studies in the literature designed to confirm this possibility. The present study was designed to demonstrate the feasibility of use of the external iliac artery as a substitute for the renal artery in surgical revascularization of renal artery fibrodysplasia and to assess the long-term biologic behavior of the external iliac artery so used.

METHODS

Twelve patients (11 female, 1 male), ages 1 to 43 years (mean, 24.4 years), with severe hypertension underwent aortorenal bypass grafting with use of the external iliac artery to treat preocclusive stenotic lesions (n = 7), complete occlusion (n = 3), or aneurysm (n = 2) of the renal artery. It was considered unnecessary to reestablish circulation in the donor limb in 2 patients (young children), and transposition of the ipsilateral internal iliac artery was performed in 9 patients; in the remaining patient circulation was reestablished with insertion of an iliofemoral prosthesis.

RESULTS

There were no operative deaths. In 1 patient nephrectomy was necessary because of occlusion of the graft as a consequence of technical complications. In 8 patients there was immediate normalization of blood pressure without aid of medication, and in the remaining 3 patients an antihypertensive drug was prescribed. Two patients were lost to follow-up; the other 9 were assessed with angiography at a mean of 8.8 years after the operation. All grafts were found to be in excellent condition, with no evidence of dilatation, kinking, twisting, anastomotic fibroplasia, or wall irregularities.

CONCLUSION

On the basis of this experience, the external iliac artery is confirmed as a substitute for the renal artery, and the excellent long-term results would seem to make it particularly useful in young patients with long life expectancy, such as those with renal artery fibrodysplasia.

Surgical repair of transplant renal artery stenosis with preserved cadaveric iliac artery grafts

OBJECTIVE

To review the authors' experience with ABO-matched, preserved, cadaveric, iliac artery grafts for treatment of transplant renal artery stenosis (TRAS).

SUMMARY BACKGROUND DATA

TRAS is an important and treatable cause of hypertension and graft dysfunction in renal allograft recipients. Surgical treatment is reserved for lesions that are not amenable to percutaneous transluminal angioplasty (PTA) or for recurrence after PTA. Various surgical options for reconstruction of the transplant renal artery exist, although no single technique has been demonstrated to be superior. The authors have used preserved, blood type-matched, iliac artery grafts procured from cadaver organ donors to reconstruct transplant renal arteries in patients with specific lesions and following unsuccessful PTAs.

METHODS

Between 1991 and 2001, 21 patients underwent reconstruction of allograft renal arteries using cadaveric iliac artery as conduit. Charts, operative notes, and imaging studies of all patients were reviewed. A successful intervention for TRAS was defined as technical success as well as a decrease in serum creatinine and/or blood pressure 6 weeks after the procedure. Development of a hemodynamically significant lesion following renal artery reconstruction was considered a recurrence.

RESULTS

In patients treated with surgical reconstruction, hemodynamically significant TRAS occurred at or within 1 to 2 mm of the anastomosis in 13 patients, in the middle of the renal artery in 4, and secondary to a kink in 2 patients. Surgical treatment was undertaken in seven patients following unsuccessful PTA. Two patients had aneurysms of the iliac artery. Reconstruction using cadaveric iliac artery was successful in 19 of 21 (90%) patients, and only 1 these patients (4.8%) failed due to recurrence, with a median follow-up of 42 months. Graft loss secondary to TRAS occurred in two patients. The authors have not seen any long-term complications related to cadaveric iliac artery grafts, and the majority of the allografts continue to function well.

CONCLUSIONS

Surgical reconstruction of the transplant renal artery with blood type-matched iliac artery grafts should be considered a viable option for patients with specific anatomic lesions, those who have had an unsuccessful PTA, and those with recurrence following PTA.

Aneurysmal degeneration and late rupture of an aortorenal vein graft: case report, review of the literature, and implications for conduit selection

The saphenous vein is among the most commonly used conduits for renal artery revascularization in adults. Vein grafts are more durable in the renal artery bed than in coronary and peripheral beds, and mechanisms of potential graft failure vary. Coronary vein grafts often fail because of atherosclerotic degeneration, whereas lower extremity grafts fail because of intimal hyperplasia or progression of underlying disease. In contrast, renal vein grafts may dilate over time but seldom fail. This may relate to the distinct hemodynamic environment of the renal bed with low-resistance, high-velocity blood flow. However, frank aneurysmal degeneration of renal vein grafts is rare with only a single report of rupture in the literature. We report an additional case of rupture of a late graft aneurysm and review the literature and our own experience with renal revascularization to underscore the rarity of this serious complication. The saphenous vein for aortorenal bypass grafting continues to be a favorable conduit for renal revascularization. Long-term duplex ultrasound scanning follow-up is recommended to survey the reconstructed artery and perhaps more important, to evaluate progression of subclinical disease in the contralateral renal artery.