Aortic aneurysm repair with a functioning renal transplant: therapeutic options

Abdominal Aortic Aneurysm Repair in Renal and Liver Transplant Recipients

BACKGROUND

Abdominal aortic aneurysm (AAA) repair in patients with organ transplant remains a challenge. We looked at AAA repair in patients with organ transplants at our tertiary liver and kidney transplant unit.

METHODS

A retrospective analysis of a prospectively maintained database was undertaken from January 2008 to July 2018. We looked at patient demographics, type of repair, and technical success including reinterventions, perioperative transplant organ function, and 30-day and 1-year survival rate. Eight of 662 patients who underwent AAA repair had a solid organ transplant. Of these, 5 were kidney transplants, 2 liver transplants, and 1 had kidney and liver transplant; 75% were male; and average age was 63.4 (range: 49-83). All patients had asymptomatic AAAs, and 6 were treated with standard endovascular repair, 1 standard repair with iliac branch device, and 1 open repair. Adjunctive techniques such as CO₂ angiograms, deployment of main body through contralateral iliac, low-profile sheaths, custom-made stent grafts, and temporary axillo-femoral shunting were used to protect transplant organs. Thirty-day survival was 100% with 1 death at 5 months from liver failure, and 1 patient has a persistent type-2 endoleak 3 years after the procedure.

CONCLUSION

Abdominal aortic aneurysm repair in patients with organ transplants can be undertaken using adjunctive endovascular and open surgical techniques.

Renofemoral shunt for protection of abdominal allografts during emergency abdominal aortic surgery

Emergency aortic surgery can be a daunting task in patients with functioning kidney and pancreas allografts because it poses the risk of allograft loss due to prolonged warm ischemia created by aortic cross-clamping. We present a case in which dual allografts, both originating from the right iliac arterial system, were protected from warm ischemia during aortic cross-clamping by creation of a temporary renofemoral shunt between the native left renal artery and right femoral artery. This simple technique maintained pulsatile allograft perfusion during aortic reconstruction for treatment of a ruptured mycotic aortic aneurysm complicated by an aortocolonic fistula.

Endovascular abdominal aortic aneurysm repair in patients with renal transplant

The repair of abdominal aortic aneurysm (AAA) in patients with functioning renal transplant is critical because it is important to avoid ischemic and reperfusion injury to the transplanted kidney. Endovascular aneurysm repair (EVAR) avoids aortic cross clamping and can prevent renal graft ischemia. Here we report the endovascular management and outcome of AAA in two renal transplant patients using a bifurcated aortic stent graft. One patient underwent EVAR using a small amount of contrast (30 mL) due to decreased renal function resulting from chronic rejection. Another patient had EVAR performed with iliac conduit because of the heavily calcified, stenotic lesion of external iliac artery. EVAR in patients with a renal transplant is a feasible option without impairing renal arterial flow.

Aortic clamping in pancreas transplantation: is there any harm to the transplanted kidney graft?

INTRODUCTION

Some special situations may require aortic clamping during pancreas transplantation (PT). The most important problem is ischemic injury to a previous transplanted kidney. We sought to demonstrate experience with aortic clamping in PT without special kidney allograft protection measures and its impact on kidney function.

METHODS

Retrospective study that analyzed 6 patients who underwent PT (5 pancreas after kidney and 1 simultaneous pancreas-kidney) with aortic clamping. In all cases, the pancreas graft was placed on the right with retrocolic portal-enteric drainage. Serum creatinine was evaluated pre- and posttransplantation.

RESULTS

The average clamping time was 19 minutes. The mean serum creatinine was 1.1, 1.15, 0.95, and 1.0, respectively, at pre and postoperative days 1 and 7 and at hospital discharge. Patient, kidney, and pancreatic graft survivals were 100%, 100%, and 83%, respectively.

CONCLUSION

The need for aortic clamping in selected cases of PT did not seem to affect the transplanted kidney, even without protective measures, provided that the ischemic time was short.

Modification of a bifurcated stent graft for aortouniiliac endovascular aneurysm repair in a renal transplant patient

INTRODUCTION

We describe a case of aortouniiliac (AUI) endovascular aortic aneurysm repair (EVAR) using combined iliac limb and bifurcated body stent graft modular system.

CASE REPORT

This technique is demonstrated in a 58-year-old man with a 6-cm abdominal aortic aneurysm suitable for EVAR. The patient has a functioning cadaveric renal transplant anastamosed to the mid right external iliac artery, an occluded left iliac system and stenosed right iliac system. The renal allograft was protected with minimal passage across the transplant artery origin using this modified approach. The patient was successfully treated with a bifurcated main body deployed within a contralateral limb endoprosthesis. Subsequent scans confirmed no endoleaks or stent migration.

CONCLUSIONS

The AUI conversion from existing Gore excluder stent graft system is safe and should be considered when faced with challenging anatomy of a pelvic renal transplant, slender access, and contralateral iliac occlusion.

Abdominal aortic aneurysm repair with a functional autotransplanted kidney

During the course of their practice, most urologists will encounter only a few patients with renal autotransplants. Even fewer will encounter those with renal autotransplants requiring abdominal aortic aneurysm (AAA) surgery. Although there is some literature describing AAA surgery in renal allotransplant patients, there is little such literature regarding AAA surgery in patients with autotransplanted kidneys. We present a case of a patient with a single, functioning, autotransplanted kidney who required AAA surgery. We also discuss the issue of the need for renal protection.

Aortoiliac Aneurysm Repair in Kidney Transplant Recipients

A potential problem during endovascular aortic aneurysm repair (EVAR) or open repair in renal allograft patients is ischemia of the transplanted kidney. In this study, kidney transplant patients who underwent aortic aneurysm repair in our institution were added to similar cases extracted from the literature to represent the basis of this work. Comparisons between patients treated with open surgery versus EVAR were performed in terms of renal function. In the EVAR group, most aneurysms were infrarenal, and 84% were treated with modular bifurcated devices. Protective kidney allograft perfusion measures were not used. The pre- and postoperative Cr was 1.69 and 1.73 mg/dL, respectively (P = .412). All EVAR patients had good outcomes. Complications included 8 endoleaks and 1 limb ischemia case. Three patients died from aortic repair-unrelated reasons. In the open group, the pre-and postoperative Cr was 1.45 and 1.37 mg/dL, respectively (P = .055). Most cases were infrarenal and mostly treated by aortobiiliac bypasses. In 16%, no adjuvant allograft perfusion was provided. In the rest, temporary axillofemoral bypasses were used most often. Most outcomes were favorable (57%). Reported procedural-related complications included arterial embolism, wound infection, and pneumonia. Deaths were reported in 5 occasions (none allograft failure dependent). No differences in Cr between EVAR and open techniques (P = .13) were seen. Aneurysm repair in kidney transplant recipients is associated with excellent renal preservation. Adverse outcomes were all allograft failure independent in both groups. EVAR without special allograft protection measures seems to be equally effective as open surgery with or without adjuvant kidney transplant perfusion.

Renal Function after Elective Infrarenal Aortic Aneurysm Repair in Patients with Pelvic Kidneys

Pelvic kidneys complicate aortic reconstructions because of increased risk of renal ischemia. Strategies for protection include shunting, cooling, and reliance on collaterals. A review identified two congenital pelvic kidney (not solitary) and five transplanted kidney patients who underwent elective abdominal aortic aneurysm repair. For congenital pelvic kidneys, topical cooling was used in one patient while no preservation was performed for the other patient. Three transplanted kidney patients were shunted, and one had endovascular repair. Postoperative creatinine values were compared to preoperative values. The two congenital pelvic kidney patients had no significant elevation of creatinine postoperatively. The transplanted kidney patient who underwent endovascular repair had no increase in creatinine postoperatively. All transplanted kidney patients who had open repair had significant but transient increase in creatinine postoperatively. Three patients who were shunted intraoperatively had normalization of creatinine. The patient who had persistent elevation of creatinine at discharge was not shunted. Aortorenal shunting or endovascular repair in transplanted pelvic kidney patients maintains renal function. For patients with congenital pelvic kidneys and adequate collaterals, cooling and collateral perfusion is usually sufficient. Though experience is limited, endovascular repair is likely to be superior to open repair in minimizing renal ischemia.

Endovascular Abdominal Aortic Aneurysm Repair in the Presence of a Kidney Transplant: Therapeutic Considerations

Abdominal aortic aneurysm (AAA) repair in the presence of a kidney transplant can be extremely challenging, as it carries significant risks of renal ischemia. Endovascular repair is an attractive option, as it can be performed with little or no impairment of renal arterial flow. We describe the endovascular management of a recurrent AAA in a patient with a functioning renal transplant using a custom-made aorto-uni-iliac device. We discuss the planning and the potential problems of the technique.