Treatment options in the management of abdominal aortic aneurysm in patients with renal transplant

Hybrid Percutaneous Brachiofemoral Shunt and Open Abdominal Aortic Aneurysm Repair in a Kidney Transplant Recipient

Abdominal aortic aneurysm (AAA) repair in kidney transplant recipients may cause ischemia in the transplanted kidney. As a result, various techniques have been described for protection of the renal allograft during AAA repair including temporary shunt, extracorporeal bypass, cold renal perfusion, endovascular aortic aneurysm repair (EVAR), and operation without renal allograft protection. We successfully treated a 56-year-old man, a case of kidney transplantation with AAA, using a temporary hybrid percutaneous brachiofemoral shunt using vascular prosthesis with a long 7-French (Fr) catheter sheath introducer (CSI) in the aortic arch via the right brachial artery and 8 Fr CSI in the right femoral artery that were connected together with a 7 Fr guiding catheter, before aortic cross-clamping and repair of AAA using a Dacron tube graft. The patient recovered well from the surgery without any complication and was discharged on the 6^th postoperative day. To our knowledge, this is the first report of using a temporary hybrid percutaneous brachiofemoral shunt for renal allograft protection in AAA repair surgery in a patient with kidney transplantation, and we think that this temporary shunt is an easy, safe, and rapid method for renal allograft protection from ischemia.

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.

Successful endovascular repair of ruptured abdominal aortic aneurysm in a renal transplant recipient

A renal transplant recipient presented in the early post-transplantation period with rupture of an abdominal aortic aneurysm. The high mortality rate of the surgical repair of ruptured aneurysm in addition to the concern of preserving the renal graft prompted us to seek alternative approaches, such as repairing the aneurysm by means of endovascular techniques. The ruptured aneurysm was confirmed by performing computed tomography and digital angiography and thereafter was successfully repaired by endovascular stenting technique (Talent stent-graft), which seems to be a safe and effective method of preserving a renal graft.

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.

Aortic aneurysm repair with a functioning renal transplant: therapeutic options

BACKGROUND

Aortic aneurysm repair in the presence of a functioning renal transplant carries significant risks of renal ischaemia. We describe the management of patients undergoing this treatment by using a temporary, externally sited axillofemoral bypass and discuss other treatment options.

METHODS

Three patients underwent a temporary, externally sited axillary artery to common femoral artery bypass. The aneurysm was then dissected via a transperitoneal incision. When the aneurysm was clamped, the axillofemoral graft was opened allowing retrograde perfusion to the renal transplant.

RESULTS

All three patients made a good recovery without postoperative deterioration of renal function.

CONCLUSION

Numerous methods of protecting the transplanted kidney have been described, including expeditious surgery with no renal protection or some form of temporary shunt to perfuse the donor iliac artery. Temporary insertion of an axillofemoral bypass adds 45-60 min of extra operating time if two surgeons are present. However, this technique should completely avoid transplant ischaemia and is an excellent technique for dealing with abdominal aneurysms in patients with functioning transplants.

Endovascular treatment of aortic aneurysms in patients with renal transplants

Endovascular treatment of an abdominal aortic aneurysm was undertaken in two orthotopic renal transplant recipients with US Food and Drug Administration-approved aortic stents without specific measures taken to protect the transplanted kidney. Renal function remained unchanged in both patients. Follow-up imaging studies showed successful aneurysm exclusion. Endovascular abdominal aortic aneurysm treatment in renal transplant recipients does not appear to place the transplanted kidney at undue ischemic risk and may be the preferred approach in select patients.

Aortic reconstruction in patients with functioning renal allografts

Patients with functioning renal allografts requiring aortic reconstruction pose a considerable challenge to the vascular surgeon. A variety of strategies for renal allograft preservation during intervention have been described including hypothermia, indwelling shunts, cold renal perfusion, axillofemoral bypass, and endovascular stent-grafting. Reported here are two cases of successful aortic reconstruction utilizing standard open surgical techniques designed simply to minimize warm renal ischemia. The first case was that of a 55 year-old patient with a functional renal allograft originating from the right external iliac artery, who presented acutely with large symptomatic aortic and bilateral iliac artery aneurysms. He was treated with aorto-right femoral/left iliac bypass grafting. The right femoral anastomosis was performed first so that warm renal ischemia was limited to the 34 min required to perform the proximal end-to-end aortic anastomosis. The second case was that of a 44-year-old patient also with a transplanted kidney originating from the right external iliac artery. He presented with worsening hypertension, decreasing renal function, claudication, and severe aortoiliac occlusive disease. He was treated with aorto-left femoral bypass grafting via a retroperitoneal approach, followed by femorofemoral crossover bypass for retrograde perfusion of the kidney (total warm ischemia time 20 min). Both patients recovered uneventfully without a decrement in renal function and remain well on follow-up. It is concluded that standard open surgery without adjunctive shunts or bypasses remains a viable treatment option for these patients, provided warm renal ischemia can be minimized.