Surgical Techniques and Procedures for Kidney Transplant Recipients With Severe Atherosclerosis

Application of homograft for intraoperative severe atherosclerotictic iliac vessel finding in renal transplantation: A case report

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Severe atherosclerosis is a complicated condition in patients with CKD and as the number of waiting list for renal transplantation rose, the rate is increasing.

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Surgeons should not omit artherosclerosis even pre-operative results did not suggest it.

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One-stage approach (renal transplantation and vascular reconstruction altogether) is a feasible and safe method for treating the conditions.

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The role of the surgeon’s skills and experiences, and especially tissue bank should be highlighted.

Introduction

Severe atherosclerosis is a complicated condition in chronic kidney disease (CKD) and could lead to the operation’s failure, when it was not detectable by pre-operative diagnostic imaging. Several methods including two-stage approach, synthetic graft, stent… have been reported, but complications (i.e. infection, graft rejection) are a matter of concern. The aim of this case is to provide the one-stage approach, in which renal transplantation and vascular reconstruction using fresh homografts from one brain-dead donor were used.

Presentation of case

We reported a case of a 33-year-old male, who was diagnosed with CKD caused by chronic glomerulonephritis since the age of 28 and had been on hemodialysis. Not until did the transplantation take place that the operation team spotted the atherosclerotic external iliac artery, and vessel graft from the same donor was used and the renal was transplanted. The patient was discharged 14 days after the surgery without any complications.

Discussion

Kidney transplantation has revolutionized the life of patients with end-stage renal disease (ESRD). Around 6% of patients have severe atherosclerosis and the figure is increasing. Vascular degradation in ESRD might lead to unsuccessful operation. One-stage approach (including renal transplantation and external iliac artery replacement) using homograft from one doner is feasible to handle the situation.

Conclusion

Severe atherosclerosis often accompanies with CKD. The difficulties of doing arterial anastomosis increases, which requires advanced techniques to deal with. Surgeons should be prepared about this circumstance. One-stage approach using one donor’s homografts, is a possible and safe procedure.

Iloprost in Acute Post-kidney Transplant Atheroembolism: A Case Report of Two Successful Treatments

Cholesterol embolization (CE) is a rare and alarming post-transplant complication, responsible for primary non-function (PNF) or delayed graft function (DGF). Its incidence is expected to rise due to increasingly old donors and recipients and the extended criteria for donation. Therapy with statins and steroids has not been shown to be effective, while agonism of prostaglandin I₂ has been reported to be useful in systemic CE. We report two cases of acute post-transplant CE in which intravenous iloprost (0.05 mg/kg/day) was added to standard statin and steroid therapy. In the first instance, CE was due to embolization from the kidney artery resulting in embolization of the small vessels; after a long DGF and 15 days of iloprost therapy, renal function recovered. The second instance is a case of embolization from the iliac artery of the recipient, where CE manifested as a partial renal infarction. After 5 days of iloprost administration, creatinine levels improved. Iloprost acts on vasodilation and on different inflammatory pathways, improving the anti-inflammatory profile. Post-transplant CE is difficult to diagnose and, if not treated, can lead to loss of function. Iloprost added to standard therapy could be beneficial in accelerating renal function recovery immediately after transplant.

Arterial reconstruction with donor iliac vessels during kidney transplantation in a patient with severe atherosclerosis

Atherosclerosis is common in patients with end-stage renal disease. Severe calcification of the iliac vessels is expected in the growing pool of kidney transplant candidates. Thus, transplant surgeons must constantly develop alternative operative strategies to deal with the technical challenges that this condition confers. This case report aims to highlight a reconstructive vascular technique to salvage a completely calcified recipient external iliac artery using a deceased donor's arterial iliac allograft from the same donor as the renal allograft in a 59-year-old man, as an effective method to decrease vascular complications.

Chimney-Patch Arterial Graft in Kidney or Pancreas Transplantation for Recipients with Heavily Calcified Iliac Arteries

Iliac artery calcification is a common phenomenon complicating renal transplantation, particularly in those with diabetes. The potential for vascular clamp injury can threaten the renal allograft, ipsilateral lower extremity, or both. Utilization of internal balloon occlusion can allow for placement of a "Chimney Patch" graft, fashioned from a deceased donor artery, to the calcified vessel, eliminating the risk of clamp injury and minimizing warm ischemic time. We present a series of 6 patients transplanted with internal balloon occlusion with successful renal and pancreatic allograft function and no ipsilateral vascular complications. Internal balloon occlusion is a safe and effective adjunct for renal or pancreas transplant to prevent clamp injury with no adverse effect on allograft function.

Renal Transplantation with Simultaneous Aortoiliac Reconstruction Using a Polytetrafluoroethylene Vascular Graft for Severe Atherosclerosis

Studies on aortoiliac reconstruction for severe atherosclerosis with renal transplantation are limited. Here, we report a rare experience of the simultaneous reconstruction of the external iliac artery caused by severe atherosclerosis with polytetrafluoroethylene vascular graft and renal transplantation in a 55-year-old female; she was unable to undergo standard renal artery anastomosis to the right external iliac artery because of severe atherosclerosis, which would result in complete occlusion. Next, we directly anastomosed the donor renal artery to the polytetrafluoroethylene graft. After transplantation, delayed graft function occurred; therefore, the patient had to undergo hemodialysis. On day 7 after transplantation, her creatine level started to decrease. She was discharged from the hospital on the 14th day after transplantation. After 1 month, her serum creatinine level reduced to 1.12 mg/dL. After 3 years of transplantation, her serum creatinine level was 1.2 mg/dL. The simultaneous implantation of the polytetrafluoroethylene graft and renal transplantation was feasible as well as safe, with no infectious complications and stable renal function noted on long time follow-up. Although our case was rare, it emphasizes the need for transplant surgeons to gain surgical skills for vascular surgery using vascular grafts.