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Corresponding author. I. Matia, MD, Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Videnska 1958/9, 140 21 Prague, Czech Republic.
An increasing number of aortoiliac lesions and abdominal aortic aneurysms occur in renal failure patients waiting for renal transplantation. The aim of our study was to assess long term results of simultaneous renal transplantation and surgical repair of aortoiliac lesions with arterial allografts.
Design
A retrospective observational study.
Patients and methods
From October 1997 to June 2007, we performed simultaneous aortoiliac reconstructions using fresh arterial allografts and kidney transplantation in 14 patients with chronic renal failure (men 9, women 5, mean age 53 years). The indication for vascular reconstruction was an asymptomatic abdominal aneurysm in 6 patients or aortoiliac stenosis/occlusion in 8 patients. The median follow up period for the cohort was 55.5 months (range from 1 to 116 months).
Results
Three patients died during the follow up period. In none of them there was an allograft (neither arterial nor renal) related death. No signs of arterial grafts infection or aneurysmal formation and no need for secondary intervention (angioplasty and/or thrombolysis) of any arterial reconstruction was observed during the follow up period in any patient. The renal grafts failed in three patients.
Conclusions
Our experience suggests that it is possible and safe to use arterial allografts in the treatment of arterial occlusive disease or abdominal aortic aneurysm simultaneously with renal transplantation.
Vascular surgery for recipient preparation, improvement of graft quality and acceptability, and therapy of ischemic graft damage in kidney transplantation.
Haemodialysis and chronic renal failure are associated with hypertension and lipid disorders that predispose to accelerated atherosclerosis and many of potential recipients suffer from aortoiliac atherosclerosis or abdominal aortic aneurysms (AAA).
Comparison of several atherogenicity indices by the analysis of serum lipoprotein composition in patients with chronic renal failure with or without haemodialysis, and in renal transplant patients.
The age and number of comorbities of renal recipients is increasing as well. Transplant surgeons therefore face a more frequent need for vascular intervention prior to or simultaneously with the transplantation.
Vascular surgery for recipient preparation, improvement of graft quality and acceptability, and therapy of ischemic graft damage in kidney transplantation.
In all patients included, the vascular prosthesis were used as conduits for arterial reconstruction with varied success.
In our retrospective observational single-center study we report the long term results of simultaneous renal transplantation and aortoiliac reconstruction using fresh arterial allografts obtained from the same donor.
Patients and Methods
The study was approved by our local ethical committee.
Patient population
From October 1997 to June 2007 1800 adult kidney transplantations were performed at our Department. In 14 renal graft recipients (0.7% of all kidney transplantations) we simultaneously used fresh arterial grafts as vascular conduits for aortoiliac reconstructions. The mean age of patients, comprising 9 males and 5 females was 53 years (range 32 to 67 years). The median follow up period was 55.5 months (range 1 to 116 months).
Three patients (21%) in this group had a previous history of at least one unsuccessful renal transplantation with subsequent graftectomy. The aetiology of the renal failure included renal arteries occlusion in 3 cases (21%), chronic pyelonephritis in 2 cases (14%), glomerulonephritis in 2 cases (14%), vascular nephrosclerosis in 2 cases (14%), renal polycystosis in 2 cases (14%), diabetic nephropathy in 1 case (7%), tubulointestinal nephritis in 1 case (7%), and bilateral nephrectomy due to Grawitz tumour in 1 case (7%). Of the renal recipients, 12 (86%) were current or past smokers, 7 (50%) had ischaemic heart disease, and 2 (14%) had diabetes.
In thirteen (93%) of the presented patients simultaneous aortoiliac reconstruction and renal transplantation was electively planned. The aortoiliac lesions were preoperatively verified by angiography (conventional or computed) and patients were put on a special waiting list for renal transplant candidates.
An asymptomatic AAA was present in 6 cases (46%). The median diameter of aneurysms was 53 mm (range 45 to 65 mm). Three patients were operated in the period before the endovascular treatment of AAA was introduced at our Institute. Two were not suitable for an endovascular procedure due to tortuosity of the iliac vessels. One patient was operated on 16 months after unsuccessful stentgraft implantation due to significant iliac occlusive disease.
Four patients (31%) with claudication presented with bilateral iliac occlusions or stenoses not suitable for endovascular treatment. All were selected for simultaneous aortobiiliac reconstruction and renal transplantation.
One patient (8%) with unilateral claudications due to iliac occlusion and one patient (8%) with toe gangrene due to prosthetic aortofemoral bypass occlusion were selected for simultaneous aortofemoral bypass and kidney transplantation. The renal artery was anastomosed to the arterial allograft in both cases.
One patient (8%) who had received two failed renal transplantations and also presented with a iliac occlusion was selected for iliofemoral bypass to provide a good blood supply for the renal graft transplanted simultaneously.
An acute iliac artery resection and replacement due to dissection during renal transplantation was performed in one (7%) of fourteen presented patients. The iliac allograft obtained from the same donor as renal and liver grafts was used for the arterial substitution. The iliofemoral grafts are obtained regularly with liver but not renal grafts at our Institute.
Harvest and preservation of arterial grafts
All arterial and renal grafts were obtained from donors with the diagnosis of cerebral death in the course of a multiorgan harvest. The mean age of donors (14 males) was 31.5 years (range 15 to 44 years). Renal and arterial grafts obtained from one donor were both used in a single recipient.
After removal the arterial grafts were flushed with conservation solutions used in renal harvest. The grafts were then stored at a temperature of about 4 degrees Centigrade using the same types of solutions as those used for flushing, with no additional antibiotics. The mean cold ischemic time was 12.7 hours (range 5 to 24 hours) for arterial and 14.3 hours (range 7 to 26) for renal grafts, respectively.
The types of arterial allografts obtained during multiorgan harvest and used as conduits for vascular reconstructions are summarized in Table 1.
Table 1Types of fresh arterial allografts used for vascular reconstruction and specifications of renal transplantation procedures in 14 patients
The immunosuppressive protocol in patients with the renal and arterial transplantations performed simultaneously did not differ from those used after a simple renal transplantation at our department. In the case of renal graft failure, the immunosuppression was restricted to monotherapy with cyclosporine A or tacrolimus as described previously.
After arterial and renal transplantation patients are carefully monitored by vascular surgeons and nephrologists during the entire follow up period. The patency of the arterial reconstructions was verified by clinical examinations, ultrasonography and/or angiography (conventional or computed), periodically (Fig. 1). The function of transplanted kidneys and level of immunosuppresive drugs are monitored in accordance with our Institute's standard policy stipulating the level of care to be extended to organ recipients.
Fig. 1CT angiography 108 months after simultaneous aortobifemoral bypass with arterial allograft and renal transplantation in to left illiac fossa. The second renal transplantation in to right iliac fossa was performed at 71 months after the primary procedure. No sings of arterial allograft dilatation or stenosis were seen during the all follow up period.
In all but one patient acetylsalicylic acid was used as an antithrombotic drug. In one patient after implantation of an aortic valve prosthesis warfarin was prescribed.
Results
There were three deaths (21%) during the follow up period. Two patients died one month and 32 months, respectively, after vascular reconstruction and renal transplantation due to gastrointestinal (GIT) hemorrhage. Another one died at 27 months due to intracerebral hemorrhage. One patient was lost to follow up 60 months after operation. There was no arterial or renal allograft related deaths in the presented group of patients.
Three patients (21%) developed a problem with wound healing. In two of them a wound dehiscence required re-suturing and in another one a wound lymph leak was treated conservatively. An ischemic colitis with colon perforation developed in one patient after a simultaneous abdominal aortic aneurysm (AAA) repair and renal transplantation in the early postoperative period. The inferior mesenteric artery was ligated during the AAA resection. A subtotal colectomy was undertaken 8 days after the primary operation. Subsequently, an acute renal graft failure with a short-term need for dialysis developed. The acute rejection was successfully treated. No signs of arterial allograft infection were noticed in this patient during the subsequent follow up period.
No patient developed signs of arterial grafts infection, stenosis or dilatation of implanted allografts and there was no need for secondary interventions (angioplasty and/or thrombolysis) during the follow up period.
One primary renal allograft failure due to acute rejection with consecutive graftectomy occurred in one patient. Renal allografts failed due to chronic rejection in two (14%) other patients 62 and 96 months after transplantation. In one of them a second renal transplantation in the contralateral iliac fossa was performed 71 months after the primary operation. The renal artery was anastomosed to the arterial allograft. This second renal allograft failed after 30 months due to chronic rejection. Ureteral stenosis of transplanted kidney was observed in two patients (14%) during the first 6 months postoperatively. They were both successfully treated by short-term percutaneous nephrostomy.
Discussion
The most suitable timing for vascular reconstruction of aortoiliac vessels in renal recipients has been controversial since the first successful renal artery anastomosis to a vascular prosthesis was published by Sterioff et al. in 1974.
The main advantages of this one-stage procedure summarised by Wright are: (1) there are no technical difficulties in the dissection due to reoperation; (2) the cost and hospitalisation time are significantly decreased; (3) the patient incurs only one anaesthetic risk.
However, the risk of prosthesis infection in immunosuppressed patients is still present. The largest series of patients with aortoiliac prosthetic reconstruction and renal transplantation performed as one-stage procedure was recently published.
During the four years period a vascular graft was implanted in 11 renal recipients. No infectious complications of the vascular graft were noticed during this follow up period. On the other hand Gouny et al.
described one patient's death due to prosthetic graft infection secondary to a urinary tract fistula in a group of two patients with implanted bifurcated prosthetic grafts during renal transplantation. A two-stage procedure with intervals from 6 weeks to 3 months was recommended by these authors. A vascular prosthesis infection was described in the work of Pittaluga et al. as well.
who evaluated the outcome of renal transplantation with an arterial anastomosis to a vascular prosthesis in 13 patients, regards simultaneous renal transplant and arterial reconstruction as hazardous with relatively poor short- and long term results.
Arterial allografts have been successfully used in the treatment of mycotic aneurysms and infected vascular prostheses for last 20 years.
Fresh and cryopreserved arterial homografts in the treatment of prosthetic graft infections: experience of the Italian Collaborative Vascular Homograft Group.
No patient in our study develop signs of arterial grafts infection. This finding was despite one patient developing ischemic colitis and colon perforation during the early postoperative period.
Ischaemia of the large intestine following parallel kidney transplantation and the abdominal aortic aneurysm replacement using a fresh arterial graft implant.
Aneurysm formation, mural thrombosis, degenerative changes and occlusions have been reported in the intermediate and long term follow up of many patients after early clinical experience with aortic allografts in the 1950s and 1960s.
published in 2004 the study of fresh and cryopreserved arterial implantation for infrarenal aortic graft infection in 179 patients. There were three allograft-related late deaths from rupture of the allograft and late nonlethal aortic events (occlusion, dilatation, aneurysm) in 10 patients, respectively. The only significant risk factor for late aortic events was use of a thoracic aorta allograft. In addition, there were 63 late, mostly occlusive, iliofemoral events. No immunosuppression was used in these patients. None of late aortic or iliofemoral events mentioned above occurred in our patients. In all cases immunosuppressive therapy was prescribed during the follow up period.
Important factors influencing the quality of fresh arterial allografts are duration of conservation and the type of conservation solution.
the allograft were harvested during donor autopsy with mean time elapsed from death to autopsy of 10.1 hours. The grafts were then stored in Hank's solution for the mean time of 25.8 days. Fresh arterial allografts used by Kieffer et al.
were obtained from brain dead donors as part of a program to retrieve multiorgan transplant tissue. The grafts were then stored in modified RPMI 1640 Medium with addition of antibiotics and heparin for the mean time of 13.0 days. In our study all arterial allografts were stored in modern conservation solutions (Custodiol, University of Wisconsin, Euro-Collins) used routinely in transplant medicine with no addition of antibiotics and all were transplanted within 24 hours (mean 12.7 hours).
We conclude that renal transplantation and aortoiliac reconstruction with fresh arterial allografts can be undertaken simultaneously as a one stage procedure with satisfactory long term results of both renal and arterial allografts. The good long term patency rates of arterial allografts can be attributed to modern conservative solutions, short cold ischaemic times and particulary the use of effective immunosuppression.
Acknowledgement
The work was supported by Grant No. NR/9371 – 3/2007 awarded by the Internal Grant Agency of the Ministry of Health of the Czech Republic.
References
Pfeiffer T.
Sandmann W.
Luther B.
Böhner H.
Voiculescu A.
Grabensee B.
et al.
Vascular surgery for recipient preparation, improvement of graft quality and acceptability, and therapy of ischemic graft damage in kidney transplantation.
Comparison of several atherogenicity indices by the analysis of serum lipoprotein composition in patients with chronic renal failure with or without haemodialysis, and in renal transplant patients.
Fresh and cryopreserved arterial homografts in the treatment of prosthetic graft infections: experience of the Italian Collaborative Vascular Homograft Group.
Ischaemia of the large intestine following parallel kidney transplantation and the abdominal aortic aneurysm replacement using a fresh arterial graft implant.
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