Renal Transplant Artery Inflow Stenosis Treated with Femorofemoral Bypass

Abstract

In this case report we describe a novel and successful revascularization approach in instances of allograft and distal limb ischemia after kidney transplantation. Stenosis proximal to transplant renal artery anastomoses is a complication leading to allograft dysfunction and/or loss. We present a femorofemoral bypass graft with ringed polytetrafluoroethylene (PTFE). In this occasion, revascularization was achieved by a backflow mechanism. The approach described achieved its goal of revascularizing the allograft as well as the distal extremity, with both short- and long-term successful outcomes. Benefits of this approach when compared with re-implantation or procedures directly involving the transplant renal artery include minimization of ischemic time, no need to repair the stenosis, anastomoses with vessels of greater diameter, no need to perfuse the kidney, no need to take down the renal artery anastomosis, no need to dissect the transplanted kidney, and no further lower extremity ischemia. This approach does not require any proximal temporary inflow occlusion (as seen with stent placement) or clamping of the arterial inflow to the kidney. This procedure was completed without having to infuse any preservation fluid into the kidney.

Keywords

renal transplantation - kidney transplantation - vascular stenosis - revascularization - limb ischemia - bypass - organ ischemia

^* Both the authors have equal contribution.

Publication History

Article published online:
16 May 2020

• References

• 1 Suthanthiran M, Strom TB. Renal transplantation. N Engl J Med 1994; 331 (06) 365-376
• 2 Schnuelle P, Lorenz D, Trede M, Van Der Woude FJ. Impact of renal cadaveric transplantation on survival in end-stage renal failure: evidence for reduced mortality risk compared with hemodialysis during long-term follow-up. J Am Soc Nephrol 1998; 9 (11) 2135-2141
• 3 Ozban, Murat, Cagatay Aydin, Belda Dursun, Baki Yagci, Onur Birsen, and Koray Tekin. Post-kidney transplantation external iliac artery stenosis due to vascular clamp: report of a case. J Vasc Bras 2014;13(03):254–256
• 4 Patel NH, Jindal RM, Wilkin T. et al. Renal arterial stenosis in renal allografts: retrospective study of predisposing factors and outcome after percutaneous transluminal angioplasty. Radiology 2001; 219 (03) 663-667
• 5 Bruno S, Remuzzi G, Ruggenenti P. Transplant renal artery stenosis. J Am Soc Nephrol 2004;15(01):134–141
• 6 Weigele JB. Iliac artery stenosis causing renal allograft-mediated hypertension: angiographic diagnosis and treatment. AJR Am J Roentgenol 1991; 157 (03) 513-515
• 7 Sankari BR, Geisinger M, Zelch M, Brouhard B, Cunningham R, Novick AC. Post-transplant renal artery stenosis: impact of therapy on long-term kidney function and blood pressure control. J Urol 1996; 155 (06) 1860-1864
• 8 Audard V, Matignon M, Hemery F. et al. Risk factors and long-term outcome of transplant renal artery stenosis in adult recipients after treatment by percutaneous transluminal angioplasty. Am J Transplant 2006; 6 (01) 95-99
• 9 Voiculescu A, Schmitz M, Hollenbeck M. et al. Management of arterial stenosis affecting kidney graft perfusion: a single-centre study in 53 patients. Am J Transplant 2005; 5 (07) 1731-1738
• 10 Ferrari M, Bonanomi G, Vistoli F, Moretto C, Carmellini M, Mosca F. Surgical endarterectomy for suprarenal iliac artery stenosis in renal allograft recipient. Ann Vasc Surg 2001; 15 (05) 571-574
• 11 Tovbin D, Feldman L, Basok A. et al. Renal transplant dysfunction due to severe aorto-iliac atherosclerosis in the presence of patent renal transplant artery. Am J Nephrol 2000; 20 (06) 487-490
• 12 Demir, Tolga, Mehmet Ümit Ergenoğlu, Nursen Tanrıkulu, Abdurrahman Ekinci, and Ergun Demirsoy. Renal allograft dysfunction due to iliac artery occlusion: Cross-over femoro-femoral bypass saves the day. Turkish J Vasc Surg 2017;26(02)
• 13 Voiculescu A, Hollenbeck M, Plum J. et al. Iliac artery stenosis proximal to a kidney transplant: clinical findings, duplex-sonographic criteria, treatment, and outcome. Transplantation 2003; 76 (02) 332-339
• 14 El-Harakeh MA, Barbari A, Stephan A, Saggi S, Kilany H, Barakeh A. A transplanted kidney surviving total vessel occlusion and anuria. Clin Nephrol 2005; 64 (02) 159-162
• 15 O'Hare AM, Rodriguez RA, Bacchetti P. Low ankle-brachial index associated with rise in creatinine level over time: results from the atherosclerosis risk in communities study. Arch Intern Med 2005; 165 (13) 1481-1485
• 16 Langsfeld M, Nepute J, Hershey FB. et al. The use of deep duplex scanning to predict hemodynamically significant aortoiliac stenoses. J Vasc Surg 1988; 7 (03) 395-399
• 17 Humar A, Grubbs B, Zapzalka D, Nazarian W, Hunter D, Matas A. Isolated iliac artery stenosis as a cause of kidney graft dysfunction post-transplant. Clin Transplant 1998; 12 (05) 406-408
• 18 Knuth J, Wenzel D, Goßmann A, Aleksic M. Blood will find its way. Retrograde perfusion of a transplant-kidney via a femoro-femoral crossover bypass. Vasa 2013; 42 (06) 453-456