Aortoiliac Surgery and Kidney Transplantation Pierre Gouny, MD, Bernard Lenot, MD, Benoit Decaix, MD, Eric Rondeau, MD, Michel Kitzis, MD, Roger Lacave, MD, Jaber Bensenane, MD, Oscar Nussaume, MD, Paris and Clichy, France
Between January 1980 and December 1989, we performed 407 renal transplantations. Twelve of these patients (3%) underwent aortoiliac reconstruction before (Group I, two patients), concomitant to (Group II, five patients) or after (Group III, five patients) renal transplantation. The aortoiliac lesions treated included four aneurysms and seven occlusions of the abdominal aorta and one postarteriography dissection of the iliac artery. A prosthetic graft was inserted in nine cases (75%). Endarterectomy was performed in the three other cases (25%). Four of five patients in Group III were operated on without any particular protection for the transplant. There were no postoperative deaths in Groups I and III. In Group II, one patient died of infection secondary to a urinary tract fistula. Early and late vascular morbidity (renal artery stenosis, occlusion of aortoiliac reconstruction, anastomotic false aneurysm) occurred with equal frequency in the three groups. Renal transplantation in patients having already undergone aortoiliac surgery and, conversely, aortoiliac reconstruction in the renal transplant patient, are possible without any particular technical precautions with minimal mortality and kidney morbidity. Simultaneous renal transplantation and aortoiliac reconstruction carries a significant risk of infection and a two-stage procedure should be considered in this situation. (Ann Vasc Surg 1991 ;5: 26-31). KEY WORDS: Aortoiliac surgery; abdominal aortic aneurysm; renal artery; kidney transplantation.
Aortoiliac lesions associated with end-stage renal failure are encountered with increasing frequency [1] because of extended indications for renal transplantation, more elderly patients coming to transplantation, and improved survival after transplanta-
tion. Of the possible candidates for renal transplantation, some either have aortoiliac lesions or have already been operated on for their treatment. Other patients, already transplanted, will develop aortoiliac disease. Isolated cases or small series of one of the above-mentioned associations [2-7] have been reported. We report on a series of 12 patients, among whom the three types of associations were encountered.
From the Service de Chirurgie Thoracique et Vasculaire, HOpital Rothschild, Service de N~phrolo~oie, H6pital Tenon, Paris and Service de Chirurgie Thoracique et Vasculaire, HOpital Beaujon, Clichy, France. Presented at the Annual Meeting of the SociOt~ de Chirurgie Vasculaire de Langue Franqaise, May 18-19, 1990, Nancy, France.
PATIENTS AND METHODS Between 1980 and 1989, 407 renal transplantations were performed at Beaujon Hospital (Clichy, France). Of these, 11 men and one woman under-
Reprint requests: P. Gouny, MD, Service de Chirurgie Thoracique et Vasculaire, HOpital Rothschild, 33 Boulevard de Picpus, 75012 Paris, France:
26
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A OR TOILIA C S U R G E R Y A N1) K I D N E Y TRA N S P L A N T A T 1 0 N
TABLE I.--Kidney transplantation in two patients with previous aortoiliac revascularization (Group I) Patient No. Age (years) Kidney disease Indication for arterial restoration Arterial restoration procedure Delay between the two procedures (months) Implantation of transplant renal artery Late complications Duration survival (months) Blood pressure (mmHg*) Serum creatinine (mmoles/L)*
1 47 Hypertensive kidney disease Aortoiliac occlusive disease Aortobifemoral bypass 84
2 42 Glomerulonephritis Aortobiiliac aneurysm
Prosthetic limb
Prosthetic limb
-12
Aortobiiliac bypass 4
Femoral false aneurysm 26
120/80
140/85
130
130
*When seen last
went aortoiliac reconstruction prior to, simultaneous with, or after renal transplantation. At the time of the second procedure (renal transplantation or aortoiliac surgery), the mean age of patients was 43.5 years (range 26 to 60 years old). Four patients had an aneurysm of the abdominal aorta, seven had aortoiliac occlusive disease, and one patient had an iatrogenic (postarteriography) dissection of the lilac artery. The kidney diseases responsible for terminal kidney failure included glomerulonephritis (n 5), polycystic kidney disease (n = 3), schistosomiasis (n - 2), and hypertensive nephropathy (n - 2). Based on the date of transplantation with regard to vascular surgery, three groups of patients were designated: In Group 1 (two patients), renal transplantation was performed in patients already having undergone aortoiliac revascularization (Tablc I). One hypertensive patient had undergone arterial reconstruction by aortobifemoral prosthetic replacement seven years previously for occlusive disease. He had not yet had dialysis. Another patient, already under hemodialysis, had received an aortobiiliac prosthetic graft four months earlier for cure of an aneurysm of the abdominal aorta. In both cases, the renal artery of the transplant was implanted directly into the aortic graft. In one patient, the renal vein of the transplant was anastomosed to the interior vena cava because of difficulties encountered in the dissection of the iliac vein. In Group i1 (five patients), aortoiliac revascularization and renal transplantation were performed simultaneously (Table I1). All patients had occlu-
27
sive disease. In two cases occlusion was known before operation; arteriograms were obtained during pretransplantation workup because of antecedent claudication. Prosthetic replacement was performed prior to renal transplantation in these cases. In one patient, the renal artery of the transplant was implanted into the right limb of the aortobifemoral prosthetic graft. In the other patient, the transplant renal artery was revascularized by one of the branches of the bifurcated prosthetic graft, the other limb being used for the anastomosis with the femoral artery. In two patients, aortoiliac lesions were discovered intraoperatively. They were treated before renal transplantation by lilac endarterectomy. In these four cases, the duration of warm ischemia (20 to 35 minutes) was not longer than the time usually necessary for renal transplantation. In the last patient, the lilac lesions were initially neglected and the renal transplantation was performed first. An iliac endarterectomy was necessary because the kidney remained soft; in this case, however, the duration of warm ischemia was prolonged 30 minutes. In Group III (five patients), aortoiliac surgery was performed in patients already having undergone kidney transplantation (Table III). The interval between the renal transplantation and the aortoiliac operation was 15 months on average (seven months to seven years). In one patient, aortoiliac lesions were occlusive and responsible for intermittent claudication of the lower limbs associated with hypertension. Three patients had aneurysm of the abdominal aorta. One further patient had a dissection of the iliac artery which had been anastomosed to the transplant renal artery as a complication occurring during follow-up arteriography. All patients had normal renal function (serum creatinine less than 120 micromoles/liter) at the time of their operation on the abdominal aorta. One patient had medically stabilized hypertension due to tight stenosis of the lilac artery proximal to the implantation of the transplant renal artery. In the first patient in this series, renal protection was procured by temporary extraanatomic shunt [8]. The four other patients had simple clamping, responsible for renal ischemia lasting between 20 and 60 minutes (mean: 36 minutes). Three patients had an aortobiiliac bypass revascularizing the iliac artery proximal to the implantation of the renal transplant artery. In two of these cases, renal artery reimplantation was n o t necessary. In the other, the two renal arteries were reimplanted indirectly into one of the limbs of the prosthetic graft, one through a vein graft, the other by a prosthetic tube (Fig. 1) because of the absence of pulsations in the renal arteries of the transplant. Another patient underwent an aortobifemoral bypass with direct reimplantation of the transplant renal artery into one of the limbs of the prosthetic graft. In the last patient, an iliofemoral
28
ANNALS OF VASCULAR SURGERY
AORTOILIAC S URGER Y A N D K I D N E Y T R A N S P L A N T A T I O N
TABLE II.aConcomitant surgery (Group II) Patient Age (years) Kidney disease
Indication for arterial restoration Arterial restoration procedure Duration warm ischemia (min) Postoperative complication
Late complications
Duration survival (months) Blood pressure (mmHg)* Serum creatinine (mmoles/L)*
3 32 Membranoproliferativeglomerulonephritis lilac occlusion
4 60 Polycystosis
5 48 Hypertensive nephropathy
lilac occlusion
lilac occlusion
Endarterectomy +patch
Endarterectomy bypass
Endarterectomy bypass
30 + 30
20
25
Bifurcated aortoto-left femoral and transplant renal artery 30
Repeat operation (hemorrhage) Tubulonephritis with preserved output
--
--
--
Retranstransplantation 16 months
Aorto-to-right femoral and left external lilac bypass 10 months
62
30
41
120/80
120/80
140/85
140
120
200
6 45 Membranoproliferativeglomerulonephritis Aortoiliac occlusion
7 42 Polycystosis
Aortoiliac occlusion Aortobifemoral bypass 35 Repeat operation (u reteral stenosis) Septic shock Death D4
Repeat operation for stenosis transplant renal artery 12 months 26 140/80 110
*When seen last
bypass was performed and renal revascularization was achieved by means of an anastomosis between the internal iliac artery and the renal artery of the transplant. All groups had immunosuppressor treatment during~and after renal transplantation. One patient, having undergone endarterectomy, did not receive heparin, whereas the 11 other patients had systemic heparinization at a dose of 0.5 mg/kg. Perioperative antibiotic prophylaxis was a second-generation cephalosporin used routinely for patients undergoing simple regal transplantation or for those who had a prosthetic replacement. Ureterovesical reimplantation was performed according to the technique of Lich and Gregoir [9]. Postoperatively, patients were monitored for clinical (blood pressure, urine output, palpation of the kidney), biologic (ionic balance, serum creatinine), and sonographic signs of urologic complications every three days. All patients were followed in the Nephrology Unit of Tenon Hospital (Paris, France). Doppler investigation of the aorta and lower limbs was performed every six months. Follow-up arteriograms were not obtained routinely.
RESULTS There were no postoperative deaths in Group I. Mean follow-up was 19 months (12 and 26 months). One patient had a false aneurysm in the femoral triangle, prompting an uneventful reoperation 12 months after renal transplantation. Renal function remained unchanged. In Group II, one patient died of infection. Reoperation had been necessary on the second day after operation because of postoperative stenosis of the ureterovesical anastomosis. In the immediate repeat postoperative course, an infected collection of urine was mistaken for transplant rejection. The patient died of septic shock and kidney rupture on the fourth postoperative day. The patient who underwent 30 minutes of supplementary warm ischemia was reoperated for postoperative hemorrhage due to endarterectomy suture failure and then had nonoliguric acute renal failure. A repeat transplantation was performed 16 months later. In this group of patients, mean follow-up was 40 months (26 to 62 months). Stenosis of the end-toend prosthetorenal artery anastomosis developed in one transplanted patient and was responsible for
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AORTOILIAC SURGERY AND KIDNEY TRANSPLANTATION
29
TABLE IIl.--Aortoiliac surgery in five patients who had renal transplantation (Group Ill)
Patient Age (years) Kidney disease
Indication arterial restoration Delay transplantation to arterial restoration (months) Arterial restoration Reimplantation renal artery Duration warm ischemia (rain) Late complications Duration followup (months) Blood pressure (mmHg) t Serum creatinine (mmoles/L) t
8* 44 Membranoproliferative kidney disease Aortoiliac aneurysm 84
Aortobiiliac bypass
9
10
11
12
50 Schistosomiasis
42 Polycystosis
44 Glomerulonephritis
26 Schistosomiasis
Aortoiliac aneurysm
Aortoiliac aneurysm
Aortoiliac occlusive disease 29
Post arteriography dissection 27
Aortobifemoral bypass Direct reimplantation in prosthetic limb 25
Iliofemoral bypass Reimplantation internal lilac artery
--
12
0
40
Aortobiiliac bypass Indirect reimplantation in prosthetic limb 60
--
--
--
99
12
21
Femoropopliteal bypass 12
150/90
140/80
120/80
140/90
120/80
140
100
130
130
150
--
Aortobiitiac bypass --
7
20
20
*Case already published [8] tWhen seen last
hypertension and aggravation of kidney failure. The stenosis was resected followed by end-to-end anastomosis 12 months after the initial operation. In one patient who had undergone endarterectomy, the aortoiliac lesions increased while hypertension and intermittent claudication appeared. Ten months later, an aorta-to-right femoral and left external iliac artery bypass was performed: the transplant renal artery was reimplanted directly into the prosthetic limb (Figs. 2a,b). Kidney function was normal in the three surviving patients who did not require retransplantation. There were no postoperative deaths in Group III. All patients, including the patient who had renal protection by temporary shunt, had a transient postoperative increase in serum creatinine which attained no more than twice the preoperative values. At the time of discharge, mean serum creatinine was 126 micromoles/L (100 to 140 micromoles) in all patients. Mean follow-up of patients in this group was 33 months (range 12 to 99 months). One patient underwent a femoropopliteal bypass four months after his aortoiliac procedure because of persistent intermittent claudication. Kidney function showed no major disorders at follow-up.
Fig. 1. (Patient 10) Postoperative arteriogram demonstrating aortobiiliac bypass with reimplantation of both arteries of previous kidney transplant into contralateral limb using separate grafts.
30
AORTOILIAC S U R G E R Y A N D K1DNEY T R A N S P L A N T A T I O N
Fig. 2. (Patient 5) Late deterioration in patient in whom an lilac endarterectomy had been combined with kidney transplantation. (a) Arteriogram at 10 months demonstrating stenosis of common lilac artery proximal to kidney transplant. (b) Arteriogram following aorto-to-right femoral left lilac artery with direct reimplantation of renal artery into right prosthetic limb of graft.
DISCUSSION Our series shows that both surgical problems and outcome clearly differ according to whether aortoiliac reconstruction is performed before, concomitantly, or after kidney transplantation. Kidney transplantation is possible without major difficulties in the patient with aortobiiliac or aortobifemoral prosthetic substitutes [2,10]. Because of difficulty in the dissection of the iliac vein, the renal vein may require reimplantation in another site, e.g. the vena cava, as in one of our patients. Conversely, aortoiliac restoration procedures are possible in patients with kidney transplants. No special
ANNALS OF VASCULAR SURGERY
protective measures are needed [5,6,11,12] if the duration of vascular clamping is kept to a minimum and if retrograde flow through the iliac and lumbar arteries is preserved during the aortic anastomosis. This is rather simple to achieve when the distal prosthetic anastomosis can be performed proximal to the reimplantation of the transplant renal artery. If not, the transplant renal artery has to be reimplanted. This should be performed on the prosthetic limb before completing the distal anastomosis [5]. All candidates for renal transplantation should have routine vascular work-up. This includes clinical examination and duplex Doppler-sonographic investigation of the abdominal aorta and lower limb arteries. Arteriograms and computed tomography are not requi.red in all cases, but are indispensable when concomitant restorative surgery is considered. Simultaneous renal transplantation and aortoiliac reconstruction entails an infective risk; we prefer a two-stage procedure~ The most severe complications observed in our series were those occurring when kidney transplantation was performed during the same operation as the aortoiliac procedure (Group lI). In the literature reviewed on this subject, [7,13-15], only one death due to colonic ischemia has been reported by Chapman [16]. The advantages of simultaneous surgery are obvious: the patient is hospitalized and undergoes general anesthesia only once; there are no difficulties in dissection due to reoperation; overall costs are lower. Arterial reconstruction should precede the renal transplantation in order not to prolong the warm ischemia time. However, even if experimental studies [17] have not shown that prosthetic infections are more frequent in immunosuppressed animals, the risk of septic urologic complications exists in all cases. Urologic complications have been reported to occur in 12.5 to 19% of patients after kidney transplantation [18,19]. Urinary fistulas represent 40 to 50% of these complications; ureteral stenosis is the second most frequent complication. When simultaneous surgery is performed, either electively or because arterial lesions are discovered during the operation for kidney transplantation, several procedures can be used to reduce the risk of infection. Endarterectomy or endoluminal dilatation avoids the need for prosthetic replacement and therefore the risk of septic contamination. Calcified or aneurysmal lesions, however, preclude the use of such procedures. Covering the prosthetic graft with omentum can theoretically isolate the vascular and urologic fields. When cadaver kidneys are used, the donor iliac artery can be retrieved for arterial reconstruction without having to resort to using prosthetic material [20]. Performing uretero- or pyeloureteral anastomosis [21] with the recipient ureter avoids opening the
VOI,UME 5 NO I - 1991
AORTOILIAC SURGER Y A N D K I D N E Y I R A N S P L A N T A TION
b l a d d e r , b u t this t e c h n i q u e m a y b e u s e d o n l y if v e s i c o u r e t e r a l reflux is n o t p r e s e n t . M o r e o v e r , this procedure does not always prevent septic complic a t i o n s as s o m e a u t h o r s b e l i e v e t h a t u r e t e r o u r e t e r a l anastomoses may be responsible for a greater a m o u n t o f u r i n a r y t r a c t l e a k a g e s [22]. E a r l y d i a g n o sis o f u r o l o g i c c o m p l i c a t i o n s s h o u l d p r e v e n t o n s e t o f i n f e c t i o n , w h i c h c a n b e s e v e r e in t h e i m m u n o s u p p r e s s e d p a t i e n t [18,19,23]. O r t h o t o p i c t r a n s p l a n t a t i o n [24] w i t h r e i m p l a n t a t i o n o f t h e d o n o r renal artery into the splenic artery or suprarenal a o r t a o b v i a t e s t h e n e e d to p e r f o r m s i m u l t a n e o u s arterial reconstruction for infrarenal lesions. Howe v e r , this i n c r e a s e s t h e m a g n i t u d e o f o p e r a t i o n , as initial n e p h r e c t o m y is n e c e s s a r y , a n d it d o e s n o t p r o v i d e t h e s o l u t i o n to o c c l u s i v e o r a n e u r y s m a l arterial problems which must be treated, ultimately. Two-stage surgery, with aortoiliac reconstruction p r e c e d i n g t h e k i d n e y t r a n s p l a n t a t i o n , is o c c a s i o n ally n e c e s s a r y w h e n an a o r t i c a n e u r y s m o r s e v e r e arterial occlusive disease do not permit waiting for compatible renal transplantation. This also avoids infectious complications. The recommended delay b e f o r e p e r f o r m i n g t h e k i d n e y t r a n s p l a n t is a m i n i m u m o f six w e e k s [7], b u t w e b e l i e v e t h a t t h e optimal delay should be three months.
8.
9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
REFERENCES 19,
l. LINDNER A, CHARRA B, SHERRARD DJ. et ah Accelerated atherosclerosis in prolonged maintenance hemodialysis. N Engl ,I Med 1974;290:697-701. 2. STERIOFF S, ZACHARY JB, WILLIAMS GM. Dacron vascular grafts in renal transplant patients. Am J S/~rg' 1974;/27:525-528. 3. GIBBONS GW, MADRAS PN, WHEELOCK FC, et al. Aortoiliac reconstruction following renal transplantation, Surgeo' 1982;91:435~[37. 4. HUGHES JD, MILFELD DJ. SHIELD CF. Renal trans plant peffusion during aortoiliac aneurysmectomy. ,I Vase Surg 1985;2:600-602. 5. LACOMBE M. Abdominal aortic aneurysmectomy in renal transplant patients. Ann Surg 1986;203:62-68. 6. SCHWARTZ RA, CARACCI BF, PETERSON GJ. Successful repair of a ruptured abdominal aortic aneurysm in a renal transplant recipient. Ann Vase Surg 1988;2:189-192. 7. PIQUET P, BERLAND Y, COULANGE C, et al. Aortoil-
I
20. 21. 22. 23.
24.
m
IIII
31
iac reconstruction and renal transplantation: staged or simultaneous. Ann Vasc Surg 1989;3:251-256. NUSSAUME O. COUFFINHAL JC, MOULONGUETDOLERIS L, et al. Cure d'un anevrysme de l'aorte abdominalc en amont d'un rein transplant(}. Presse Med 1983;12: 1537-1539. BRIAND O. NUSSAUME O, COHEN G, et al. R6implantation uldtdro-v6sicale: technique ddriv6e du proc6d6 de Lich et Gregoir. Nora' Presse Med 1982;11:2779-2780. AHLMEN J, HENRIKSSON C, CLAES G, et al. Successful kidney transplantation in a man with dacron "trouser" prosthesis. Scand .1 Urol Nephrol 1979;13:133-135. HARR1S JP. MAY J. Successful aortic surgery afler renal transplantation without protection of the transplanted kidney. ,f Vase Sm'o 1987:5:457~461. JIVEGARD L, BLOHME l. HOLM J, et al. Abdominal aortic reconstruction without renal bypass in renal transplant patients. Surgery 1989:106:110-113. KJELLSTRAND CM. S1MMONS RL, GOETZ FC, el al. Renal transplantation in patients with insulin-dependent diabetes. Lancet 1973:2:4-8. CERILLI J, EVANS WE. VACCARO PS. Successful simultaneous renal transplantation and abdominal aortic aneu ry smectom y. Ar{'h Sur~' 1977:112:1218-1219. GIANELLO P, SQU1FFLET JP, PONLOT R, et aI. Mise en place d'une prothese aortique et transplantation rdnale simullande. J Chit 1987:124:/57-160. CHAPMAN JR, HILSON AJW. Polycystic kidneys and abdominal aortic aneurysms. Lancet 1980;1:646-647. SWEAT JL, ALLEN CF, KWONG KH, et al. Influence of preparation and immunosuppression upon longevity of grafted aortic valves. Arch Surg, 1970:101:658-662. MUNDY AR, PODESTA ML. BEWICK M, et al. The urological complications of 1000 renal transplants. Br J U r o t 1981 ;53:397-402. CHOQUENET C. ATTIGNAC P, DUFOUR B, et al. Complications urologiques chez les transplant6s r6naux adultes. Ann Urol 1985:19:172-176. AMES SA, BOWERS VD. CORRY RJ. Arterial homograft use in an atherosclerotic renal allograft recipient. Transplant Proc 1989:21:3853-3855. GUITER J, CUENANT E. MOURAD G, et al. Le r6tablissement de la continuit~ urinaire par urdtdro-ur6tdrostomie en transplantation rdnale. J Urol 1985;9:27-32. GUERIN C. HERITIER P. LEVIGNE F, et al. Les fistules urinaires apr6s transplantation r6nale. J Urol 1990;96:73-80. WALTZER WC, WOODS JE. Z1NCKE H, et al. Urinary tract reconstruction in renal transplantation: Mayo clinic experience and review of literature. Urology 1980;16:233241. GIL-VERNET JM, G1L-VERNET A, CARALPS A, et al. Ortholopic renal transplant and results in 139 consecutive cases. J Urol 1989:142:248 252.
Between January 1980 and December 1989, we performed 407 renal transplantations. Twelve of these patients (3%) underwent aortoiliac reconstruction before (Group I, two patients), concomitant to (Group II, five patients) or after (Group III, five patients) renal transplantation. The aortoiliac lesions treated included four aneurysms and seven occlusions of the abdominal aorta and one postarteriography dissection of the iliac artery. A prosthetic graft was inserted in nine cases (75%). Endarterectomy was performed in the three other cases (25%). Four of five patients in Group III were operated on without any particular protection for the transplant. There were no postoperative deaths in Groups I and III. In Group II, one patient died of infection secondary to a urinary tract fistula. Early and late vascular morbidity (renal artery stenosis, occlusion of aortoiliac reconstruction, anastomotic false aneurysm) occurred with equal frequency in the three groups. Renal transplantation in patients having already undergone aortoiliac surgery and, conversely, aortoiliac reconstruction in the renal transplant patient, are possible without any particular technical precautions with minimal mortality and kidney morbidity. Simultaneous renal transplantation and aortoiliac reconstruction carries a significant risk of infection and a two-stage procedure should be considered in this situation. (Ann Vasc Surg 1991 ;5: 26-31). KEY WORDS: Aortoiliac surgery; abdominal aortic aneurysm; renal artery; kidney transplantation.
Aortoiliac lesions associated with end-stage renal failure are encountered with increasing frequency [1] because of extended indications for renal transplantation, more elderly patients coming to transplantation, and improved survival after transplanta-
tion. Of the possible candidates for renal transplantation, some either have aortoiliac lesions or have already been operated on for their treatment. Other patients, already transplanted, will develop aortoiliac disease. Isolated cases or small series of one of the above-mentioned associations [2-7] have been reported. We report on a series of 12 patients, among whom the three types of associations were encountered.
From the Service de Chirurgie Thoracique et Vasculaire, HOpital Rothschild, Service de N~phrolo~oie, H6pital Tenon, Paris and Service de Chirurgie Thoracique et Vasculaire, HOpital Beaujon, Clichy, France. Presented at the Annual Meeting of the SociOt~ de Chirurgie Vasculaire de Langue Franqaise, May 18-19, 1990, Nancy, France.
PATIENTS AND METHODS Between 1980 and 1989, 407 renal transplantations were performed at Beaujon Hospital (Clichy, France). Of these, 11 men and one woman under-
Reprint requests: P. Gouny, MD, Service de Chirurgie Thoracique et Vasculaire, HOpital Rothschild, 33 Boulevard de Picpus, 75012 Paris, France:
26
VOLUME 5 N o 1 - 1991
A OR TOILIA C S U R G E R Y A N1) K I D N E Y TRA N S P L A N T A T 1 0 N
TABLE I.--Kidney transplantation in two patients with previous aortoiliac revascularization (Group I) Patient No. Age (years) Kidney disease Indication for arterial restoration Arterial restoration procedure Delay between the two procedures (months) Implantation of transplant renal artery Late complications Duration survival (months) Blood pressure (mmHg*) Serum creatinine (mmoles/L)*
1 47 Hypertensive kidney disease Aortoiliac occlusive disease Aortobifemoral bypass 84
2 42 Glomerulonephritis Aortobiiliac aneurysm
Prosthetic limb
Prosthetic limb
-12
Aortobiiliac bypass 4
Femoral false aneurysm 26
120/80
140/85
130
130
*When seen last
went aortoiliac reconstruction prior to, simultaneous with, or after renal transplantation. At the time of the second procedure (renal transplantation or aortoiliac surgery), the mean age of patients was 43.5 years (range 26 to 60 years old). Four patients had an aneurysm of the abdominal aorta, seven had aortoiliac occlusive disease, and one patient had an iatrogenic (postarteriography) dissection of the lilac artery. The kidney diseases responsible for terminal kidney failure included glomerulonephritis (n 5), polycystic kidney disease (n = 3), schistosomiasis (n - 2), and hypertensive nephropathy (n - 2). Based on the date of transplantation with regard to vascular surgery, three groups of patients were designated: In Group 1 (two patients), renal transplantation was performed in patients already having undergone aortoiliac revascularization (Tablc I). One hypertensive patient had undergone arterial reconstruction by aortobifemoral prosthetic replacement seven years previously for occlusive disease. He had not yet had dialysis. Another patient, already under hemodialysis, had received an aortobiiliac prosthetic graft four months earlier for cure of an aneurysm of the abdominal aorta. In both cases, the renal artery of the transplant was implanted directly into the aortic graft. In one patient, the renal vein of the transplant was anastomosed to the interior vena cava because of difficulties encountered in the dissection of the iliac vein. In Group i1 (five patients), aortoiliac revascularization and renal transplantation were performed simultaneously (Table I1). All patients had occlu-
27
sive disease. In two cases occlusion was known before operation; arteriograms were obtained during pretransplantation workup because of antecedent claudication. Prosthetic replacement was performed prior to renal transplantation in these cases. In one patient, the renal artery of the transplant was implanted into the right limb of the aortobifemoral prosthetic graft. In the other patient, the transplant renal artery was revascularized by one of the branches of the bifurcated prosthetic graft, the other limb being used for the anastomosis with the femoral artery. In two patients, aortoiliac lesions were discovered intraoperatively. They were treated before renal transplantation by lilac endarterectomy. In these four cases, the duration of warm ischemia (20 to 35 minutes) was not longer than the time usually necessary for renal transplantation. In the last patient, the lilac lesions were initially neglected and the renal transplantation was performed first. An iliac endarterectomy was necessary because the kidney remained soft; in this case, however, the duration of warm ischemia was prolonged 30 minutes. In Group III (five patients), aortoiliac surgery was performed in patients already having undergone kidney transplantation (Table III). The interval between the renal transplantation and the aortoiliac operation was 15 months on average (seven months to seven years). In one patient, aortoiliac lesions were occlusive and responsible for intermittent claudication of the lower limbs associated with hypertension. Three patients had aneurysm of the abdominal aorta. One further patient had a dissection of the iliac artery which had been anastomosed to the transplant renal artery as a complication occurring during follow-up arteriography. All patients had normal renal function (serum creatinine less than 120 micromoles/liter) at the time of their operation on the abdominal aorta. One patient had medically stabilized hypertension due to tight stenosis of the lilac artery proximal to the implantation of the transplant renal artery. In the first patient in this series, renal protection was procured by temporary extraanatomic shunt [8]. The four other patients had simple clamping, responsible for renal ischemia lasting between 20 and 60 minutes (mean: 36 minutes). Three patients had an aortobiiliac bypass revascularizing the iliac artery proximal to the implantation of the renal transplant artery. In two of these cases, renal artery reimplantation was n o t necessary. In the other, the two renal arteries were reimplanted indirectly into one of the limbs of the prosthetic graft, one through a vein graft, the other by a prosthetic tube (Fig. 1) because of the absence of pulsations in the renal arteries of the transplant. Another patient underwent an aortobifemoral bypass with direct reimplantation of the transplant renal artery into one of the limbs of the prosthetic graft. In the last patient, an iliofemoral
28
ANNALS OF VASCULAR SURGERY
AORTOILIAC S URGER Y A N D K I D N E Y T R A N S P L A N T A T I O N
TABLE II.aConcomitant surgery (Group II) Patient Age (years) Kidney disease
Indication for arterial restoration Arterial restoration procedure Duration warm ischemia (min) Postoperative complication
Late complications
Duration survival (months) Blood pressure (mmHg)* Serum creatinine (mmoles/L)*
3 32 Membranoproliferativeglomerulonephritis lilac occlusion
4 60 Polycystosis
5 48 Hypertensive nephropathy
lilac occlusion
lilac occlusion
Endarterectomy +patch
Endarterectomy bypass
Endarterectomy bypass
30 + 30
20
25
Bifurcated aortoto-left femoral and transplant renal artery 30
Repeat operation (hemorrhage) Tubulonephritis with preserved output
--
--
--
Retranstransplantation 16 months
Aorto-to-right femoral and left external lilac bypass 10 months
62
30
41
120/80
120/80
140/85
140
120
200
6 45 Membranoproliferativeglomerulonephritis Aortoiliac occlusion
7 42 Polycystosis
Aortoiliac occlusion Aortobifemoral bypass 35 Repeat operation (u reteral stenosis) Septic shock Death D4
Repeat operation for stenosis transplant renal artery 12 months 26 140/80 110
*When seen last
bypass was performed and renal revascularization was achieved by means of an anastomosis between the internal iliac artery and the renal artery of the transplant. All groups had immunosuppressor treatment during~and after renal transplantation. One patient, having undergone endarterectomy, did not receive heparin, whereas the 11 other patients had systemic heparinization at a dose of 0.5 mg/kg. Perioperative antibiotic prophylaxis was a second-generation cephalosporin used routinely for patients undergoing simple regal transplantation or for those who had a prosthetic replacement. Ureterovesical reimplantation was performed according to the technique of Lich and Gregoir [9]. Postoperatively, patients were monitored for clinical (blood pressure, urine output, palpation of the kidney), biologic (ionic balance, serum creatinine), and sonographic signs of urologic complications every three days. All patients were followed in the Nephrology Unit of Tenon Hospital (Paris, France). Doppler investigation of the aorta and lower limbs was performed every six months. Follow-up arteriograms were not obtained routinely.
RESULTS There were no postoperative deaths in Group I. Mean follow-up was 19 months (12 and 26 months). One patient had a false aneurysm in the femoral triangle, prompting an uneventful reoperation 12 months after renal transplantation. Renal function remained unchanged. In Group II, one patient died of infection. Reoperation had been necessary on the second day after operation because of postoperative stenosis of the ureterovesical anastomosis. In the immediate repeat postoperative course, an infected collection of urine was mistaken for transplant rejection. The patient died of septic shock and kidney rupture on the fourth postoperative day. The patient who underwent 30 minutes of supplementary warm ischemia was reoperated for postoperative hemorrhage due to endarterectomy suture failure and then had nonoliguric acute renal failure. A repeat transplantation was performed 16 months later. In this group of patients, mean follow-up was 40 months (26 to 62 months). Stenosis of the end-toend prosthetorenal artery anastomosis developed in one transplanted patient and was responsible for
VOLUME 5 N o 1 - 1991
AORTOILIAC SURGERY AND KIDNEY TRANSPLANTATION
29
TABLE IIl.--Aortoiliac surgery in five patients who had renal transplantation (Group Ill)
Patient Age (years) Kidney disease
Indication arterial restoration Delay transplantation to arterial restoration (months) Arterial restoration Reimplantation renal artery Duration warm ischemia (rain) Late complications Duration followup (months) Blood pressure (mmHg) t Serum creatinine (mmoles/L) t
8* 44 Membranoproliferative kidney disease Aortoiliac aneurysm 84
Aortobiiliac bypass
9
10
11
12
50 Schistosomiasis
42 Polycystosis
44 Glomerulonephritis
26 Schistosomiasis
Aortoiliac aneurysm
Aortoiliac aneurysm
Aortoiliac occlusive disease 29
Post arteriography dissection 27
Aortobifemoral bypass Direct reimplantation in prosthetic limb 25
Iliofemoral bypass Reimplantation internal lilac artery
--
12
0
40
Aortobiiliac bypass Indirect reimplantation in prosthetic limb 60
--
--
--
99
12
21
Femoropopliteal bypass 12
150/90
140/80
120/80
140/90
120/80
140
100
130
130
150
--
Aortobiitiac bypass --
7
20
20
*Case already published [8] tWhen seen last
hypertension and aggravation of kidney failure. The stenosis was resected followed by end-to-end anastomosis 12 months after the initial operation. In one patient who had undergone endarterectomy, the aortoiliac lesions increased while hypertension and intermittent claudication appeared. Ten months later, an aorta-to-right femoral and left external iliac artery bypass was performed: the transplant renal artery was reimplanted directly into the prosthetic limb (Figs. 2a,b). Kidney function was normal in the three surviving patients who did not require retransplantation. There were no postoperative deaths in Group III. All patients, including the patient who had renal protection by temporary shunt, had a transient postoperative increase in serum creatinine which attained no more than twice the preoperative values. At the time of discharge, mean serum creatinine was 126 micromoles/L (100 to 140 micromoles) in all patients. Mean follow-up of patients in this group was 33 months (range 12 to 99 months). One patient underwent a femoropopliteal bypass four months after his aortoiliac procedure because of persistent intermittent claudication. Kidney function showed no major disorders at follow-up.
Fig. 1. (Patient 10) Postoperative arteriogram demonstrating aortobiiliac bypass with reimplantation of both arteries of previous kidney transplant into contralateral limb using separate grafts.
30
AORTOILIAC S U R G E R Y A N D K1DNEY T R A N S P L A N T A T I O N
Fig. 2. (Patient 5) Late deterioration in patient in whom an lilac endarterectomy had been combined with kidney transplantation. (a) Arteriogram at 10 months demonstrating stenosis of common lilac artery proximal to kidney transplant. (b) Arteriogram following aorto-to-right femoral left lilac artery with direct reimplantation of renal artery into right prosthetic limb of graft.
DISCUSSION Our series shows that both surgical problems and outcome clearly differ according to whether aortoiliac reconstruction is performed before, concomitantly, or after kidney transplantation. Kidney transplantation is possible without major difficulties in the patient with aortobiiliac or aortobifemoral prosthetic substitutes [2,10]. Because of difficulty in the dissection of the iliac vein, the renal vein may require reimplantation in another site, e.g. the vena cava, as in one of our patients. Conversely, aortoiliac restoration procedures are possible in patients with kidney transplants. No special
ANNALS OF VASCULAR SURGERY
protective measures are needed [5,6,11,12] if the duration of vascular clamping is kept to a minimum and if retrograde flow through the iliac and lumbar arteries is preserved during the aortic anastomosis. This is rather simple to achieve when the distal prosthetic anastomosis can be performed proximal to the reimplantation of the transplant renal artery. If not, the transplant renal artery has to be reimplanted. This should be performed on the prosthetic limb before completing the distal anastomosis [5]. All candidates for renal transplantation should have routine vascular work-up. This includes clinical examination and duplex Doppler-sonographic investigation of the abdominal aorta and lower limb arteries. Arteriograms and computed tomography are not requi.red in all cases, but are indispensable when concomitant restorative surgery is considered. Simultaneous renal transplantation and aortoiliac reconstruction entails an infective risk; we prefer a two-stage procedure~ The most severe complications observed in our series were those occurring when kidney transplantation was performed during the same operation as the aortoiliac procedure (Group lI). In the literature reviewed on this subject, [7,13-15], only one death due to colonic ischemia has been reported by Chapman [16]. The advantages of simultaneous surgery are obvious: the patient is hospitalized and undergoes general anesthesia only once; there are no difficulties in dissection due to reoperation; overall costs are lower. Arterial reconstruction should precede the renal transplantation in order not to prolong the warm ischemia time. However, even if experimental studies [17] have not shown that prosthetic infections are more frequent in immunosuppressed animals, the risk of septic urologic complications exists in all cases. Urologic complications have been reported to occur in 12.5 to 19% of patients after kidney transplantation [18,19]. Urinary fistulas represent 40 to 50% of these complications; ureteral stenosis is the second most frequent complication. When simultaneous surgery is performed, either electively or because arterial lesions are discovered during the operation for kidney transplantation, several procedures can be used to reduce the risk of infection. Endarterectomy or endoluminal dilatation avoids the need for prosthetic replacement and therefore the risk of septic contamination. Calcified or aneurysmal lesions, however, preclude the use of such procedures. Covering the prosthetic graft with omentum can theoretically isolate the vascular and urologic fields. When cadaver kidneys are used, the donor iliac artery can be retrieved for arterial reconstruction without having to resort to using prosthetic material [20]. Performing uretero- or pyeloureteral anastomosis [21] with the recipient ureter avoids opening the
VOI,UME 5 NO I - 1991
AORTOILIAC SURGER Y A N D K I D N E Y I R A N S P L A N T A TION
b l a d d e r , b u t this t e c h n i q u e m a y b e u s e d o n l y if v e s i c o u r e t e r a l reflux is n o t p r e s e n t . M o r e o v e r , this procedure does not always prevent septic complic a t i o n s as s o m e a u t h o r s b e l i e v e t h a t u r e t e r o u r e t e r a l anastomoses may be responsible for a greater a m o u n t o f u r i n a r y t r a c t l e a k a g e s [22]. E a r l y d i a g n o sis o f u r o l o g i c c o m p l i c a t i o n s s h o u l d p r e v e n t o n s e t o f i n f e c t i o n , w h i c h c a n b e s e v e r e in t h e i m m u n o s u p p r e s s e d p a t i e n t [18,19,23]. O r t h o t o p i c t r a n s p l a n t a t i o n [24] w i t h r e i m p l a n t a t i o n o f t h e d o n o r renal artery into the splenic artery or suprarenal a o r t a o b v i a t e s t h e n e e d to p e r f o r m s i m u l t a n e o u s arterial reconstruction for infrarenal lesions. Howe v e r , this i n c r e a s e s t h e m a g n i t u d e o f o p e r a t i o n , as initial n e p h r e c t o m y is n e c e s s a r y , a n d it d o e s n o t p r o v i d e t h e s o l u t i o n to o c c l u s i v e o r a n e u r y s m a l arterial problems which must be treated, ultimately. Two-stage surgery, with aortoiliac reconstruction p r e c e d i n g t h e k i d n e y t r a n s p l a n t a t i o n , is o c c a s i o n ally n e c e s s a r y w h e n an a o r t i c a n e u r y s m o r s e v e r e arterial occlusive disease do not permit waiting for compatible renal transplantation. This also avoids infectious complications. The recommended delay b e f o r e p e r f o r m i n g t h e k i d n e y t r a n s p l a n t is a m i n i m u m o f six w e e k s [7], b u t w e b e l i e v e t h a t t h e optimal delay should be three months.
8.
9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
REFERENCES 19,
l. LINDNER A, CHARRA B, SHERRARD DJ. et ah Accelerated atherosclerosis in prolonged maintenance hemodialysis. N Engl ,I Med 1974;290:697-701. 2. STERIOFF S, ZACHARY JB, WILLIAMS GM. Dacron vascular grafts in renal transplant patients. Am J S/~rg' 1974;/27:525-528. 3. GIBBONS GW, MADRAS PN, WHEELOCK FC, et al. Aortoiliac reconstruction following renal transplantation, Surgeo' 1982;91:435~[37. 4. HUGHES JD, MILFELD DJ. SHIELD CF. Renal trans plant peffusion during aortoiliac aneurysmectomy. ,I Vase Surg 1985;2:600-602. 5. LACOMBE M. Abdominal aortic aneurysmectomy in renal transplant patients. Ann Surg 1986;203:62-68. 6. SCHWARTZ RA, CARACCI BF, PETERSON GJ. Successful repair of a ruptured abdominal aortic aneurysm in a renal transplant recipient. Ann Vase Surg 1988;2:189-192. 7. PIQUET P, BERLAND Y, COULANGE C, et al. Aortoil-
I
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