Aortoiliac surgery in renal transplant patients Michel Lacombe, MD, Paris, France Fifteen patients who had undergone renal transplantation 3 months to 25 years earlier were operated on for treatment of complicated aortoiliac atherosclerosis; eight had aneurysms and seven had stenotic or obstructive lesions. Except for the first patient, operated on in 1973, in whom the kidney was protected by general hypothermia, no special measure was used to protect the kidneys. A transient increase in creatinemia occurred in 11 patients during the postoperative period, whereas creatinine values remained unchanged in the other four. All patients had regained renal function identical to the + preoperative state in less than 10 days; three of them had significant improvement as a result of correction of a lesion that was impairing renal blood flow. Results obtained in this series show that protection of the transplant during aortic surgery is not necessary, provided an adequate surgical technique is used. This technique avoids the complex methods employed in the majority of previously reported cases and appears to be a safe procedure. (J V~sc Sling 1991;13:712-8.)
An increase in the number of renal transplant recipients who will require surgical repair of atherosclerotic arteries is foreseeable. First, these patients often have accelerated atherosclerosis because of prolonged hemodialysis, arterial hypertension, and other risk factors, and arterial lesions may become progressively worse despite renal transplantation. Second, more elderly patients and patients with diabetes now undergo renal transplantation and the increasing rate of long-term successes results in survival of more recipients into later decades of life. Until now, surgical series of aortoiliac repair in renal transplant recipients were infrequent and included small numbers of patients. This article reports personal experience with 15 patients who were operated on successfully. MATERIAL AND METHODS O f a total of 1196 patients who had undergone renal transplantation in the Department of Nephrology at Necker Hospital in Paris, France, from 1959 to 1989, 15 patients between 27 and 63 years of age were operated on because of aortoiliac atherosclerotic lesions. Before being accepted as a transplant candidate, each patient who was more than 50 years old at the time the renal transplantation was considered underwent a complete vascular checkup, including ultraFrom the Consultation de Chirurgie, H6pital Beanjon, 92110 Clichy, France. Reprint requests: Prof. M. Lacombe, 49 rue Guersant, 75017 Paris, France. 24/1/27056 712
sonic scanning and Doppler velocimetry studies of the abdominal aorta and lower limb and carotid arteries, plain x-ray films of the abdomen to disclose any aortoiliac calcifications, and angiography of abdominal arteries. These investigations have been routine for about the last 10 years because of the extension of indications for transplantation to older and arteriosclerotic recipients. Patients under 50 years of age did not undergo a routine arterial check-up; nor did those operated on in the early years of our transplant experience. Data on renal transplantation are summarized in Table I according to the type of arterial lesions. The arterial lesions were diagnosed under various circumstances. In four patients, they were recognized in the pretransplant study; at that time, the lesions were clinically silent but worsened after transplantation and became symptomatic during postoperative follow-up. In four other patients, who had not had a preoperative vascular checkup, atherosclerotic arteries were found at operation; vascular investigations were performed as soon as the transplant function was stable and satisfactory. In the remaining seven patients, the lesions developed or were recognized after transplantation, either on routine clinical examination in symptom-free patients or because the occurrence of symptoms suggestive of lower limb arteriopathy prompted vascular investigations. Associated atherosclerotic lesions in other areas were found in 10 of these patients. Seven had coronary artery disease, with previous myocardial infarct in two; three had cerebrovascular accidents
Volume 13 Number 5
Aortoiliac repair after renal transplant
May 1991
713
Table I. Features of renal transplantation Patient No.
Nephropathy
Date Kidney Tx
Transplant
Immunosuppression
I. Abdominal aortic aneurysms 1 2 3 4 5 6 7 8
SFG NAS NAS CGN CIN MGN IgA NAS
9 10 11 12 13 14 15
MGN NPT CGN MGN CGN SFG SFG
1969 1981 1972 1982 1959 1974 1988 1989
LRD CK CK CK LRD CK CK CK
Azathioprine-steroids-ALS Azathiprine-steroids-ATG Azathioprine-steroids Azathioprine-steroids Total bodyirradiation Azathioprine-steroids Azathioprine-steroids-ATG-CyA Azathioprine-steroids-OKT3-CyA
CK CK CK LRD LRD CK CK
Azathioprine-steroids Azathioprine-steroids-ATG Azathioprine-steroids-cyclophosphamide Azathioprine-steroids Azathiopnne-steroids Azathioprine-steroids-ATG-CyA Azathioprine-steroids-OKT3
II. Stenotic and obstructive aortoiliac lesions 1976 1981 1973 1980 1969 1988 1988
Tx, Transplantation; SFG, segmental and focal glomerulosclerosis; NAS, nephroangiosclerosis; CGN, chronic glomerulonephritis; CIN, chronic interstitial nephritis; MGN, membranous glomerulonephritis; IgA, IgA nephropathy; NPT, nephronophthisis; LRD, living related donor; CK, cadaver kidney; ALS, antilymphocyte serum; ATG, antithymocyte globulin; CyA, cyclosporin A; OKT3, anti-human T cell monoclonal antibody.
before (two cases) or after (one case) the transplantation, with spontaneous regression of the deficits. Thirteen of the patients had arterial hypertension. All were heavy smokers. None had diabetes. The site and extent of the arterial lesions were assessed by aortography (Seldinger's technique) in 11 patients and by intra-arterial digital angiography in four. The latter examination was performed in patients who had aortic aneurysms. In other cases, aortograms with opacificarion of arteries of the lower limbs were obtained. Three patients with aortic aneurysms were also examined by ultrasonic echography before angiography and two others by computed tomography. Two types of lesion were operated on: aneurysms (eight patients) and stenotic or obstructive lesions (seven patients). Both types were atherosclerotic, and this etiologic factor was authenticated in all cases by histologic examination of the aortic wall. Four of the eight aneurysms were localized to the aorta with intact common iliac arteries, and in one of them an embolus migrated in the common iliac artery opposite the transplanted kidney. In the other four patients, the aneurysms involved the common iliac arteries in all and the internal iliac in one; reattachment of the transplant artery to the prosthesis was required in three. One aneurysm was expanding and required an emergency operation. Stenotic or obstructive lesions were often massively calcified. In five patients, they occurred in the
aorta and common iliac arteries proximal to the origin of the artery of the transplanted kidney. In three patients they were severe enough to alter renal blood flow and consequently impair renal function; in one of them, the common iliac was totally obstructed above the origin of the transplant artery and the kidney was vascularized by retrograde flow from collateral arteries only. In these five patients, arterial repair remained proximal to the transplanted kidney. In the remaining two patients, the diffuse character of the lesions required aortofemoral repair with reattachment of the transplant artery to the reconstructed iliac axis. In one patient, a malignant bladder tumor was treated secondarily by total cystectomy with cutaneous ureterostomy. Details of the surgical treatment of the patients are summarized in Table II according to the type of arterial lesion. In five patients, reimplantation of the transplant artery in the prosthesis or endarterectomized artery was necessary. In all other patients, reconstruction remained proximal to the origin of the
transplant artery. Except for the first patient in the series, who was operated on in 1973 and in whom protection of the transplant was afforded by general hypothermia, no protection of the transplanted kidney was used during aortic reconstruction in this series. Intraoperative and postoperative care included standard intravenous fluid therapy, blood loss re-
714
Journal of VASCULAR SURGERY
Lacombe
Table II. Features of aortoiliac repair
Patient No.
Years Age +
Date
posttransplant
Type of repair
Reimplantation of transplant artery
Duration of vascular Protection clampina @kidney (minurest
I. Abdominal aortic aneurysms 1
27
1973
4
2 3 4 5 6 7
52 56 46 63 37 50
1981 1982 1983 1984 1985 1988
0.3 10 1 25 11 0.4
8 61 1989 0.4 II. Stenotic and obstructive aortoifiaclesions 9 10 11 12 13 14 15
35 41 49 48 41 50 49
1978 1981 1984 1985 1987 1988 1990
2 0.9 11 5 18 0.5 1.5
Straight aortic tube
No
Aorta to both external iliac prosthesis Aorta to both common iliac prosthesis Aorta to both common iliac prosthesis Aorta to both external iliac prosthesis Aorta to both common ifiac prosthesis Aorta to left common fight external iliac prosthesis Aorta to both common iliac prosthesis Aorto-ilio-femoral endarterectomy Aortoifiac endarterectomy Aorta to both common femoral prosthesis Aorta to right common iliac prosthesis Aorta to both common iliac prosthesis Aorta to both common iliac prosthesis Aorta to both external iliac prosthesis
No Yes Yes Yes No No
General hypothermia None None None None None None
43 49 30 50 20 20
No
None
50
Yes Yes Yes No No No No
None None None None None None None
45 27 34 20 38 35 13
25
+Age at date of vascular repair.
placement, usual monitoring of renal function and cardiovascular condition, and administration of broad-spectrum antibiotics. Administration of furosemide was routine in all patients during the period of vascular clamping and after renal revascularization; continuous infusion of dopamine (doses of 3 to 8 ixg/kg/minute, depending on urinary output) was added in patients operated on since 1982; both drugs were given during the first 6 to 24 postoperative hours. Evolution of transplant function was assessed by daily measurement of blood creatinine. Immunosuppressive medication was administered intravenously until intestinal transit reappeared; it was then given orally. Postoperative digital angiography was performed in 13 patients. Because of chronic rejection with impaired renal function (which was present before operation), repeat angiography was not performed in the two remaining patients to avoid further deterioration of transplant function. Observation periods ranged from 6 months to 17 years. No patient was lost to follow-up. RESULTS Mortality No patients in the series died while hospitalized after their operations. During the long-term follow-up, four late deaths occurred after the aortic operation-two from mas-
sive myocardial infarct after 5 and 8 years, one from diffuse peritoneal metastases of a bladder tumor after I year, and one from a cerebral hemorrhage 5 months after the operation. Morbidity In one patient, embolic occlusion of the left common femoral artery by an aortic clot occurred at the end of the operation and was treated successfully with embolectomy. In another patient, abdominal wound dehiscence led to incisional hernia, which was repaired secondarily. All other patients had uneventful postoperative courses. Renal function Before the operations, nine patients had normal transplant function (blood creatinine < 1.4 mg/dl) and six had slight to moderate impairment of transplant function (1.7 mg/dl < blood creatinine < 3.1 mg/dl). During the operation, urine excretion stopped in each case during the period of vascular clamping and resumed after restoration of normal circulation to the transplant. In each patient, adequate urine output was restored by the end of the operation and remained satisfactory during the whole postoperative COurse.
Early postoperative renal function is summarized on Fig. 1 according to the preoperative level of
Volume 13 Number 5 May 1991
Aortoiliac repair after renal transplant
I
l Pre-surge~/ Normal fun~on 4.0
715
Pm-suroewY I AbnormalfunclJonJ
OI~RATION
1
3.5
~" 3.0 E
~= 2.5 .== 2.0 i
"
1.5
1.1 . . . . . . . . . . . .
....
0 -1 0 1 2 3 4 5 6 7 8 910 Time (days)
2 3 4 5
8 ....
7 8 910
Fig. 1. Early postoperative renal function after aortoiliac reconstruction. Left, Patients with preoperative normal transplant function (n = 9); right, patients with preoperative impaired
transplant function (n = 6).
transplant function. After operation, three patients had no increase in serum creatinine level; a slight increase (_
An increase in the number of renal transplant recipients who will require surgical repair of atherosclerotic arteries is foreseeable. First, these patients often have accelerated atherosclerosis because of prolonged hemodialysis, arterial hypertension, and other risk factors, and arterial lesions may become progressively worse despite renal transplantation. Second, more elderly patients and patients with diabetes now undergo renal transplantation and the increasing rate of long-term successes results in survival of more recipients into later decades of life. Until now, surgical series of aortoiliac repair in renal transplant recipients were infrequent and included small numbers of patients. This article reports personal experience with 15 patients who were operated on successfully. MATERIAL AND METHODS O f a total of 1196 patients who had undergone renal transplantation in the Department of Nephrology at Necker Hospital in Paris, France, from 1959 to 1989, 15 patients between 27 and 63 years of age were operated on because of aortoiliac atherosclerotic lesions. Before being accepted as a transplant candidate, each patient who was more than 50 years old at the time the renal transplantation was considered underwent a complete vascular checkup, including ultraFrom the Consultation de Chirurgie, H6pital Beanjon, 92110 Clichy, France. Reprint requests: Prof. M. Lacombe, 49 rue Guersant, 75017 Paris, France. 24/1/27056 712
sonic scanning and Doppler velocimetry studies of the abdominal aorta and lower limb and carotid arteries, plain x-ray films of the abdomen to disclose any aortoiliac calcifications, and angiography of abdominal arteries. These investigations have been routine for about the last 10 years because of the extension of indications for transplantation to older and arteriosclerotic recipients. Patients under 50 years of age did not undergo a routine arterial check-up; nor did those operated on in the early years of our transplant experience. Data on renal transplantation are summarized in Table I according to the type of arterial lesions. The arterial lesions were diagnosed under various circumstances. In four patients, they were recognized in the pretransplant study; at that time, the lesions were clinically silent but worsened after transplantation and became symptomatic during postoperative follow-up. In four other patients, who had not had a preoperative vascular checkup, atherosclerotic arteries were found at operation; vascular investigations were performed as soon as the transplant function was stable and satisfactory. In the remaining seven patients, the lesions developed or were recognized after transplantation, either on routine clinical examination in symptom-free patients or because the occurrence of symptoms suggestive of lower limb arteriopathy prompted vascular investigations. Associated atherosclerotic lesions in other areas were found in 10 of these patients. Seven had coronary artery disease, with previous myocardial infarct in two; three had cerebrovascular accidents
Volume 13 Number 5
Aortoiliac repair after renal transplant
May 1991
713
Table I. Features of renal transplantation Patient No.
Nephropathy
Date Kidney Tx
Transplant
Immunosuppression
I. Abdominal aortic aneurysms 1 2 3 4 5 6 7 8
SFG NAS NAS CGN CIN MGN IgA NAS
9 10 11 12 13 14 15
MGN NPT CGN MGN CGN SFG SFG
1969 1981 1972 1982 1959 1974 1988 1989
LRD CK CK CK LRD CK CK CK
Azathioprine-steroids-ALS Azathiprine-steroids-ATG Azathioprine-steroids Azathioprine-steroids Total bodyirradiation Azathioprine-steroids Azathioprine-steroids-ATG-CyA Azathioprine-steroids-OKT3-CyA
CK CK CK LRD LRD CK CK
Azathioprine-steroids Azathioprine-steroids-ATG Azathioprine-steroids-cyclophosphamide Azathioprine-steroids Azathiopnne-steroids Azathioprine-steroids-ATG-CyA Azathioprine-steroids-OKT3
II. Stenotic and obstructive aortoiliac lesions 1976 1981 1973 1980 1969 1988 1988
Tx, Transplantation; SFG, segmental and focal glomerulosclerosis; NAS, nephroangiosclerosis; CGN, chronic glomerulonephritis; CIN, chronic interstitial nephritis; MGN, membranous glomerulonephritis; IgA, IgA nephropathy; NPT, nephronophthisis; LRD, living related donor; CK, cadaver kidney; ALS, antilymphocyte serum; ATG, antithymocyte globulin; CyA, cyclosporin A; OKT3, anti-human T cell monoclonal antibody.
before (two cases) or after (one case) the transplantation, with spontaneous regression of the deficits. Thirteen of the patients had arterial hypertension. All were heavy smokers. None had diabetes. The site and extent of the arterial lesions were assessed by aortography (Seldinger's technique) in 11 patients and by intra-arterial digital angiography in four. The latter examination was performed in patients who had aortic aneurysms. In other cases, aortograms with opacificarion of arteries of the lower limbs were obtained. Three patients with aortic aneurysms were also examined by ultrasonic echography before angiography and two others by computed tomography. Two types of lesion were operated on: aneurysms (eight patients) and stenotic or obstructive lesions (seven patients). Both types were atherosclerotic, and this etiologic factor was authenticated in all cases by histologic examination of the aortic wall. Four of the eight aneurysms were localized to the aorta with intact common iliac arteries, and in one of them an embolus migrated in the common iliac artery opposite the transplanted kidney. In the other four patients, the aneurysms involved the common iliac arteries in all and the internal iliac in one; reattachment of the transplant artery to the prosthesis was required in three. One aneurysm was expanding and required an emergency operation. Stenotic or obstructive lesions were often massively calcified. In five patients, they occurred in the
aorta and common iliac arteries proximal to the origin of the artery of the transplanted kidney. In three patients they were severe enough to alter renal blood flow and consequently impair renal function; in one of them, the common iliac was totally obstructed above the origin of the transplant artery and the kidney was vascularized by retrograde flow from collateral arteries only. In these five patients, arterial repair remained proximal to the transplanted kidney. In the remaining two patients, the diffuse character of the lesions required aortofemoral repair with reattachment of the transplant artery to the reconstructed iliac axis. In one patient, a malignant bladder tumor was treated secondarily by total cystectomy with cutaneous ureterostomy. Details of the surgical treatment of the patients are summarized in Table II according to the type of arterial lesion. In five patients, reimplantation of the transplant artery in the prosthesis or endarterectomized artery was necessary. In all other patients, reconstruction remained proximal to the origin of the
transplant artery. Except for the first patient in the series, who was operated on in 1973 and in whom protection of the transplant was afforded by general hypothermia, no protection of the transplanted kidney was used during aortic reconstruction in this series. Intraoperative and postoperative care included standard intravenous fluid therapy, blood loss re-
714
Journal of VASCULAR SURGERY
Lacombe
Table II. Features of aortoiliac repair
Patient No.
Years Age +
Date
posttransplant
Type of repair
Reimplantation of transplant artery
Duration of vascular Protection clampina @kidney (minurest
I. Abdominal aortic aneurysms 1
27
1973
4
2 3 4 5 6 7
52 56 46 63 37 50
1981 1982 1983 1984 1985 1988
0.3 10 1 25 11 0.4
8 61 1989 0.4 II. Stenotic and obstructive aortoifiaclesions 9 10 11 12 13 14 15
35 41 49 48 41 50 49
1978 1981 1984 1985 1987 1988 1990
2 0.9 11 5 18 0.5 1.5
Straight aortic tube
No
Aorta to both external iliac prosthesis Aorta to both common iliac prosthesis Aorta to both common iliac prosthesis Aorta to both external iliac prosthesis Aorta to both common ifiac prosthesis Aorta to left common fight external iliac prosthesis Aorta to both common iliac prosthesis Aorto-ilio-femoral endarterectomy Aortoifiac endarterectomy Aorta to both common femoral prosthesis Aorta to right common iliac prosthesis Aorta to both common iliac prosthesis Aorta to both common iliac prosthesis Aorta to both external iliac prosthesis
No Yes Yes Yes No No
General hypothermia None None None None None None
43 49 30 50 20 20
No
None
50
Yes Yes Yes No No No No
None None None None None None None
45 27 34 20 38 35 13
25
+Age at date of vascular repair.
placement, usual monitoring of renal function and cardiovascular condition, and administration of broad-spectrum antibiotics. Administration of furosemide was routine in all patients during the period of vascular clamping and after renal revascularization; continuous infusion of dopamine (doses of 3 to 8 ixg/kg/minute, depending on urinary output) was added in patients operated on since 1982; both drugs were given during the first 6 to 24 postoperative hours. Evolution of transplant function was assessed by daily measurement of blood creatinine. Immunosuppressive medication was administered intravenously until intestinal transit reappeared; it was then given orally. Postoperative digital angiography was performed in 13 patients. Because of chronic rejection with impaired renal function (which was present before operation), repeat angiography was not performed in the two remaining patients to avoid further deterioration of transplant function. Observation periods ranged from 6 months to 17 years. No patient was lost to follow-up. RESULTS Mortality No patients in the series died while hospitalized after their operations. During the long-term follow-up, four late deaths occurred after the aortic operation-two from mas-
sive myocardial infarct after 5 and 8 years, one from diffuse peritoneal metastases of a bladder tumor after I year, and one from a cerebral hemorrhage 5 months after the operation. Morbidity In one patient, embolic occlusion of the left common femoral artery by an aortic clot occurred at the end of the operation and was treated successfully with embolectomy. In another patient, abdominal wound dehiscence led to incisional hernia, which was repaired secondarily. All other patients had uneventful postoperative courses. Renal function Before the operations, nine patients had normal transplant function (blood creatinine < 1.4 mg/dl) and six had slight to moderate impairment of transplant function (1.7 mg/dl < blood creatinine < 3.1 mg/dl). During the operation, urine excretion stopped in each case during the period of vascular clamping and resumed after restoration of normal circulation to the transplant. In each patient, adequate urine output was restored by the end of the operation and remained satisfactory during the whole postoperative COurse.
Early postoperative renal function is summarized on Fig. 1 according to the preoperative level of
Volume 13 Number 5 May 1991
Aortoiliac repair after renal transplant
I
l Pre-surge~/ Normal fun~on 4.0
715
Pm-suroewY I AbnormalfunclJonJ
OI~RATION
1
3.5
~" 3.0 E
~= 2.5 .== 2.0 i
"
1.5
1.1 . . . . . . . . . . . .
....
0 -1 0 1 2 3 4 5 6 7 8 910 Time (days)
2 3 4 5
8 ....
7 8 910
Fig. 1. Early postoperative renal function after aortoiliac reconstruction. Left, Patients with preoperative normal transplant function (n = 9); right, patients with preoperative impaired
transplant function (n = 6).
transplant function. After operation, three patients had no increase in serum creatinine level; a slight increase (_
