108
The pr otection of a tr an splant ed kidney during vascular reconstructive procedures pr oximal to th e graft represents a special technic al pr oblem. Wolf et al. reported on the appli cation of extracorporeal circulation by femoral cann ulation for kidn ey protection in a patient who und erwent infrarenal aortic replacement for aortic aneurysm (5). In contrast to the reported usage of extraco rpore al circulation for kidn ey graft protection , we illustrate a case in which cold in-situ-perfusi on of a transplant ed kidn ey was performed. A 57-year-old male und erw ent kidney transplantation in th e left iliac fossa for kidn ey insufficiency due to glomerulonephritis. In th e beginning of 1990 , the patient developed intermittent claudication which limited his walking distance to ab out 100 feet. The pati ent was on double immunosup pr ession using cyclosporine and prednis olone. The function of the transplanted kidn ey was unimpaired with a crea tinine of 140flmo1lL; however, uncontrolled hypertony was being treated with 4 antihypertensive dru gs includin g enalapril, nifedipin, dihydr alazine and clonidine . Digital subtraction angiography Fig. 1 revealed severe athe roscle rotic cha nges of th e infrar enal abdomina l aor ta with occlusion of th e right common iliac artery and the left external iliac artery. The left internal iliac artery showe d a 70 % stenos is pri or to the tr an splant ed kidn ey with an un impair ed renal arte ry of the kidney graft. The opera tion was planned as an aorto-bifemoral Ypr osth esis with in-situ pr otection of the tr an splanted kidney using Bretschneider's HTK-solution. With this solution, excellent gra ft pr otection in kidn ey and liver tr ansplant ation has been documented (4). Intra operatively, th e infrarenal aorta was freed and sub sequ ently th e an ast omosis of the tr ansplanted kidney dissected. Protection of th e tr an splant ed kidney consisted of 500ml HTK-solution after clamping of th e common iliac vein and incision of th e left femoral vein . Subsequently, a gelantine-covered Dacron prosthesis 14/7/7 mm was sutured to th e infrarenal aorta in an end-to-side fashion . Due to severe calcification, th is was necessar y directly und erneath both renal arteries. Following completion of this an astomosis, a second protection of th e kidney with additional 750 ml HTK-solution was given. Ther eafter, an end-to-side anas tomosis with the renal artery was perform ed and perfusion of th e transplant ed kidn ey reestablish ed . Consec utively, th e left and right anastomos is of th e Y-prosthes is in both groins was perform ed on th e pr ofunda femora l ar tery. Fifteen minut es following declamp ing of the kidney graft , diuresis restar ted with flow of 100-200 mllh. Postoperatively, a tran sient rise of the crea tinine up to 190 umol/ L and a leucocytosis of 20000/mm 2 was noted. With minimal diuretic sup port, diur esis average d 80- 160 mllh . Hypert ensi on could be controlled with a single dru g (nifedipin), and th e perfusion of the transplanted kidn ey was excellent as document ed by doppler sonography. The patient could be discharged on th e 12th postoperative day without an y sequelae after pr imar y wound healing.
Thora c. ca rdiovasc . Sur geon 40 (1992) 108 © Georg Thiem e Verl ag Stuttgart· New York
Fig. 1 DSAviewof infrarenalaortic occlusions
Comment We agree with other authors (1- 3,5) that tr ansplant ed kidneys are more sensitive to intraoperative ischemia and ther efore have to be pr otected , even if the ischemic period period should be short. In contras t to the application of extra corporea l circulation by pr otection Wolf et al.'s protection by application of extracorporea l circulation, th e in-situ perfusion with cold HTK-solution represents a mor e simpl e meth od which is appli cable even in hospitals without the facilities for extracorpore al circulation. In our opinion this method offers adequate protection and should be pr eferred for finan cial, logistic, and technical reasons. References 1
2
3
4
5
Camp ell, D. A.. M. I. Lorber. W. A. Arneson. M. N. Kirsh . 1. G. Turcotte. and J. C. Stan ley: Rena l tran splant pro tection du rin g ab do minal aneurysm ectom y with a pump -oxygenator. Surg ery 90 (1981) : 559 Gibbons. G. W . P. N. Madras. F. C. Wheelock. A. l. Sahyoun. A. P. Manoca: Aortoilia c recons tru ction following renal tr an splantation. Surge ry 91 (1982) : 435 Nuss aume, 0 ., J. C. Couffinhal, L. Moulonquet-Doleris. et al.: Cure d'un aneurysm de I'aorte abdom inale en amont d'un aein tr a nsplante. Presse Med . 12 (1983 ): 15 37 Pichlmau r, R.. H. J. Bretschneider. E. Kirchner. et al.: Ex situ Oper a tion a n der Leber. Eine neue Moglichk eit in der Leber chirurgie. Langenb ecks Arch. Chir . 37 3 (1988): 122-126 Woif. W . K. Ayisi. P. Kalmar. H. Poker , and S. Trautwein: Abdom ina l aorti c an eurysm after renal transplantation with extracorporeal bypass . Tho rac . cardiovasc. Surgeon 39 (1991) : 384- 385
U. Frank e. MD Th. Wahlers. MD Dept. of Thoraci c and Cardiovascular Surgery Hann over Medical Schoo l Konsta nty-Gutsc how-Str. 8 0-3 000 Hannover 61 Germa ny
Downloaded by: Universite Laval. Copyrighted material.
Protection of a Transplanted Kidney during Aortoiliac Reconstruction
The pr otection of a tr an splant ed kidney during vascular reconstructive procedures pr oximal to th e graft represents a special technic al pr oblem. Wolf et al. reported on the appli cation of extracorporeal circulation by femoral cann ulation for kidn ey protection in a patient who und erwent infrarenal aortic replacement for aortic aneurysm (5). In contrast to the reported usage of extraco rpore al circulation for kidn ey graft protection , we illustrate a case in which cold in-situ-perfusi on of a transplant ed kidn ey was performed. A 57-year-old male und erw ent kidney transplantation in th e left iliac fossa for kidn ey insufficiency due to glomerulonephritis. In th e beginning of 1990 , the patient developed intermittent claudication which limited his walking distance to ab out 100 feet. The pati ent was on double immunosup pr ession using cyclosporine and prednis olone. The function of the transplanted kidn ey was unimpaired with a crea tinine of 140flmo1lL; however, uncontrolled hypertony was being treated with 4 antihypertensive dru gs includin g enalapril, nifedipin, dihydr alazine and clonidine . Digital subtraction angiography Fig. 1 revealed severe athe roscle rotic cha nges of th e infrar enal abdomina l aor ta with occlusion of th e right common iliac artery and the left external iliac artery. The left internal iliac artery showe d a 70 % stenos is pri or to the tr an splant ed kidn ey with an un impair ed renal arte ry of the kidney graft. The opera tion was planned as an aorto-bifemoral Ypr osth esis with in-situ pr otection of the tr an splanted kidney using Bretschneider's HTK-solution. With this solution, excellent gra ft pr otection in kidn ey and liver tr ansplant ation has been documented (4). Intra operatively, th e infrarenal aorta was freed and sub sequ ently th e an ast omosis of the tr ansplanted kidney dissected. Protection of th e tr an splant ed kidney consisted of 500ml HTK-solution after clamping of th e common iliac vein and incision of th e left femoral vein . Subsequently, a gelantine-covered Dacron prosthesis 14/7/7 mm was sutured to th e infrarenal aorta in an end-to-side fashion . Due to severe calcification, th is was necessar y directly und erneath both renal arteries. Following completion of this an astomosis, a second protection of th e kidney with additional 750 ml HTK-solution was given. Ther eafter, an end-to-side anas tomosis with the renal artery was perform ed and perfusion of th e transplant ed kidn ey reestablish ed . Consec utively, th e left and right anastomos is of th e Y-prosthes is in both groins was perform ed on th e pr ofunda femora l ar tery. Fifteen minut es following declamp ing of the kidney graft , diuresis restar ted with flow of 100-200 mllh. Postoperatively, a tran sient rise of the crea tinine up to 190 umol/ L and a leucocytosis of 20000/mm 2 was noted. With minimal diuretic sup port, diur esis average d 80- 160 mllh . Hypert ensi on could be controlled with a single dru g (nifedipin), and th e perfusion of the transplanted kidn ey was excellent as document ed by doppler sonography. The patient could be discharged on th e 12th postoperative day without an y sequelae after pr imar y wound healing.
Thora c. ca rdiovasc . Sur geon 40 (1992) 108 © Georg Thiem e Verl ag Stuttgart· New York
Fig. 1 DSAviewof infrarenalaortic occlusions
Comment We agree with other authors (1- 3,5) that tr ansplant ed kidneys are more sensitive to intraoperative ischemia and ther efore have to be pr otected , even if the ischemic period period should be short. In contras t to the application of extra corporea l circulation by pr otection Wolf et al.'s protection by application of extracorporea l circulation, th e in-situ perfusion with cold HTK-solution represents a mor e simpl e meth od which is appli cable even in hospitals without the facilities for extracorpore al circulation. In our opinion this method offers adequate protection and should be pr eferred for finan cial, logistic, and technical reasons. References 1
2
3
4
5
Camp ell, D. A.. M. I. Lorber. W. A. Arneson. M. N. Kirsh . 1. G. Turcotte. and J. C. Stan ley: Rena l tran splant pro tection du rin g ab do minal aneurysm ectom y with a pump -oxygenator. Surg ery 90 (1981) : 559 Gibbons. G. W . P. N. Madras. F. C. Wheelock. A. l. Sahyoun. A. P. Manoca: Aortoilia c recons tru ction following renal tr an splantation. Surge ry 91 (1982) : 435 Nuss aume, 0 ., J. C. Couffinhal, L. Moulonquet-Doleris. et al.: Cure d'un aneurysm de I'aorte abdom inale en amont d'un aein tr a nsplante. Presse Med . 12 (1983 ): 15 37 Pichlmau r, R.. H. J. Bretschneider. E. Kirchner. et al.: Ex situ Oper a tion a n der Leber. Eine neue Moglichk eit in der Leber chirurgie. Langenb ecks Arch. Chir . 37 3 (1988): 122-126 Woif. W . K. Ayisi. P. Kalmar. H. Poker , and S. Trautwein: Abdom ina l aorti c an eurysm after renal transplantation with extracorporeal bypass . Tho rac . cardiovasc. Surgeon 39 (1991) : 384- 385
U. Frank e. MD Th. Wahlers. MD Dept. of Thoraci c and Cardiovascular Surgery Hann over Medical Schoo l Konsta nty-Gutsc how-Str. 8 0-3 000 Hannover 61 Germa ny
Downloaded by: Universite Laval. Copyrighted material.
Protection of a Transplanted Kidney during Aortoiliac Reconstruction
