Abdominal Aortic Aneurysm Repair in Patient with a Renal Allograft: A Case Report

Abstract

Renal transplant recipients requiring aortic reconstruction due to abdominal aortic aneurysm (AAA) pose a unique clinical problem. The concern during surgery is causing ischemic injury to the renal allograft. A variety of strategies for protection of the renal allograft during AAA intervention have been described including a temporary shunt, cold renal perfusion, extracorporeal bypass, general hypothermia, and endovascular stent-grafting. In addition, some investigators have reported no remarkable complications of the renal allograft without any specific measures. We treated a case of AAA in a patient with a renal allograft using a temporary aortofemoral shunt with good result. Since this technique is safe and effective, it should be considered in similar patients with AAA and previously placed renal allografts.

Hybrid Percutaneous Brachiofemoral Shunt and Open Abdominal Aortic Aneurysm Repair in a Kidney Transplant Recipient

“…The AAA in a kidney-transplanted patient requires surgical management and is truly a life-threatening condition and has a more complicated repair. The transplanted kidney has a solitary arterial supply and lacks collateral circulation, so it is more susceptible to ischemic injury, so aortic cross-clamping may put the renal allograft at risk for ischemic damage [ 11 ]. If the period of aortic cross-clamping in open surgery is less than 50 min, slight protection may be needed and a clamp and go method could be done [ 6 ].…”

“…A different renal protecting mechanism could be the endovascular repair. The benefit is that the allograft ischemia is limited to a short time that the graft is ballooned into place, but the disadvantages are the emboli to the kidney from dislodged atherosclerotic debris during the procedure as well as the risk of contrast-induced nephropathy [ 7 , 11 ].…”

Emergency Endovascular Repair in a Patient With Abdominal Aortic Aneurysm With Pelvic Transplant Kidneys: Case Report

“…Emergency endovascular repair has the theoretical advantage of minimizing interruption of the blood flow within the artery of the renal allograft, whose ischemic time is limited to the time that the aortic graft is ballooned into place. 7 Moreover, further potential advantages of EVAR include selecting the side for the main body deployment of the aortic graft, 12 and a significant reduction in surgical stress on the patient when compared to open surgery. 8 On the other hand, EVAR requires injection of contrast media, which may stimulate contrast-induced nephropathy, especially if the renal functional reserve is limited (as can occur in renal transplant recipients).…”

“…6 Consequently, transplant patients show higher rates of AAA ruptures, which carry a high risk of death for 2 reasons: (1) the impairment of the immune surveillance deriving from life-long immunosuppression (which significantly increases preoperative morbidity and mortality) and (2); the risk for surgery-related ischemic injury to the renal graft owing to a solitary arterial supply and lack of collateral circulation. 7 When rupture does occur, emergency surgery should aim not only at providing effective aortic replacement but also, at minimizing ischemic damage to avoid deterioration of renal function and graft loss. To reduce the ischemic time of the renal graft in course of open surgery (namely, the traditional approach), several methods have been described.…”

Endovascular abdominal aortic aneurysm repair in patients with renal transplant

“…Conventional open repair of AAA in these patients requires ischemia-protecting procedures for transplanted kidney such as a temporary axillo-femoral bypass, aortoiliac shunt, aorto-femoral shunt, atrio-femoral bypass, femorofemoral bypass with extracorporeal circulation, topical cooling, and cold perfusion of the graft [1,2]. …”