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Abdominal Aortic Aneurysm Repair in Kidney Transplant Recipients
Abdominal Aortic Aneurysm Repair in Kidney Transplant Recipients I.S. Moon, S.C. Park, S.N. Kim, and Y.B. Koh ABSTRACT Renal transplant recipients currently survive many years with a consequent increase in the risk of presentation with vascular diseases. So aortic reconstruction in transplant patients has been increasingly reported the most common procedures involving abdominal aorta aneurysms (AAAs). The most important problem during the operation is ischemic injury to the transplanted kidney during aortic clamping. Protection for the grafted kidney from ischemic or reperfusion injury may be achieved by permanent or temporary axillo-femoral, femoro-femoral, aorto-iliac bypass, cold perfusion, local cold preservation, or autotransplantation. Some authors have reported protection of the transplanted kidney function without any other procedures. We had experience with four AAA cases in kidney transplant patients, including two cases of direct reconstruction of the AAA without any other surgical protection, one autotransplantation, and one AAA excision with using temporary aortofemoral bypass with good results. Herein, we report two cases of successful AAA excision without a surgical procedure for graft protection.
W
ITH INCREASING NUMBERS and survival of kidney transplant patients and extended graft survival, increasing numbers of patients require aortic reconstruction surgery due to abdominal aortic aneurysm (AAA). The most difficult problem is the possibility of ischemic injury to the transplanted kidney upon cessation of aortic blood flow. Irreversible ischemic injury to the transplanted kidney results in graft failure. Various prophylactic methods have been used to avoid this problem. In addition to the most common method of installation of a transient bypass between arteries, the other methods include localized hypothermia, perfusion with cold fluid, or transient kidney autotransplantation.1,2 Recently, good results have been reported with endovascular surgery.3,4 However, one publication has reported successful aortic surgery without any protection of the grafted kidney, depending only on meticulous pre- and postoperative care.5 MATERIALS AND METHODS Since 1969, the first kidney transplantation in Korea in our transplantation center, to October 2005 there have been 1500 cases of kidney transplantations performed in our center. Four patients were diagnosed with abdominal aneurysm during follow-up at the outpatient clinic (Table 1). In two of four AAA patients, we performed repair without kidney graft protection. The first case was a 46-year-old man who was diagnosed with abdominal aneurysm 4 years after kidney transplantation. Using a temporary aorta-right femoral artery bypass, aorta-bifemoral artery bypass surgery was performed. The second case was a 48-year-old man
with a 5 ⫻ 6 cm abdominal aneurysm, which occurred 6 years after transplantation. He was treated with aorta-bifemoral artery bypass surgery with perfusion of cold fluid and kidney autotransplantation. In another two cases, successful aorta-bifemoral artery bypass surgery was performed without any additional procedures to maintain renal artery flow to preserve the function of the transplanted kidney.
CASE REPORTS Case 1 A 56-year-old man received a kidney transplantation 1 year after starting hemodialysis due to diabetes mellitus. A pulsatile abdominal mass was found during follow-up in the outpatient clinic. The computed tomography (CT) images showed an 8 ⫻ 13 cm infrarenal abdominal aortic aneurysm. The grafted kidney was functioning normally. Mannitol and diuretics were used to preserve kidney function without surgical protection during AAA surgery. We performed an aorta-bifemoral artery bypass using Dacron 14-7 mm and an inferior mesenteric artery reconstruction. Total ischemic
From the Department of Surgery, Kangnam St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea. Address reprint requests to Sun Cheol Park, MD, Department of Surgery, KangNam St Mary’s Hospital, #505, Banpo Dong, Seocho Gu, Seoul, Korea 137-040. E-mail: sun60278@catholic. ac.kr
0041-1345/06/$–see front matter doi:10.1016/j.transproceed.2006.06.108
© 2006 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2022
Transplantation Proceedings, 38, 2022–2024 (2006)
ABDOMINAL AORTIC ANEURYSM REPAIR
2023
Table 1. Summary of Four Cases of Aorta Reconstruction After Renal Transplantation No.
Sex
Age (y)
Duration (y)
Size (cm)
1 2 3 4
M M F M
46 48 52 56
4 6 8 5
6⫻7 5⫻6 4 ⫻ 10 8 ⫻ 13
Operation
Aortobiiliac Aortobiiliac Aortobiiliac Aortobiiliac
bypass bypass bypass bypass
with with with with
Dacron Dacron Dacron Dacron
16-8 14-7 18-9 14-7
mm mm mm mm, IMA reimplantation
Kidney Protection
Ischemic Time (min)
Aorto-iliac bypass Cold perfusion No No
32 45 37 25
IMA,
time of the transplanted kidney was 15 minutes. There was a temporary increase in creatinine level on the first to second postoperative day, which was normalized by postoperative day 7. The patient was discharged in good condition without any complications.
Case 2 Due to recurrent pyelonephritis a 52-year-old female patient underwent kidney transplantation 3 years prior to AAA. During a follow-up study for upper gastrointestinal obstruction a 4 ⫻ 10 cm infrarenal abdominal aneurysm was observed to compress the duodenum upon CT scan. The AAA excision and aorto-bifemoral artery bypass surgery with a Dacron 14-7 mm graft was performed without additional surgical procedures. Total ischemic time was 37 minutes. There was a temporary increased in the serum creatinine for 4 days postoperatively which normalized on postoperative day 7. The patient was discharged in good condition without any significant complication.
DISCUSSION
As the number of patients receiving kidney transplantation is increasing, the lifespan of these patients has been prolonged with increased numbers of associated diseases. Many vascular disorders as well as chronic diseases, such as diabetes mellitus and hypertension, coexist in these patients. Abdominal aneurysm and peripheral obstructive vascular disease are common among transplant patients who have had their lives significantly prolonged. This observation has been attributed to the rapid progression of atherosclerosis caused by prolonged hypertension, uremic syndrome, and other chronic diseases.1 It is inevitable to cause some degree of kidney graft ischemic injury during surgical treatment of the aorta. Prolonged ischemic injury to the graft may result in kidney failure. Many methods have been reported to solve the problems with ischemia during a vascular operation, including permanent6 or transient axillo-femoral artery bypass,7 femoro-femoral artery bypass surgery, or aorta-iliac artery bypass.8,9 Recently, Forbes et al10 and Abab et al11 had successfully treated abdominal aortic aneurysms while preserving the function of the transplanted kidney with endovascular surgery.12 Theoretically, the kidney is not influenced by blood flow blockade of approximately 30 minutes. Harris et al,13 Gouny et al,14 and Lacombe15 have reported good results without surgical interventions to preserve kidney function. Walberg and others16 have emphasized that the most important risk factor predisposing to kidney ischemic damage is the time of clamping of the aorta proximal to the
renal artery. In addition, the function of the kidney prior to surgery (creatinine levels above 1.25 mg/dL) and hypotension during operation (systolic blood pressure below 70 mmHg for more than 10 minutes) have been reported to have an influence on ischemic damage. So the prompt release of the aortic clamp at less than 60 minutes is most important. In the our cases described above, kidney function was preserved by quick anastomoses without any additional operative protection, using aorta clamp times of 25 and 37 minutes. Thus, the function of the transplanted kidney was successfully maintained by reducing the ischemia time to less than 60 minutes. There were temporary increases in serum creatinine levels during the second and third postoperative days. However, it returned to normal within a week, and the patient was discharged without any particular complications. It is possible to prevent ischemic damage to the kidney without additional operative protections, during operation for abdominal aneurysm in kidney transplantation, by adequate and thorough preoperative and postoperative care. The most important factor in preventing ischemic damage to the kidney is minimizing the aortic clamp time.
REFERENCES 1. Kashyap VS, Quinones-Baldrich WJ: Abdominal aortic aneurysm repair in patients with renal allografts. Ann Vasc Surg 13:199, 1999 2. Chacko KN, Ninan S, Jacob CK, et al: Transplant kidney protection during aortic aneurysm surgery. J Urol 161:891, 1999 3. Forbes TL, DeRose G, Kribs S, et al: Endovascular repair of abdominal aortic aneurysm with coexisting renal allograft: case report and literature review. Ann Vasc Surg 15:586, 2001 4. Abad C, Maynar M, De Blas M, et al: Endovascular repair of abdominal aortic aneurysm in a renal transplant patient. J Cardiovasc Surg (Torino) 41:915, 2000 5. Boudreaux JP, Wolma FL, Fish JC: Abdominal aortic aneurysm repair after renal transplantation without extracorporeal bypass. Transplant Proc 22:403, 1990 6. Shons A, DeShazo C, Rattazzi L, et al: Renal transplantation with blood supply by axillofemoral bypass graft. Am J Surg 132:97, 1976 7. Giulini S, Maffeis R, Cangiotti L: Temporary axillo-femoral bypass graft for renal transplant protection during aortic aneurysm repair. J Cardiovasc Surg (Torino) 37:575, 1996 8. Wolf W, Ayisi K, Ismail M: Abdominal aortic aneurysm repair after renal transplantation with extracorporeal bypass. Thoracic and Cardiovascular Surgery 39:384, 1991
2024 9. Albers M, De Luccia N, Nahas W: Reducing cross-clamping duration in aortoiliac reconstruction after renal transplantation. A case report. Angiology 47:1181, 1996 10. Forbes TL, DeRose G, Kribs S, et al: Endovascular repair of abdominal aortic aneurysm with coexisting renal allograft: case report and literature review. Ann Vasc Surg 15:586, 2001 11. Abad C, Maynar M, DeBlas M, et al: Endovascular repair of abdominal aortic aneurysm in a renal transplant patient. J Cardiovasc Surg 41:915, 2000 12. Panneton J, Gloviczki P, Canton L: Aortic reconstruction in kidney transplant recipients. Ann Vasc Surg 10:97, 1996
MOON, PARK, KIM ET AL 13. Harris JP, May J: Successful aortic surgery after renal transplantation without protection of the transplanted kidney. J Vasc Surg 5:457, 1987 14. Gouny P, Lenot B, Decaix B, et al: Aortioiliac surgery and kidney transplantation. Ann Vasc Surg 5:21, 1991 15. Lacombe M: Aortoiliac surgery in renal transplant patients. J Vasc Surg 13:712, 1991 16. Wahlberg E, DiMuzio PJ, Stoney RJ: Aortic clamping during elective operations for infrarenal disease: the influence of clamping time on renal function. J Vasc Surg 36:13, 2002
W
ITH INCREASING NUMBERS and survival of kidney transplant patients and extended graft survival, increasing numbers of patients require aortic reconstruction surgery due to abdominal aortic aneurysm (AAA). The most difficult problem is the possibility of ischemic injury to the transplanted kidney upon cessation of aortic blood flow. Irreversible ischemic injury to the transplanted kidney results in graft failure. Various prophylactic methods have been used to avoid this problem. In addition to the most common method of installation of a transient bypass between arteries, the other methods include localized hypothermia, perfusion with cold fluid, or transient kidney autotransplantation.1,2 Recently, good results have been reported with endovascular surgery.3,4 However, one publication has reported successful aortic surgery without any protection of the grafted kidney, depending only on meticulous pre- and postoperative care.5 MATERIALS AND METHODS Since 1969, the first kidney transplantation in Korea in our transplantation center, to October 2005 there have been 1500 cases of kidney transplantations performed in our center. Four patients were diagnosed with abdominal aneurysm during follow-up at the outpatient clinic (Table 1). In two of four AAA patients, we performed repair without kidney graft protection. The first case was a 46-year-old man who was diagnosed with abdominal aneurysm 4 years after kidney transplantation. Using a temporary aorta-right femoral artery bypass, aorta-bifemoral artery bypass surgery was performed. The second case was a 48-year-old man
with a 5 ⫻ 6 cm abdominal aneurysm, which occurred 6 years after transplantation. He was treated with aorta-bifemoral artery bypass surgery with perfusion of cold fluid and kidney autotransplantation. In another two cases, successful aorta-bifemoral artery bypass surgery was performed without any additional procedures to maintain renal artery flow to preserve the function of the transplanted kidney.
CASE REPORTS Case 1 A 56-year-old man received a kidney transplantation 1 year after starting hemodialysis due to diabetes mellitus. A pulsatile abdominal mass was found during follow-up in the outpatient clinic. The computed tomography (CT) images showed an 8 ⫻ 13 cm infrarenal abdominal aortic aneurysm. The grafted kidney was functioning normally. Mannitol and diuretics were used to preserve kidney function without surgical protection during AAA surgery. We performed an aorta-bifemoral artery bypass using Dacron 14-7 mm and an inferior mesenteric artery reconstruction. Total ischemic
From the Department of Surgery, Kangnam St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea. Address reprint requests to Sun Cheol Park, MD, Department of Surgery, KangNam St Mary’s Hospital, #505, Banpo Dong, Seocho Gu, Seoul, Korea 137-040. E-mail: sun60278@catholic. ac.kr
0041-1345/06/$–see front matter doi:10.1016/j.transproceed.2006.06.108
© 2006 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2022
Transplantation Proceedings, 38, 2022–2024 (2006)
ABDOMINAL AORTIC ANEURYSM REPAIR
2023
Table 1. Summary of Four Cases of Aorta Reconstruction After Renal Transplantation No.
Sex
Age (y)
Duration (y)
Size (cm)
1 2 3 4
M M F M
46 48 52 56
4 6 8 5
6⫻7 5⫻6 4 ⫻ 10 8 ⫻ 13
Operation
Aortobiiliac Aortobiiliac Aortobiiliac Aortobiiliac
bypass bypass bypass bypass
with with with with
Dacron Dacron Dacron Dacron
16-8 14-7 18-9 14-7
mm mm mm mm, IMA reimplantation
Kidney Protection
Ischemic Time (min)
Aorto-iliac bypass Cold perfusion No No
32 45 37 25
IMA,
time of the transplanted kidney was 15 minutes. There was a temporary increase in creatinine level on the first to second postoperative day, which was normalized by postoperative day 7. The patient was discharged in good condition without any complications.
Case 2 Due to recurrent pyelonephritis a 52-year-old female patient underwent kidney transplantation 3 years prior to AAA. During a follow-up study for upper gastrointestinal obstruction a 4 ⫻ 10 cm infrarenal abdominal aneurysm was observed to compress the duodenum upon CT scan. The AAA excision and aorto-bifemoral artery bypass surgery with a Dacron 14-7 mm graft was performed without additional surgical procedures. Total ischemic time was 37 minutes. There was a temporary increased in the serum creatinine for 4 days postoperatively which normalized on postoperative day 7. The patient was discharged in good condition without any significant complication.
DISCUSSION
As the number of patients receiving kidney transplantation is increasing, the lifespan of these patients has been prolonged with increased numbers of associated diseases. Many vascular disorders as well as chronic diseases, such as diabetes mellitus and hypertension, coexist in these patients. Abdominal aneurysm and peripheral obstructive vascular disease are common among transplant patients who have had their lives significantly prolonged. This observation has been attributed to the rapid progression of atherosclerosis caused by prolonged hypertension, uremic syndrome, and other chronic diseases.1 It is inevitable to cause some degree of kidney graft ischemic injury during surgical treatment of the aorta. Prolonged ischemic injury to the graft may result in kidney failure. Many methods have been reported to solve the problems with ischemia during a vascular operation, including permanent6 or transient axillo-femoral artery bypass,7 femoro-femoral artery bypass surgery, or aorta-iliac artery bypass.8,9 Recently, Forbes et al10 and Abab et al11 had successfully treated abdominal aortic aneurysms while preserving the function of the transplanted kidney with endovascular surgery.12 Theoretically, the kidney is not influenced by blood flow blockade of approximately 30 minutes. Harris et al,13 Gouny et al,14 and Lacombe15 have reported good results without surgical interventions to preserve kidney function. Walberg and others16 have emphasized that the most important risk factor predisposing to kidney ischemic damage is the time of clamping of the aorta proximal to the
renal artery. In addition, the function of the kidney prior to surgery (creatinine levels above 1.25 mg/dL) and hypotension during operation (systolic blood pressure below 70 mmHg for more than 10 minutes) have been reported to have an influence on ischemic damage. So the prompt release of the aortic clamp at less than 60 minutes is most important. In the our cases described above, kidney function was preserved by quick anastomoses without any additional operative protection, using aorta clamp times of 25 and 37 minutes. Thus, the function of the transplanted kidney was successfully maintained by reducing the ischemia time to less than 60 minutes. There were temporary increases in serum creatinine levels during the second and third postoperative days. However, it returned to normal within a week, and the patient was discharged without any particular complications. It is possible to prevent ischemic damage to the kidney without additional operative protections, during operation for abdominal aneurysm in kidney transplantation, by adequate and thorough preoperative and postoperative care. The most important factor in preventing ischemic damage to the kidney is minimizing the aortic clamp time.
REFERENCES 1. Kashyap VS, Quinones-Baldrich WJ: Abdominal aortic aneurysm repair in patients with renal allografts. Ann Vasc Surg 13:199, 1999 2. Chacko KN, Ninan S, Jacob CK, et al: Transplant kidney protection during aortic aneurysm surgery. J Urol 161:891, 1999 3. Forbes TL, DeRose G, Kribs S, et al: Endovascular repair of abdominal aortic aneurysm with coexisting renal allograft: case report and literature review. Ann Vasc Surg 15:586, 2001 4. Abad C, Maynar M, De Blas M, et al: Endovascular repair of abdominal aortic aneurysm in a renal transplant patient. J Cardiovasc Surg (Torino) 41:915, 2000 5. Boudreaux JP, Wolma FL, Fish JC: Abdominal aortic aneurysm repair after renal transplantation without extracorporeal bypass. Transplant Proc 22:403, 1990 6. Shons A, DeShazo C, Rattazzi L, et al: Renal transplantation with blood supply by axillofemoral bypass graft. Am J Surg 132:97, 1976 7. Giulini S, Maffeis R, Cangiotti L: Temporary axillo-femoral bypass graft for renal transplant protection during aortic aneurysm repair. J Cardiovasc Surg (Torino) 37:575, 1996 8. Wolf W, Ayisi K, Ismail M: Abdominal aortic aneurysm repair after renal transplantation with extracorporeal bypass. Thoracic and Cardiovascular Surgery 39:384, 1991
2024 9. Albers M, De Luccia N, Nahas W: Reducing cross-clamping duration in aortoiliac reconstruction after renal transplantation. A case report. Angiology 47:1181, 1996 10. Forbes TL, DeRose G, Kribs S, et al: Endovascular repair of abdominal aortic aneurysm with coexisting renal allograft: case report and literature review. Ann Vasc Surg 15:586, 2001 11. Abad C, Maynar M, DeBlas M, et al: Endovascular repair of abdominal aortic aneurysm in a renal transplant patient. J Cardiovasc Surg 41:915, 2000 12. Panneton J, Gloviczki P, Canton L: Aortic reconstruction in kidney transplant recipients. Ann Vasc Surg 10:97, 1996
MOON, PARK, KIM ET AL 13. Harris JP, May J: Successful aortic surgery after renal transplantation without protection of the transplanted kidney. J Vasc Surg 5:457, 1987 14. Gouny P, Lenot B, Decaix B, et al: Aortioiliac surgery and kidney transplantation. Ann Vasc Surg 5:21, 1991 15. Lacombe M: Aortoiliac surgery in renal transplant patients. J Vasc Surg 13:712, 1991 16. Wahlberg E, DiMuzio PJ, Stoney RJ: Aortic clamping during elective operations for infrarenal disease: the influence of clamping time on renal function. J Vasc Surg 36:13, 2002