- Email: [email protected]
Abdominal Aortic Aneurysm Repair in Patients with Renal Allografts
Abdominal Aortic Aneurysm Repair in Patients with Renal Allografts Vikram S. Kashyap, MD, and William J. Quin˜ones-Baldrich, MD, Los Angeles, California
Aortic reconstruction is being reported in an increasing number of patients after renal transplantation as a result of improved renal graft survival and life expectancy. Aortic surgery in these patients places the pelvic allograft at risk for ischemic damage. We present two separate modalities that have been successfully used in protecting the renal transplant from prolonged warm ischemia during abdominal aortic aneurysm (AAA) repair in two cases. One technique involves an aortofemoral shunt using the perirenal aorta for proximal cannulation and the other technique utilizes an indwelling shunt through the prosthetic graft. Both patients had an uneventful recovery with no evidence of renal dysfunction and their renal function has been stable on long-term follow-up. These cases illustrate two useful alternatives in providing pulsatile perfusion to a transplanted kidney in the iliac fossa during AAA repair. They have been used successfully as simpler alternatives to temporary axillofemoral bypass or extracorporeal pump oxygenation in preventing postoperative renal dysfunction. (Ann Vase Surg 1999;13:199–203).
INTRODUCTION Renal transplantation is successful in treating increasing numbers of patients with end-stage renal disease. With long-term renal allograft and patient survival, some patients have developed aortic aneurysmal and occlusive disease necessitating operative intervention. Many of these patients are at risk for accelerated atherogenesis due to their longstanding hypertension, uremia, and other comorbid factors. Aortic reconstruction with aortic crossclamping places the renal allograft in the pelvis at risk for ischemic damage. We present two alternatives to provide pulsatile perfusion to the pelvic kidney during aortic reconstruction that are less complex than previously described adjuncts.
From the Department of Surgery, UCLA Center for the Health Sciences, Los Angeles, CA. Presented at the Sixteenth Annual Meeting of the Southern California Vascular Surgical Society, La Jolla, CA, April 24–26, 1998. Correspondence to: W.J. Quin˜ones-Baldrich, MD, Department of Surgery, UCLA Center for the Health Sciences, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA.
PATIENTS AND METHODS Case 1 A 60-year-old male underwent renal transplantation to the left iliac fossa 12 years prior to evaluation for a 6.5-cm abdominal aortic aneurysm (AAA) (Fig. 1). He had originally developed renal failure due to a combination of hypertension and the presence of a horseshoe kidney. He had undergone renal transplantation and removal of the horseshoe kidney in 1980, but the graft failed and he underwent retransplantation in 1983 with long-term graft survival. Also, the patient had significant cardiac disease and had undergone combined coronary artery bypass grafting and mitral valve replacement in 1991. Lastly, he also had undergone femoral-toperoneal bypass grafting in the left leg. The patient underwent AAA repair with a tube prosthesis and use of a temporary aortofemoral shunt. The aorta was approached through a midline incision and dissection was made through the scarred retroperitoneum. The visceral aorta was carefully dissected up to the level of the superior mesenteric artery, requiring division of a renal vein remnant. A separate left groin incision was made to 199
200
Kashyap and Quin˜ones-Baldrich
Annals of Vascular Surgery
Fig. 2. Case 1. Aortofemoral Gott shunt from the perirenal aorta to the left femoral artery allowing perfusion of the pelvic allograft and a left leg distal bypass graft (not shown) during aortic reconstruction. Note the presence of renal artery atresia facilitates placement of the aortic cannulation site.
evidence of renal dysfunction and was discharged after a 6-day hospitalization. The patient’s renal function has remained stable over a 3-year followup (Cr = 1.4 mg/dL).
Fig. 1. Case 1. MR images revealing A left pelvic renal allograft and B 6.5 cm infrarenal AAA.
expose the femoral vessels. Cannulation of the juxtarenal aorta was performed with an aortic cannula through two concentric purse-string sutures (Fig. 2). This was feasible given the renal artery atresia present due to chronic renal failure. A Gott shunt was placed into the common femoral artery using a single purse-string suture to provide pulsatile perfusion to the renal transplant and left leg distal bypass during cross-clamping. The renal allograft produced urine throughout the repair of the aneurysm with an 18-mm Dacron tube graft. The aortic cannulation site was simply closed with the pursestring suture and the femoral arteriotomy was closed with a Dacron patch. The patient had an uneventful recovery with no
Case 2 A 42-year-old male underwent treatment of a symptomatic 5-cm AAA and common iliac artery aneurysm 7 years after renal transplantation in the right iliac fossa. He suffered acute renal failure in 1983 after a hospitalization and operation for perforated appendicitis. The exact etiology of his renal failure remains obscure, but his renal function did not recover and he underwent renal transplantation in 1987. This failed because of acute rejection, he was retransplanted, and his allograft has been functioning well since. The patient had also undergone coronary artery bypass grafting in 1985 after having a myocardial infarction and congestive heart failure. An abdominal/pelvic CT scan and an angiogram (Fig. 3) were obtained for evaluation of worsening back pain, which revealed a 5-cm AAA, left common iliac artery aneurysm, and no evidence of rupture.
Vol. 13, No. 2, 1999
AAA repair of renal allografts 201
Fig. 4. Case 2. Aortic reconstruction using a bifurcated graft with an indwelling shunt through the right graft limb to provide perfusion to the pelvic allograft.
remained in the hospital 6 days. On follow-up, his renal function has remained at baseline following AAA repair (Cr = 2.0 mg/dL).
Fig. 3. Case 2. Angiogram of the aorta revealing the wellperfused right pelvic allograft and an infrarenal AAA lined with laminated thrombus. Note the renal artery atresia secondary to chronic renal failure.
DISCUSSION
The patient underwent urgent repair of the AAA using a bifurcated prosthesis and an indwelling shunt passed through the graft to maintain allograft perfusion. The aorta was exposed from the left retroperitoneal approach. Rumel tourniquets were placed around the infrarenal aorta and the right common iliac artery. An inline shunt was fashioned by placing a 20 French chest tube through the right iliac limb of the bifurcated graft into the suprarenal aorta (Fig. 4). This was then guided into the right common iliac artery and held in place with the Rumel tourniquets (Fig. 5). The proximal anastomosis was performed followed by the right iliac anastomosis with removal of the shunt just prior to completion of the right side. Blood flow was restored through the right limb of the graft while the left limb anastomosis was constructed. The patient produced urine throughout the case. The patient’s recovery was uneventful with no evidence of renal dysfunction postoperatively. He
The number of reported cases involving abdominal aortic reconstruction in the setting of a pelvic renal allograft are few in the literature. Most groups have tended to use specific maneuvers to protect the transplanted kidney from prolonged warm ischemia. A recent report from the Mayo Clinic detailed the outcome of 10 kidney transplant recipients after aortic reconstruction.1 Of the five patients undergoing abdominal aortic reconstructions, the kidney was protected with aortofemoral shunt in one patient and cold renal perfusion in three. Also, topical cooling was used in two of the patients. The remainder underwent repair of descending thoracic aortic aneurysm, thoracoabdominal aneurysm, or dissection by means of temporary atriofemoral bypass. In the whole series, nine patients survived, eight having no worsening of renal function and one patient having a transient increase in serum creatinine. The group concluded that aortic reconstruction could be safely performed in kidney transplant recipients. Furthermore, artiofemoral bypass and cold renal perfusion were protective adjuncts in
202
Kashyap and Quin˜ones-Baldrich
Fig. 5. Case 2. Indwelling shunt held in place with Rumel tourniquets during construction of the proximal and right distal anastomosis.
these patients. Other groups have also used temporary means to provide perfusion to a pelvic kidney. The use of a ‘‘double proximal clamping’’ technique and the placement of a temporary aortic shunt have been described to provide blood flow to a congenital pelvic kidney.2 This involved placing a shunt held in place with Rumel tourniquets from the body of the graft to the pelvic renal artery to provide pulsatile blood flow after the proximal anastomosis was completed. A similar process was used in a renal transplant recipient, thus decreasing but not eliminating the ischemic period.3 More complex methods of renal protection have been described, including the use of a permanent4 or temporary axillofemoral bypass graft5 and use of femorofemoral bypass with a pump oxygenator.6 Also, an interesting technique has been described in which the contralateral limb of a bifurcated graft is used to serve as a temporary aortofemoral (ipsilateral to pelvic allograft) shunt prior to completion of the
Annals of Vascular Surgery
aortoiliac anastomosis on the side of the pelvic allograft.7 Others have argued that no special protection of the transplanted kidney is necessary during aortic reconstruction. One such report described the outcome of 15 patients undergoing aortic reconstruction for aneurysmal or occlusive disease between 1973 and 1991.8 No special measure for renal protection was used in this series except for the first case where general hypothermia was utilized. Four patients had no change in their postoperative creatinine, but 11 had creatinine elevation postoperatively. The elevated creatinine levels were transient and returned to baseline within 10 days. Also, other single case reports have documented the feasibility of aortic reconstruction in renal transplant patients without overt postoperative renal failure.9,10 The debate over whether any protective measures for the transplanted kidney are needed during aortic cross-clamping is sure to continue. Despite the likelihood of an increasing experience with these type of patients, a definitive study to prove the benefit (or lack thereof) from the use of any adjunct is unlikely. However, the vulnerability of a transplanted kidney to ischemic damage is a valid concept.11 Furthermore, both of the patients in this report had lost previous renal transplants and we sought to minimize the risk to the presently wellfunctioning grafts. Lastly, we could not identify any deleterious effect of using the maneuvers detailed above. The rationale for each shunting modality deserves mention. In the first case, there was sufficient length in the perirenal aorta to allow a pursestring suture and a cannula to be placed. Furthermore, significant iliac artery calcification on the side of the transplanted kidney precluded the inline shunt (as used in the second case) modality for fear of embolizing debris to the kidney. However, in the second case, iliac artery calcification was not an issue and the inline shunt could be used. In future cases, if there are no anatomic constraints, we would prefer to use the latter modality because of its simplicity. The use of cold renal perfusion has been advocated by the Mayo group1 for renal parenchymal protection during cross-clamping. In situations where shunting native blood flow to the kidney is difficult, as in thoracoabdominal aortic reconstruction, cold renal perfusion has been shown to be beneficial in preventing postoperative renal dysfunction.12 However, utilizing the shunting techniques described above provides native, oxygenated, pulsatile blood flow to the transplanted kidney. The ischemic time witnessed by the allograft is
Vol. 13, No. 2, 1999
kept to a minimum. If these shunting techniques are contraindicated, as perhaps in a ruptured AAA, the use of cold renal perfusion for allograft protection would be preferential to no adjunct at all.
AAA repair of renal allografts 203
4.
5.
CONCLUSION These cases illustrate the feasibility of avoiding renal ischemia in patients with renal transplants during AAA repair. Both techniques are applicable to other patients with pelvic allografts because of the extra room available in the infrarenal aorta in patients with renal artery atresia from chronic renal failure. These techniques can be used in similar patients to prevent jeopardizing the function of previously placed renal allografts. REFERENCES 1. Panneton J, Gloviczki P, Canton L, et al. Aortic reconstruction in kidney transplant recipients. Ann Vasc Surg 1996; 10:97-108. 2. Schneider J, Cronenwett J. Temporary perfusion of a congenital pelvic kidney during abdominal aortic aneurysm repair. J Vasc Surg 1993;17:613-617. 3. Laborde A, Hoballah J, Sharp W, et al. A simple technique of
6.
7.
8. 9.
10.
11. 12.
renal transplant preservation during aortic reconstruction. Ann Vasc Surg 1992;6:550-552. Shons A, DeShazo C, Rattazzi L, Najarian J. Renal transplantation with blood supply by axillofemoral bypass graft. Am J Surg 1976;132:97-99. Giulini S, Maffeis R, Cangiotti L, et al. Temporary axillofemoral bypass graft for renal transplant protection during aortic aneurysm repair. J Cardiovasc Surg (Torino) 1996;37: 575-578. Wolf W, Ayisi K, Ismail M, et al. Abdominal aortic aneurysm repair after renal transplantation with extracorporeal bypass. Thorac Cardiovasc Surg 1991;39:384-385. Albers M, De Luccia N, Nahas W. Reducing cross-clamping duration in aortoiliac reconstruction after renal transplantation. A case report. Angiology 1996;47:1181-1185. Lacombe M. Aortoiliac surgery in renal transplant patients. J Vasc Surg 1991;13:712-718. Neelakandhan K, Muralidhar R, Unnikrishnan M, et al. Abdominal aortic aneurysm repair in a patient with bilateral autotransplanted kidneys. Thorac Cardiovasc Surg 1994;42: 128-130. Boudreaux J, Wolma F, Fish J. Abdominal aortic aneurysm repair after renal transplantation without extracorporeal bypass. Transplant Proc 1990;22:403-404. Finn W. Prevention of ischemic injury in renal transplantation (clinical conference). Kidney Int 1990;37:171-182. Kashyap V, Cambria R, Davison J, L’Italien G. Renal failure after thoracoabdominal aortic surgery. J Vasc Surg 1997;26: 949-957.
Aortic reconstruction is being reported in an increasing number of patients after renal transplantation as a result of improved renal graft survival and life expectancy. Aortic surgery in these patients places the pelvic allograft at risk for ischemic damage. We present two separate modalities that have been successfully used in protecting the renal transplant from prolonged warm ischemia during abdominal aortic aneurysm (AAA) repair in two cases. One technique involves an aortofemoral shunt using the perirenal aorta for proximal cannulation and the other technique utilizes an indwelling shunt through the prosthetic graft. Both patients had an uneventful recovery with no evidence of renal dysfunction and their renal function has been stable on long-term follow-up. These cases illustrate two useful alternatives in providing pulsatile perfusion to a transplanted kidney in the iliac fossa during AAA repair. They have been used successfully as simpler alternatives to temporary axillofemoral bypass or extracorporeal pump oxygenation in preventing postoperative renal dysfunction. (Ann Vase Surg 1999;13:199–203).
INTRODUCTION Renal transplantation is successful in treating increasing numbers of patients with end-stage renal disease. With long-term renal allograft and patient survival, some patients have developed aortic aneurysmal and occlusive disease necessitating operative intervention. Many of these patients are at risk for accelerated atherogenesis due to their longstanding hypertension, uremia, and other comorbid factors. Aortic reconstruction with aortic crossclamping places the renal allograft in the pelvis at risk for ischemic damage. We present two alternatives to provide pulsatile perfusion to the pelvic kidney during aortic reconstruction that are less complex than previously described adjuncts.
From the Department of Surgery, UCLA Center for the Health Sciences, Los Angeles, CA. Presented at the Sixteenth Annual Meeting of the Southern California Vascular Surgical Society, La Jolla, CA, April 24–26, 1998. Correspondence to: W.J. Quin˜ones-Baldrich, MD, Department of Surgery, UCLA Center for the Health Sciences, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA.
PATIENTS AND METHODS Case 1 A 60-year-old male underwent renal transplantation to the left iliac fossa 12 years prior to evaluation for a 6.5-cm abdominal aortic aneurysm (AAA) (Fig. 1). He had originally developed renal failure due to a combination of hypertension and the presence of a horseshoe kidney. He had undergone renal transplantation and removal of the horseshoe kidney in 1980, but the graft failed and he underwent retransplantation in 1983 with long-term graft survival. Also, the patient had significant cardiac disease and had undergone combined coronary artery bypass grafting and mitral valve replacement in 1991. Lastly, he also had undergone femoral-toperoneal bypass grafting in the left leg. The patient underwent AAA repair with a tube prosthesis and use of a temporary aortofemoral shunt. The aorta was approached through a midline incision and dissection was made through the scarred retroperitoneum. The visceral aorta was carefully dissected up to the level of the superior mesenteric artery, requiring division of a renal vein remnant. A separate left groin incision was made to 199
200
Kashyap and Quin˜ones-Baldrich
Annals of Vascular Surgery
Fig. 2. Case 1. Aortofemoral Gott shunt from the perirenal aorta to the left femoral artery allowing perfusion of the pelvic allograft and a left leg distal bypass graft (not shown) during aortic reconstruction. Note the presence of renal artery atresia facilitates placement of the aortic cannulation site.
evidence of renal dysfunction and was discharged after a 6-day hospitalization. The patient’s renal function has remained stable over a 3-year followup (Cr = 1.4 mg/dL).
Fig. 1. Case 1. MR images revealing A left pelvic renal allograft and B 6.5 cm infrarenal AAA.
expose the femoral vessels. Cannulation of the juxtarenal aorta was performed with an aortic cannula through two concentric purse-string sutures (Fig. 2). This was feasible given the renal artery atresia present due to chronic renal failure. A Gott shunt was placed into the common femoral artery using a single purse-string suture to provide pulsatile perfusion to the renal transplant and left leg distal bypass during cross-clamping. The renal allograft produced urine throughout the repair of the aneurysm with an 18-mm Dacron tube graft. The aortic cannulation site was simply closed with the pursestring suture and the femoral arteriotomy was closed with a Dacron patch. The patient had an uneventful recovery with no
Case 2 A 42-year-old male underwent treatment of a symptomatic 5-cm AAA and common iliac artery aneurysm 7 years after renal transplantation in the right iliac fossa. He suffered acute renal failure in 1983 after a hospitalization and operation for perforated appendicitis. The exact etiology of his renal failure remains obscure, but his renal function did not recover and he underwent renal transplantation in 1987. This failed because of acute rejection, he was retransplanted, and his allograft has been functioning well since. The patient had also undergone coronary artery bypass grafting in 1985 after having a myocardial infarction and congestive heart failure. An abdominal/pelvic CT scan and an angiogram (Fig. 3) were obtained for evaluation of worsening back pain, which revealed a 5-cm AAA, left common iliac artery aneurysm, and no evidence of rupture.
Vol. 13, No. 2, 1999
AAA repair of renal allografts 201
Fig. 4. Case 2. Aortic reconstruction using a bifurcated graft with an indwelling shunt through the right graft limb to provide perfusion to the pelvic allograft.
remained in the hospital 6 days. On follow-up, his renal function has remained at baseline following AAA repair (Cr = 2.0 mg/dL).
Fig. 3. Case 2. Angiogram of the aorta revealing the wellperfused right pelvic allograft and an infrarenal AAA lined with laminated thrombus. Note the renal artery atresia secondary to chronic renal failure.
DISCUSSION
The patient underwent urgent repair of the AAA using a bifurcated prosthesis and an indwelling shunt passed through the graft to maintain allograft perfusion. The aorta was exposed from the left retroperitoneal approach. Rumel tourniquets were placed around the infrarenal aorta and the right common iliac artery. An inline shunt was fashioned by placing a 20 French chest tube through the right iliac limb of the bifurcated graft into the suprarenal aorta (Fig. 4). This was then guided into the right common iliac artery and held in place with the Rumel tourniquets (Fig. 5). The proximal anastomosis was performed followed by the right iliac anastomosis with removal of the shunt just prior to completion of the right side. Blood flow was restored through the right limb of the graft while the left limb anastomosis was constructed. The patient produced urine throughout the case. The patient’s recovery was uneventful with no evidence of renal dysfunction postoperatively. He
The number of reported cases involving abdominal aortic reconstruction in the setting of a pelvic renal allograft are few in the literature. Most groups have tended to use specific maneuvers to protect the transplanted kidney from prolonged warm ischemia. A recent report from the Mayo Clinic detailed the outcome of 10 kidney transplant recipients after aortic reconstruction.1 Of the five patients undergoing abdominal aortic reconstructions, the kidney was protected with aortofemoral shunt in one patient and cold renal perfusion in three. Also, topical cooling was used in two of the patients. The remainder underwent repair of descending thoracic aortic aneurysm, thoracoabdominal aneurysm, or dissection by means of temporary atriofemoral bypass. In the whole series, nine patients survived, eight having no worsening of renal function and one patient having a transient increase in serum creatinine. The group concluded that aortic reconstruction could be safely performed in kidney transplant recipients. Furthermore, artiofemoral bypass and cold renal perfusion were protective adjuncts in
202
Kashyap and Quin˜ones-Baldrich
Fig. 5. Case 2. Indwelling shunt held in place with Rumel tourniquets during construction of the proximal and right distal anastomosis.
these patients. Other groups have also used temporary means to provide perfusion to a pelvic kidney. The use of a ‘‘double proximal clamping’’ technique and the placement of a temporary aortic shunt have been described to provide blood flow to a congenital pelvic kidney.2 This involved placing a shunt held in place with Rumel tourniquets from the body of the graft to the pelvic renal artery to provide pulsatile blood flow after the proximal anastomosis was completed. A similar process was used in a renal transplant recipient, thus decreasing but not eliminating the ischemic period.3 More complex methods of renal protection have been described, including the use of a permanent4 or temporary axillofemoral bypass graft5 and use of femorofemoral bypass with a pump oxygenator.6 Also, an interesting technique has been described in which the contralateral limb of a bifurcated graft is used to serve as a temporary aortofemoral (ipsilateral to pelvic allograft) shunt prior to completion of the
Annals of Vascular Surgery
aortoiliac anastomosis on the side of the pelvic allograft.7 Others have argued that no special protection of the transplanted kidney is necessary during aortic reconstruction. One such report described the outcome of 15 patients undergoing aortic reconstruction for aneurysmal or occlusive disease between 1973 and 1991.8 No special measure for renal protection was used in this series except for the first case where general hypothermia was utilized. Four patients had no change in their postoperative creatinine, but 11 had creatinine elevation postoperatively. The elevated creatinine levels were transient and returned to baseline within 10 days. Also, other single case reports have documented the feasibility of aortic reconstruction in renal transplant patients without overt postoperative renal failure.9,10 The debate over whether any protective measures for the transplanted kidney are needed during aortic cross-clamping is sure to continue. Despite the likelihood of an increasing experience with these type of patients, a definitive study to prove the benefit (or lack thereof) from the use of any adjunct is unlikely. However, the vulnerability of a transplanted kidney to ischemic damage is a valid concept.11 Furthermore, both of the patients in this report had lost previous renal transplants and we sought to minimize the risk to the presently wellfunctioning grafts. Lastly, we could not identify any deleterious effect of using the maneuvers detailed above. The rationale for each shunting modality deserves mention. In the first case, there was sufficient length in the perirenal aorta to allow a pursestring suture and a cannula to be placed. Furthermore, significant iliac artery calcification on the side of the transplanted kidney precluded the inline shunt (as used in the second case) modality for fear of embolizing debris to the kidney. However, in the second case, iliac artery calcification was not an issue and the inline shunt could be used. In future cases, if there are no anatomic constraints, we would prefer to use the latter modality because of its simplicity. The use of cold renal perfusion has been advocated by the Mayo group1 for renal parenchymal protection during cross-clamping. In situations where shunting native blood flow to the kidney is difficult, as in thoracoabdominal aortic reconstruction, cold renal perfusion has been shown to be beneficial in preventing postoperative renal dysfunction.12 However, utilizing the shunting techniques described above provides native, oxygenated, pulsatile blood flow to the transplanted kidney. The ischemic time witnessed by the allograft is
Vol. 13, No. 2, 1999
kept to a minimum. If these shunting techniques are contraindicated, as perhaps in a ruptured AAA, the use of cold renal perfusion for allograft protection would be preferential to no adjunct at all.
AAA repair of renal allografts 203
4.
5.
CONCLUSION These cases illustrate the feasibility of avoiding renal ischemia in patients with renal transplants during AAA repair. Both techniques are applicable to other patients with pelvic allografts because of the extra room available in the infrarenal aorta in patients with renal artery atresia from chronic renal failure. These techniques can be used in similar patients to prevent jeopardizing the function of previously placed renal allografts. REFERENCES 1. Panneton J, Gloviczki P, Canton L, et al. Aortic reconstruction in kidney transplant recipients. Ann Vasc Surg 1996; 10:97-108. 2. Schneider J, Cronenwett J. Temporary perfusion of a congenital pelvic kidney during abdominal aortic aneurysm repair. J Vasc Surg 1993;17:613-617. 3. Laborde A, Hoballah J, Sharp W, et al. A simple technique of
6.
7.
8. 9.
10.
11. 12.
renal transplant preservation during aortic reconstruction. Ann Vasc Surg 1992;6:550-552. Shons A, DeShazo C, Rattazzi L, Najarian J. Renal transplantation with blood supply by axillofemoral bypass graft. Am J Surg 1976;132:97-99. Giulini S, Maffeis R, Cangiotti L, et al. Temporary axillofemoral bypass graft for renal transplant protection during aortic aneurysm repair. J Cardiovasc Surg (Torino) 1996;37: 575-578. Wolf W, Ayisi K, Ismail M, et al. Abdominal aortic aneurysm repair after renal transplantation with extracorporeal bypass. Thorac Cardiovasc Surg 1991;39:384-385. Albers M, De Luccia N, Nahas W. Reducing cross-clamping duration in aortoiliac reconstruction after renal transplantation. A case report. Angiology 1996;47:1181-1185. Lacombe M. Aortoiliac surgery in renal transplant patients. J Vasc Surg 1991;13:712-718. Neelakandhan K, Muralidhar R, Unnikrishnan M, et al. Abdominal aortic aneurysm repair in a patient with bilateral autotransplanted kidneys. Thorac Cardiovasc Surg 1994;42: 128-130. Boudreaux J, Wolma F, Fish J. Abdominal aortic aneurysm repair after renal transplantation without extracorporeal bypass. Transplant Proc 1990;22:403-404. Finn W. Prevention of ischemic injury in renal transplantation (clinical conference). Kidney Int 1990;37:171-182. Kashyap V, Cambria R, Davison J, L’Italien G. Renal failure after thoracoabdominal aortic surgery. J Vasc Surg 1997;26: 949-957.