- Email: [email protected]
Axillofemoral Bypass for Kidney Transplant Protection during Open Repair of Abdominal Aortic Aneurysm
Accepted Manuscript Axillo femoral bypass for kidney transplant protection during open repair of abdominal aortic aneurysm Antoine Monnot, Martin Rouer, Julien Horion, Didier Plissonnier PII:
S0890-5096(15)00303-9
DOI:
10.1016/j.avsg.2015.04.058
Reference:
AVSG 2337
To appear in:
Annals of Vascular Surgery
Received Date: 21 December 2014 Revised Date:
29 January 2015
Accepted Date: 30 April 2015
Please cite this article as: Monnot A, Rouer M, Horion J, Plissonnier D, Axillo femoral bypass for kidney transplant protection during open repair of abdominal aortic aneurysm, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.04.058. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Axillo femoral bypass for kidney transplant protection during open repair of abdominal aortic aneurysm.
RI PT
Monnot Antoine, Rouer Martin, Horion Julien, Plissonnier Didier Departments of Vascular Surgery and Radiology, Rouen University Hospital, France
SC
CORRESPONDING AUTHOR :
Rouen University Hospital
M AN U
D Plissonnier
1 rue de Germont – 76031 Rouen Cedex - France
DISCLOSURE:
TE D
[email protected]
AC C
EP
The authors declare no conflicts of interest.
ACCEPTED MANUSCRIPT
ABBREVIATIONS AAA : Abdominal aortic aneurysm
AC C
EP
TE D
M AN U
SC
RI PT
EVAR: Endovascular aortic repair
ACCEPTED MANUSCRIPT
ABSTRACT The need to treat an abdominal aortic aneurysm (AAA) in kidney transplanted patient is a rare
RI PT
event. To date, no method in order to protect the kidney during the aneurysm treatment has been identified as undeniably relevant. On the other hand, the advantage of endovascular treatment of the aneurysm (EVAR) is to avoid transplanted kidney injury. Unfortunately,
SC
EVAR is not always available leading to open repair and then aortic cross clamping. We
report here 3 cases of AAA open repair in kidney transplanted patients using a temporary
AC C
EP
TE D
M AN U
axillofemoral bypass in order to protect the renal function.
ACCEPTED MANUSCRIPT
INTRODUCTION Aortic cross clamping during surgical abdominal aortic aneurysm (AAA) repair jeopardize kidney transplanted patients renal function1. Various protective methods2 have been described
RI PT
to avoid this problem: perfusion with cold solution, temporary aorto or axillo-femoral bypasses, femoro-femoral bypass with a pump oxygenator and lately axillofemoral shunt with a biopump3. On the other hand Endovascular4 (EVAR) approach lower the ischemic kidney
SC
insult, therefore being a gold standard. Unfortunately AAA are not always eligible for this treatment. We hereby report 3 cases of AAA open repair using axillo femoral shunt to protect
M AN U
the kidney transplant.
CASE REPORT
TE D
These cases were referred to our department during the last decade. The first patient was a 66 years old male with kidney transplant for 37 years secondary to IGA nephropathy. The second patient was a 53 years old woman with kidney transplant for ten years. She developed end
EP
stage renal disease secondary to autosomal dominant polycystic kidney disease. Both evolution were similar: AAA were diagnosed during follow up until the diameter was
AC C
measured at the surgical threshold of 55mm. The third patient was a 59 years old male patient suffering from focal and segmental glomerulosclerosis. He had a living donor patient kidney transplantation. He had a 35 mm infrarenal abdominal aortic aneurysm before the transplantation and 2 years after, the AAA diameter increased by 15 mm. We first sought to treat them by EVAR. Because of anatomic issues, all of them were outside IFUs balancing to the surgical solution. Moreover, two of them had extended calcifications increasing the risk of kidney tranplant artery embolisation.
ACCEPTED MANUSCRIPT
In each case, a right axillo femoral shunt (Dacron 8 mm) was externally performed in order to maintain a retrograde kidney blood perfusion during upper aortic cross clamping. The systolic iliac artery blood pressure was maintained to a minimum of 75 mmHg. The aorta was repaired
RI PT
using an aorto bi-iliac bypass. Eventually, axillar and the femoral arteries were repaired by direct suture. In these 3 cases, post operative creatinin sera level remained constant. Patients
SC
were discharged at day 8.
DISCUSSION
M AN U
Nowadays there is no consensus about kidney transplant management during open AAA repair. Without renal ischemia aortic cross clamping induced, EVAR seems to be a good alternative.
Yet one of the drawbacks is the prevalent presence of major iliac arteries calcifications among
TE D
on dialysis patients. Stent graft deployment is often unappropriated due to distal embolisation risk in the transplanted renal artery. When direct aortic approach is required in these cases, 2,5
to avoid renal ischemia: temporary axillo-femoral or
EP
surgeons can use different processes
aorto-femoral bypasses, renal perfusion or local cooling of the kidney, femoro-femoral bypass
AC C
with a pump oxygenator and lately axillofemoral shunt with biopump3. We chose temporary axillo-femoral bypass. Advantages were low dose of heparin, acceptable cost and efficient warm pulsating perfusion. But operating time increased, with the risk of damaging axillar and femoral arteries.
However, Lacombe6 validated the use of the clamp and go technique considering that residual blood pressure of 25mmHg in the iliac artery prevented kideny ischemic damage. On the other hand, Lindenman et al7 recently published the rapid AAA evolution leading to
ACCEPTED MANUSCRIPT rupture in a transplanted patient. In correlation, Cron et al8 reported a faster AAA growth rate in tranplanted patients. Hence, the first-line treatment might be the treatment of small AAA
RI PT
before kidney grafts, thus avoiding transplanted kidney damages.
REFERENCES
1. Godier S, Dusseaux MM, David N et al. Intraoperative Factors Affecting Renal Outcome
M AN U
SC
After Open Repair of Suprarenal Aortic Aneurysms. Ann Vasc Surg 2012 ; 26(7):913-7
2. Sadat U, Huguet E.L, Varty K. Abdominal Aortic Aneurysm Surgery in Renal, Cardiac and Hepatic Transplant Recipients. Eur J Vasc Endovasc Surg 2010; 40: 443-449.
TE D
3. Rizzo AR, Sirignano P, Capoccia L et al. Technical Adjunct for Abdominal Aortic Aneurysm Repair in Patient with Renal Transplant. Ann Vasc Surg 2014; 28: 1790.e1–
EP
1790.e3
4. Okuma S, Fujii T, Sasaki Y et al. Endovascular abdominal aortic aneurysm repair in
30.
AC C
patients with renal transplants: reports of two cases. Ann thorac cardiovasc surg 2013, Aug
5. Moon IS, Park SC, Kim SN et al. Abdominal aortic aneurysm repair in kidney transplant recipients. Transplant Proc 2006; 38: 2022-4.
6. Lacombe M. Abdominal aortic aneurysmectomy in renal transplant patients. Ann Surg
ACCEPTED MANUSCRIPT 1986; 203: 62-68.
7. Lindeman JH, Rabelink TJ, Van Bockel JH. Immunosuppression and the Abdominal Aortic
RI PT
Aneurysm Doctor Jekyll or Mister Hyde? Circulation. 2011; 124: e463-5.
SC
8. Cron DC, Coleman DM, Sheetz KH et al. Aneurysms in abdominal organ transplant
M AN U
recipients. J Vasc surg. 2014; 59: 594-8
Legend to the Figure 1 Figure 1-A
The small diameter of the aortic bifurcation associated to arterial wall calcification were not in favour
Figure 1-B
TE D
of an EVAR.
AC C
EP
In the same way of figure 1-A, iliac arteries calcifications drove us to AAA open repair.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Figure 1-A
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Figure 1-B
S0890-5096(15)00303-9
DOI:
10.1016/j.avsg.2015.04.058
Reference:
AVSG 2337
To appear in:
Annals of Vascular Surgery
Received Date: 21 December 2014 Revised Date:
29 January 2015
Accepted Date: 30 April 2015
Please cite this article as: Monnot A, Rouer M, Horion J, Plissonnier D, Axillo femoral bypass for kidney transplant protection during open repair of abdominal aortic aneurysm, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.04.058. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Axillo femoral bypass for kidney transplant protection during open repair of abdominal aortic aneurysm.
RI PT
Monnot Antoine, Rouer Martin, Horion Julien, Plissonnier Didier Departments of Vascular Surgery and Radiology, Rouen University Hospital, France
SC
CORRESPONDING AUTHOR :
Rouen University Hospital
M AN U
D Plissonnier
1 rue de Germont – 76031 Rouen Cedex - France
DISCLOSURE:
TE D
[email protected]
AC C
EP
The authors declare no conflicts of interest.
ACCEPTED MANUSCRIPT
ABBREVIATIONS AAA : Abdominal aortic aneurysm
AC C
EP
TE D
M AN U
SC
RI PT
EVAR: Endovascular aortic repair
ACCEPTED MANUSCRIPT
ABSTRACT The need to treat an abdominal aortic aneurysm (AAA) in kidney transplanted patient is a rare
RI PT
event. To date, no method in order to protect the kidney during the aneurysm treatment has been identified as undeniably relevant. On the other hand, the advantage of endovascular treatment of the aneurysm (EVAR) is to avoid transplanted kidney injury. Unfortunately,
SC
EVAR is not always available leading to open repair and then aortic cross clamping. We
report here 3 cases of AAA open repair in kidney transplanted patients using a temporary
AC C
EP
TE D
M AN U
axillofemoral bypass in order to protect the renal function.
ACCEPTED MANUSCRIPT
INTRODUCTION Aortic cross clamping during surgical abdominal aortic aneurysm (AAA) repair jeopardize kidney transplanted patients renal function1. Various protective methods2 have been described
RI PT
to avoid this problem: perfusion with cold solution, temporary aorto or axillo-femoral bypasses, femoro-femoral bypass with a pump oxygenator and lately axillofemoral shunt with a biopump3. On the other hand Endovascular4 (EVAR) approach lower the ischemic kidney
SC
insult, therefore being a gold standard. Unfortunately AAA are not always eligible for this treatment. We hereby report 3 cases of AAA open repair using axillo femoral shunt to protect
M AN U
the kidney transplant.
CASE REPORT
TE D
These cases were referred to our department during the last decade. The first patient was a 66 years old male with kidney transplant for 37 years secondary to IGA nephropathy. The second patient was a 53 years old woman with kidney transplant for ten years. She developed end
EP
stage renal disease secondary to autosomal dominant polycystic kidney disease. Both evolution were similar: AAA were diagnosed during follow up until the diameter was
AC C
measured at the surgical threshold of 55mm. The third patient was a 59 years old male patient suffering from focal and segmental glomerulosclerosis. He had a living donor patient kidney transplantation. He had a 35 mm infrarenal abdominal aortic aneurysm before the transplantation and 2 years after, the AAA diameter increased by 15 mm. We first sought to treat them by EVAR. Because of anatomic issues, all of them were outside IFUs balancing to the surgical solution. Moreover, two of them had extended calcifications increasing the risk of kidney tranplant artery embolisation.
ACCEPTED MANUSCRIPT
In each case, a right axillo femoral shunt (Dacron 8 mm) was externally performed in order to maintain a retrograde kidney blood perfusion during upper aortic cross clamping. The systolic iliac artery blood pressure was maintained to a minimum of 75 mmHg. The aorta was repaired
RI PT
using an aorto bi-iliac bypass. Eventually, axillar and the femoral arteries were repaired by direct suture. In these 3 cases, post operative creatinin sera level remained constant. Patients
SC
were discharged at day 8.
DISCUSSION
M AN U
Nowadays there is no consensus about kidney transplant management during open AAA repair. Without renal ischemia aortic cross clamping induced, EVAR seems to be a good alternative.
Yet one of the drawbacks is the prevalent presence of major iliac arteries calcifications among
TE D
on dialysis patients. Stent graft deployment is often unappropriated due to distal embolisation risk in the transplanted renal artery. When direct aortic approach is required in these cases, 2,5
to avoid renal ischemia: temporary axillo-femoral or
EP
surgeons can use different processes
aorto-femoral bypasses, renal perfusion or local cooling of the kidney, femoro-femoral bypass
AC C
with a pump oxygenator and lately axillofemoral shunt with biopump3. We chose temporary axillo-femoral bypass. Advantages were low dose of heparin, acceptable cost and efficient warm pulsating perfusion. But operating time increased, with the risk of damaging axillar and femoral arteries.
However, Lacombe6 validated the use of the clamp and go technique considering that residual blood pressure of 25mmHg in the iliac artery prevented kideny ischemic damage. On the other hand, Lindenman et al7 recently published the rapid AAA evolution leading to
ACCEPTED MANUSCRIPT rupture in a transplanted patient. In correlation, Cron et al8 reported a faster AAA growth rate in tranplanted patients. Hence, the first-line treatment might be the treatment of small AAA
RI PT
before kidney grafts, thus avoiding transplanted kidney damages.
REFERENCES
1. Godier S, Dusseaux MM, David N et al. Intraoperative Factors Affecting Renal Outcome
M AN U
SC
After Open Repair of Suprarenal Aortic Aneurysms. Ann Vasc Surg 2012 ; 26(7):913-7
2. Sadat U, Huguet E.L, Varty K. Abdominal Aortic Aneurysm Surgery in Renal, Cardiac and Hepatic Transplant Recipients. Eur J Vasc Endovasc Surg 2010; 40: 443-449.
TE D
3. Rizzo AR, Sirignano P, Capoccia L et al. Technical Adjunct for Abdominal Aortic Aneurysm Repair in Patient with Renal Transplant. Ann Vasc Surg 2014; 28: 1790.e1–
EP
1790.e3
4. Okuma S, Fujii T, Sasaki Y et al. Endovascular abdominal aortic aneurysm repair in
30.
AC C
patients with renal transplants: reports of two cases. Ann thorac cardiovasc surg 2013, Aug
5. Moon IS, Park SC, Kim SN et al. Abdominal aortic aneurysm repair in kidney transplant recipients. Transplant Proc 2006; 38: 2022-4.
6. Lacombe M. Abdominal aortic aneurysmectomy in renal transplant patients. Ann Surg
ACCEPTED MANUSCRIPT 1986; 203: 62-68.
7. Lindeman JH, Rabelink TJ, Van Bockel JH. Immunosuppression and the Abdominal Aortic
RI PT
Aneurysm Doctor Jekyll or Mister Hyde? Circulation. 2011; 124: e463-5.
SC
8. Cron DC, Coleman DM, Sheetz KH et al. Aneurysms in abdominal organ transplant
M AN U
recipients. J Vasc surg. 2014; 59: 594-8
Legend to the Figure 1 Figure 1-A
The small diameter of the aortic bifurcation associated to arterial wall calcification were not in favour
Figure 1-B
TE D
of an EVAR.
AC C
EP
In the same way of figure 1-A, iliac arteries calcifications drove us to AAA open repair.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Figure 1-A
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Figure 1-B