- Email: [email protected]
Endovascular abdominal aortic aneurysm repair in kidney transplant recipients: Case series
t h e s u r g e o n 9 ( 2 0 1 1 ) 1 1 5 e1 1 7
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Correspondence: Case report
Endovascular abdominal aortic aneurysm repair in kidney transplant recipients: Case series Sir, As the life expectancy of kidney transplant patients is increasing,1 their risk of developing an abdominal aortic aneurysm (AAA) increases. When repairing an AAA in kidney transplant patients, preserving the renal graft blood supply is critically important. Endovascular AAA repair avoids aortic cross clamping and prevents renal graft ischemia. We describe the endovascular management and outcome of AAA in three kidney transplant patients using a bifurcated aortic stent graft. One of the three cases was complicated with type I endoleak and urosepsis. The overall outcome of the three cases was successful. In this report, we describe the endovascular management and outcome of abdominal aortic aneurysm (AAA) in three kidney transplant patients. All patients had a functioning renal graft and were on immunosuppressive therapy. In two cases AAA was picked up incidentally during routine investigations, while in the remaining case the patient presented with severe abdominal pain although haemodynamically stable. All patients underwent a spiral preoperative abdominal computed
tomography (CT) scan. The three abdominal aortic aneurysms were infra-renal, did not involve the aortic bifurcation and were suitable for endovascular repair. In view of the patients’ comorbidities and CT scan findings, an endovascular repair was considered the most appropriate treatment option in the three cases. The three cases are summarized in Table 1. All patients received preoperative hydration with intravenous fluid overnight. In each patient, the main system of the stent was deployed under general anesthesia, after surgical exposure of the left common femoral artery to avoid disrupting the blood supply to the transplant kidney in the right iliac fossa. The contralateral iliac limb was positioned within the right common iliac artery above the take off point of the donor vessel for the transplant. The proximal covered part of the stent was positioned below the native renal arteries. A stent-graft balloon catheter with a 46 mm maximum diameter (Reliant) was used to mould the stent in position. Fig. 1 shows the stent position in Case 2 (the symptomatic aneurysm). The AAA repair procedures lasted on average 2 h 40 min. Despite the use of 90 mle110 ml of radiological contrast medium
Table 1 e Patients in case series. Case Age Sex
1
55
Male
2
75
Male
3
76
Male
Indication for transplant
Time from transplant to AAA repair (year)
Kidney transplant surgery secondary to hypertensive nephropathy to right iliac fossa. Kidney transplant surgery secondary to hypertensive nephropathy to right iliac fossa.
5
5.5
108
112
Uneventful 5 years follow up.
10
4.6
152
123
88
89
Complicated by type I endoleak and urosepsis. The later complication required 3 readmissions in the first 3 months follow up. Uneventful 6 months follow up thereafter. Uneventful 6 months follow up.
Kidney transplant surgery secondary to mesangioproliferative glomerulonephritis to right iliac fossa.
8
Pre-operative Pre-operative Post-operative maximum serum serum transverse creatinine creatinine diameter (mmol/L) (mmol/L) of the AAA (cm)
6
Outcome
116
t h e s u r g e o n 9 ( 2 0 1 1 ) 1 1 5 e1 1 7
aortoiliac aneurysm repair in kidney transplant patients have been reported in the literature.4 During this same period 53 cases have been reported of kidney allograft recipients patients whose aortic aneurysm were treated with open surgery.4 In the present paper we described the endovascular management and outcome of AAA in three kidney transplant patients using a bifurcated aortic stent graft. In 2009 Luis R et al. reviewed complications in the 19 reported cases of endovascular aortoiliac repair performed on kidney allograft recipients. Complications consisted of 8 endoleaks (2 type I endoleak, 5 type II endoleak and 1 type IV endoleak) and 1 case of acute leg ischemia.4 In the case of the symptomatic aneurysm described in the present paper, the post procedure period was complicated with type I endoleak and urosepsis. Although one might argue that the presenting complaint might have been secondary to urinary tract infection, clinical signs on presentation were not consistent with urosepsis. Urosepsis did not result in infection of the renal graft. All patients’ outcomes were eventually positive. Although endovascular repair of abdominal aortic aneurysm in kidney transplant patients can potentially carry some side effects such as embolization of the transplanted kidney, iliac artery damage and the use of nephrotoxic contrast, it avoids laparotomy and aortic cross clamping.
Fig. 1 e Postoperative 3-dimentional CT scan shows a deployed stent with an endoleak (arrow) and a functioning renal graft.
in each case, postoperative renal function remained stable in all patients (Table 1). Patients in two cases made an uncomplicated recovery. The symptomatic case was complicated with type I endoleak (Fig. 1) and urosepsis. The later complication necessitated three hospitals readmissions and four different intravenous antibiotic treatments. An endovascular attempt to resolve the endoleak one week after the primary intervention by positioning an aortic cuff across the proximal neck of the in situ aortic graft stent was not successful. On all readmissions, the patient’s clinical signs were consistent with bacterial infection, and his urine samples tested positive for Escherichia coli bacteria. He was treated with a succession of antibiotic treatments administered intravenously (Augmentin, Tazocin and Gentamicin, Aztreonem, and finally Meropenem 1 g three times a day over a period of 6 weeks). The patient’s vascular condition at the vicinity of the stent graft was also monitored with ultrasonography and CT scans during hospital stays. The infection was eventually curbed. The patient’s clinical follow up thereafter was uneventful. A CT angiogram six months following his last discharge confirmed an unchanged type I endoleak.
Discussion The first successful endovascular abdominal aneurysm repair was reported in 1991.2 In 1999 Lepantalo et al. reported the first endovascular repair of an aortic aneurysm in a kidney transplant patient.3 To date only 19 cases of endovascular
Conclusion Our study adds a number of cases to the limited body of evidence suggesting that endovascular approach can be considered as the first treatment option for AAA repair with functioning renal graft.
Ethical approval Not applicable to the report.
Funding source No funding received.
Conflict of interest statement The authors have no conflict of interest.
references
1. Oniscu GC, Brown H, Forsythe JL. Impact of cadaveric renal transplantation on survival in patients listed for transplantation. J Am Soc Nephrol 2005;16:1859e65. 2. Parodi JC, Plamaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysm. Ann Vasc Surg 1991;5:491e9. 3. Lepantalo M, Biancari F, Edgren J, Eklund B, Salmela K. Treatment options in the management of abdominal aortic
t h e s u r g e o n 9 ( 2 0 1 1 ) 1 1 5 e1 1 7
aneurysm in patients with renal transplants. Eur J Vasc Endovasc Surg 1999;18:176e8. 4. Leon Luis R, Glazer Evan S, Hughes John D, Bui TD, Psalms SB, Goshima KR. Aortoiliac aneurysm repair in kidney transplant recipients. Vasc Endovas Surg 2009;43:30e45.
117
121 St Stephen’s Green, Dublin 2, Republic of Ireland. Tel.: þ353 1 402 2703, þ353 87 9595693 (mobile); fax: þ353 1 402 2459. E-mail address: [email protected] (H. Hseino) Available online 15 December 2010
Hazem Hseino*, Frank McGrath, David Hickey, Arnold D.K. Hill, Daragh Moneley Division of Vascular Surgery, Department of Surgery, Beaumont Hospital, Dublin 9, Ireland *Corresponding author. Second Floor, Surgical Training, Royal College of Surgeons in Ireland,
1479-666X/$ e see front matter ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.10.006
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Correspondence: Case report
Endovascular abdominal aortic aneurysm repair in kidney transplant recipients: Case series Sir, As the life expectancy of kidney transplant patients is increasing,1 their risk of developing an abdominal aortic aneurysm (AAA) increases. When repairing an AAA in kidney transplant patients, preserving the renal graft blood supply is critically important. Endovascular AAA repair avoids aortic cross clamping and prevents renal graft ischemia. We describe the endovascular management and outcome of AAA in three kidney transplant patients using a bifurcated aortic stent graft. One of the three cases was complicated with type I endoleak and urosepsis. The overall outcome of the three cases was successful. In this report, we describe the endovascular management and outcome of abdominal aortic aneurysm (AAA) in three kidney transplant patients. All patients had a functioning renal graft and were on immunosuppressive therapy. In two cases AAA was picked up incidentally during routine investigations, while in the remaining case the patient presented with severe abdominal pain although haemodynamically stable. All patients underwent a spiral preoperative abdominal computed
tomography (CT) scan. The three abdominal aortic aneurysms were infra-renal, did not involve the aortic bifurcation and were suitable for endovascular repair. In view of the patients’ comorbidities and CT scan findings, an endovascular repair was considered the most appropriate treatment option in the three cases. The three cases are summarized in Table 1. All patients received preoperative hydration with intravenous fluid overnight. In each patient, the main system of the stent was deployed under general anesthesia, after surgical exposure of the left common femoral artery to avoid disrupting the blood supply to the transplant kidney in the right iliac fossa. The contralateral iliac limb was positioned within the right common iliac artery above the take off point of the donor vessel for the transplant. The proximal covered part of the stent was positioned below the native renal arteries. A stent-graft balloon catheter with a 46 mm maximum diameter (Reliant) was used to mould the stent in position. Fig. 1 shows the stent position in Case 2 (the symptomatic aneurysm). The AAA repair procedures lasted on average 2 h 40 min. Despite the use of 90 mle110 ml of radiological contrast medium
Table 1 e Patients in case series. Case Age Sex
1
55
Male
2
75
Male
3
76
Male
Indication for transplant
Time from transplant to AAA repair (year)
Kidney transplant surgery secondary to hypertensive nephropathy to right iliac fossa. Kidney transplant surgery secondary to hypertensive nephropathy to right iliac fossa.
5
5.5
108
112
Uneventful 5 years follow up.
10
4.6
152
123
88
89
Complicated by type I endoleak and urosepsis. The later complication required 3 readmissions in the first 3 months follow up. Uneventful 6 months follow up thereafter. Uneventful 6 months follow up.
Kidney transplant surgery secondary to mesangioproliferative glomerulonephritis to right iliac fossa.
8
Pre-operative Pre-operative Post-operative maximum serum serum transverse creatinine creatinine diameter (mmol/L) (mmol/L) of the AAA (cm)
6
Outcome
116
t h e s u r g e o n 9 ( 2 0 1 1 ) 1 1 5 e1 1 7
aortoiliac aneurysm repair in kidney transplant patients have been reported in the literature.4 During this same period 53 cases have been reported of kidney allograft recipients patients whose aortic aneurysm were treated with open surgery.4 In the present paper we described the endovascular management and outcome of AAA in three kidney transplant patients using a bifurcated aortic stent graft. In 2009 Luis R et al. reviewed complications in the 19 reported cases of endovascular aortoiliac repair performed on kidney allograft recipients. Complications consisted of 8 endoleaks (2 type I endoleak, 5 type II endoleak and 1 type IV endoleak) and 1 case of acute leg ischemia.4 In the case of the symptomatic aneurysm described in the present paper, the post procedure period was complicated with type I endoleak and urosepsis. Although one might argue that the presenting complaint might have been secondary to urinary tract infection, clinical signs on presentation were not consistent with urosepsis. Urosepsis did not result in infection of the renal graft. All patients’ outcomes were eventually positive. Although endovascular repair of abdominal aortic aneurysm in kidney transplant patients can potentially carry some side effects such as embolization of the transplanted kidney, iliac artery damage and the use of nephrotoxic contrast, it avoids laparotomy and aortic cross clamping.
Fig. 1 e Postoperative 3-dimentional CT scan shows a deployed stent with an endoleak (arrow) and a functioning renal graft.
in each case, postoperative renal function remained stable in all patients (Table 1). Patients in two cases made an uncomplicated recovery. The symptomatic case was complicated with type I endoleak (Fig. 1) and urosepsis. The later complication necessitated three hospitals readmissions and four different intravenous antibiotic treatments. An endovascular attempt to resolve the endoleak one week after the primary intervention by positioning an aortic cuff across the proximal neck of the in situ aortic graft stent was not successful. On all readmissions, the patient’s clinical signs were consistent with bacterial infection, and his urine samples tested positive for Escherichia coli bacteria. He was treated with a succession of antibiotic treatments administered intravenously (Augmentin, Tazocin and Gentamicin, Aztreonem, and finally Meropenem 1 g three times a day over a period of 6 weeks). The patient’s vascular condition at the vicinity of the stent graft was also monitored with ultrasonography and CT scans during hospital stays. The infection was eventually curbed. The patient’s clinical follow up thereafter was uneventful. A CT angiogram six months following his last discharge confirmed an unchanged type I endoleak.
Discussion The first successful endovascular abdominal aneurysm repair was reported in 1991.2 In 1999 Lepantalo et al. reported the first endovascular repair of an aortic aneurysm in a kidney transplant patient.3 To date only 19 cases of endovascular
Conclusion Our study adds a number of cases to the limited body of evidence suggesting that endovascular approach can be considered as the first treatment option for AAA repair with functioning renal graft.
Ethical approval Not applicable to the report.
Funding source No funding received.
Conflict of interest statement The authors have no conflict of interest.
references
1. Oniscu GC, Brown H, Forsythe JL. Impact of cadaveric renal transplantation on survival in patients listed for transplantation. J Am Soc Nephrol 2005;16:1859e65. 2. Parodi JC, Plamaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysm. Ann Vasc Surg 1991;5:491e9. 3. Lepantalo M, Biancari F, Edgren J, Eklund B, Salmela K. Treatment options in the management of abdominal aortic
t h e s u r g e o n 9 ( 2 0 1 1 ) 1 1 5 e1 1 7
aneurysm in patients with renal transplants. Eur J Vasc Endovasc Surg 1999;18:176e8. 4. Leon Luis R, Glazer Evan S, Hughes John D, Bui TD, Psalms SB, Goshima KR. Aortoiliac aneurysm repair in kidney transplant recipients. Vasc Endovas Surg 2009;43:30e45.
117
121 St Stephen’s Green, Dublin 2, Republic of Ireland. Tel.: þ353 1 402 2703, þ353 87 9595693 (mobile); fax: þ353 1 402 2459. E-mail address: [email protected] (H. Hseino) Available online 15 December 2010
Hazem Hseino*, Frank McGrath, David Hickey, Arnold D.K. Hill, Daragh Moneley Division of Vascular Surgery, Department of Surgery, Beaumont Hospital, Dublin 9, Ireland *Corresponding author. Second Floor, Surgical Training, Royal College of Surgeons in Ireland,
1479-666X/$ e see front matter ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.10.006