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Endovascular Repair of Abdominal Aortic Aneurysm with Coexisting Renal Allograft: Case Report and Literature Review
Endovascular Repair of Abdominal Aortic Aneurysm with Coexisting Renal Allograft: Case Report and Literature Review Thomas L. Forbes, MD, FRCSC,1 Guy DeRose, MD, FRCSC, FACS,1 Stewart Kribs, MD, FRCPC,2 Cherrie Z. Abraham, MD, FRCSC,1 and Kenneth A. Harris, MD, FRCSC, FACS,1 London, Canada
The coexistence of an abdominal aortic aneurysm (AAA) and a pelvic renal allograft is a unique clinical situation. Because of the increased susceptibility of the transplant kidney to ischemic injury, various approaches have been developed to minimize allograft ischemia during open aneurysm repair. Endovascular techniques have the potential advantage in this situation of greatly diminishing renal ischemia time. To our knowledge, this approach has not been reported in this situation. We report a case of a 61-year-old male with a 7.0-cm AAA and a functioning right pelvic transplant kidney. There was an adequate aneurysm neck below the level of the superior mesenteric artery with occluded renal arteries. Successful endovascular repair of the aneurysm was achieved using a bifurcated graft and bilateral iliac extensions. Perfusion to the renal allograft was maintained throughout the procedure except for short periods when the graft was expanded with a balloon. Short-term follow-up reveals successful aneurysm exclusion and no deterioration in renal function. This exciting new approach to this challenging clinical problem is reviewed along with other methods of minimizing renal allograft ischemia.
The presentation of an abdominal aortic aneurysm (AAA) in patients with a renal allograft is becoming more common with the improved outcomes after kidney transplantation. There are several reports of standard open repair of these aneurysms in the presence of a functioning renal allograft. Because of the recognized susceptibility of the transplant kidney to ischemic injury,1 various techniques have 1 Division of Vascular Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada. 2 Department of Radiology, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada.
Correspondence to: T.L. Forbes, MD, Division of Vascular Surgery, London Health Sciences Centre, University of Western Ontario, 375 South Street., Suite N380, London, Ontario, Canada, N6A 4G5, E-mail: [email protected]. Ann Vasc Surg 2001; 15: 586-590 DOI: 10.1007/s10016-001-0018-7 © Annals of Vascular Surgery Inc. Published online: August 23, 2001 586
been developed to minimize allograft ischemia during standard aneurysm repair. These include the use of temporary shunts,2-7 extracorporeal bypass,8 cold renal perfusion,9,10 or general hypothermia11 and alterations in open surgical technique.12 There are also reports of successful aneurysm repair without any adjunctive renal protective measures.13 With the development of endovascular techniques,14 aortic aneurysms can be repaired without aortic clamping and the risk of distal ischemia. This has definite advantages in the presence of a pelvic renal allograft. Although endovascular repair of an aortic aneurysm in a patient with a congenital solitary pelvic kidney has been reported,15 to our knowledge, there are no published reports of endovascular aneurysm repair in the presence of a pelvic transplanted kidney. We report our experience with successful endovascular aortic aneurysm repair with a functioning pelvic renal allograft receiv-
Vol. 15, No. 5, 2001
Fig. 1. Preoperative contrast-enhanced CT scan of the 7-cm AAA.
Case reports 587
Fig. 2. Preoperative aortogram showing the occluded left renal artery and a small right renal artery.
ing its arterial supply from the right external iliac artery.
CASE REPORT A 61-year-old male presented with a 7.0-cm asymptomatic AAA and a history of chronic renal failure secondary to hypertensive nephropathy. Nine years previously he had undergone a cadaveric right pelvic kidney transplant with the arterial supply originating from the right external iliac artery. The patient was taking appropriate immunosuppressants and his preoperative creatinine was 181 µmol/L. A preoperative computed tomography (CT) scan and aortogram revealed an infrarenal aneurysm involving both common iliac arteries (Figs. 1 and 2). The arterial supply to the transplanted kidney originated from the right external iliac artery well distal to the right common iliac bifurcation (Figs. 3 and 4). The endovascular repair took place in the operating room, under general anaesthesia. Bilateral femoral artery dissections were performed and a catheter positioned via the right common femoral artery marked the position of the superior mesenteric artery (SMA). Arteriotomies were made after anticoagulation with intravenous heparinization. There were no attempts at pharmacologic renal protection. The aortouniliac component of a 30 × 16-mm standard bifurcated Talent graft was introduced via the left common femoral artery and deployed with the bare metal stent at the level of the renal artery orifices. A 16-mm left iliac extension was placed to land in the distal common iliac artery. The right limb of the graft and a 16-mm iliac extension were inserted in a retrograde
Fig. 3. Preoperative contrast-enhanced CT scan showing the pelvic renal allograft.
fashion from the right common femoral artery such that the graft terminated in the distal common iliac artery. Proximal and distal fixation sites were secured by balloon fixation. Completion aortogram revealed good proximal fixation with perfusion of the SMA (Fig. 5) and excellent
588
Case reports
Fig. 4. Preoperative aortogram showing the renal allograft with its arterial supply from the right external iliac artery.
perfusion of the renal allograft in the right iliac fossa (Fig. 6). On delayed films there was faint filling of the aneurysm sac from patent lumbar arteries. This type II endoleak had resolved on the CT exams at 2 days and 1 month postoperatively. There were no complications and the patient was discharged home on the fourth postoperative day. He continued to do well and his creatinine level 1 month after aneurysm repair was 188 µmol/L.
DISCUSSION Given the solitary arterial supply and lack of collateralization of renal allografts, these allografts are more susceptible to ischemic injury than native kidneys. When a pelvic transplanted kidney exists with an aortic aneurysm, clamping of the aneurysm neck is always suprarenal. In this case, endovascular repair has the distinct advantage of limiting allograft ischemia to those short periods when the graft is being ballooned in place. Possible disadvantages of endovascular repair with a pelvic renal allograft include emboli to the kidney from dislodged atherosclerotic debris during device placement and manipulation. This should be no more common than atheroemboli to the lower extremities during endovascular repair of other aortic aneurysms, the occurrence of which, in our experience, is rare (2.5%). In the case described here, the aortouniliac component of the device, with the larger delivery
Annals of Vascular Surgery
system, was placed via the femoral artery contralateral to the renal allograft. The smaller uniliac limb was inserted through the ipsilateral artery. This potentially reduces the risk of direct trauma to the transplant arterial anastomosis and of embolization from the donor external iliac artery. The risk of contrast-induced nephropathy is also minimized by limiting contrast volume (70 cc of Omnipaque 350) and maintaining adequate hydration. Currently, there is insufficient evidence to support the use of pharmacologic protective measures to prevent contrast-induced nephropathy.16 Although various intraoperative techniques have been used to minimize allograft ischemia with standard repair, there are several reports of successful repair without adjunctive renal protective measures. Harris and May described a series of four patients who underwent aortic surgery without any allograft protective measures.13 No serious complications resulted, although half of the patients had a transient rise in serum creatinine levels in the early postoperative period. Hypothermia via both cold renal perfusion9,10 and external cooling11 has been used in an attempt to decrease the risk of ischemic injury. Nghiem and Lee described successful aneurysm repair using direct iliac artery perfusion with Ringer’s lactate cooled to 4°C.10 Panneton et al. described the Mayo Clinic experience with five patients undergoing elective infrarenal AAA repair.9 Three of the transplanted kidneys received cold perfusion while two were also exposed to topical cooling. They concluded that these patients do well with cold renal perfusion with or without topical cooling of the renal allograft. The most obvious method of protecting a renal allograft from an ischemic insult is to maintain perfusion during aneurysm repair. A variety of techniques have been described, including femoralfemoral bypass with a pump oxygenator. Wolf et al. described this method of maintaining renal perfusion during aortic cross-clamping.8 Perfusion pressure was maintained at 60-80 mmHg with a flow of 600-1000 mL/min during 40 min of aortic clamping. Temporary bypass procedures have also been deployed to maintain renal perfusion during standard aneurysm repair. Retrograde allograft perfusion has been successfully used in this setting via a temporary axillofemoral bypass graft.4 The supraceliac or proximal abdominal aorta has also been used as inflow for temporary bypasses to the common iliac artery,7 the external iliac artery,2 and the femoral artery6 to perfuse a pelvic transplant kidney during successful aneurysm repair. Temporary shunting procedures have also been reported.
Vol. 15, No. 5, 2001
Case reports 589
Fig. 5. Proximal fixation site of the bifurcated endovascular graft.
Fig. 6. Distal fixation site of the bifurcated endovascular graft showing preservation of renal allograft perfusion.
Kashyap and Quin˜ones-Baldrich described the use of two shunting procedures in patients with aneurysms and pelvic renal allografts deriving their arterial supply from the internal iliac artery.3 In the first patient, the juxtarenal aorta and the ipsilateral common femoral artery were exposed and cannulated with a shunt through purse-string sutures. In the second patient, an in-line shunt was fashioned by placing a chest tube through the ipsilateral limb of a bifurcated graft into the suprarenal aorta. It was secured in place by Rumel tourniquets around the infrarenal aorta and the ipsilateral common iliac artery. In both cases, the renal allograft produced urine during aneurysm repair and there were no adverse sequelae. Laborde et al. described a similar technique using a Pruitt-Inahara shunt.5 Following completion of the proximal anastomosis, the body of the graft is punctured, proximal to a clamp on the graft, and the shunt is inserted into the body of the graft and through the orifice of the ipsilateral iliac artery. With this technique, the allograft ischemia time is limited to the duration of the proximal anastomosis. Several variations of standard aneurysm repair
without the use of shunts or bypasses have been described. Lacombe has reported the largest series, consisting of 15 patients with pelvic renal allografts operated on for aneurysms (8 patients) or aortoiliac occlusive disease (7 patients).12 In the presence of an aneurysm the aortic neck is divided between two clamps and the proximal anastomosis is performed. Partial renal allograft perfusion is maintained via back-bleeding from the lumbar arteries, the inferior mesenteric artery, and the iliac arteries. Full allograft revascularization is achieved by anastomosis of the graft to the ipsilateral iliac artery or by reimplantation of the allograft artery into the graft. Intraoperative furosemide and dopamine were used routinely in this series. There were no permanent deteriorations in renal function.
CONCLUSIONS With improving outcomes after kidney transplantation, the occurrence of an aneurysm in these patients will become a more frequent clinical scenario. Many centers have had some experience with standard repair of these aneurysms. There is no stan-
590
Case reports
dard published renal protective protocol for aneurysm repair in transplant patients. Endovascular repair obviates the need for further renal protective measures, as the allograft ischemia time is limited to the brief time that the graft is ballooned into place. It is important to minimize contrast load and to avoid excessive manipulation of the donor artery during graft positioning and deployment. We have shown that endovascular repair of an AAA is a safe and useful technique in the presence of a functioning pelvic renal allograft. REFERENCES 1. Finn W. Prevention of ischemic injury in renal transplantation. Kidney Int 1990;37:171-182. 2. Sparks SR, Chock A, Seslar S, Bergan JJ, Owens EL. Surgical treatment of Takayasu’s arteritis: case report and literature review. Ann Vasc Surg 2000;14:125-129. 3. Kashyap VS, Quin˜ones-Baldrich WJ. Abdominal aortic aneurysm repair in patients with renal allografts. Ann Vasc Surg 1999;13:199-203. 4. Giulini SM, Maffeis R, Cangiotti L, Bonardelli S, Bertolini G, Caratozzolo E. Temporary axillo-femoral bypass graft for renal transplant protection during aortic aneurysm repair. J Cardiovasc Surg (Torino) 1996;37:575-578. 5. Laborde AL, Hoballah JJ, Sharp WJ, Kresowik TF, Corson JD. A simple technique of renal transplant preservation during aortic reconstruction. Ann Vasc Surg 1992;6:550-552.
Annals of Vascular Surgery
6. O’Mara CS, Flinn WR, Bergan JJ, Yao JS. Use of a temporary shunt for renal transplant protection during aortic aneurysm repair. Surgery 1983;94:512-515. 7. Sterioff S, Parks L. Temporary vascular bypass for perfusion of a renal transplant during abdominal aneurysmectomy. Surgery 1977;82:558-560. 8. Wolf W, Ayisi K, Ismail M, Kalmar P, Pokar H, Trautwein S. Abdominal aortic aneurysm repair after renal transplantation with extra corporeal bypass. Thorac Cardiovasc Surg 1991;39:384-385. 9. Panneton JM, Gloviczki P, Canton LG, et al. Aortic reconstruction in kidney transplant recipients. Ann Vasc Surg 1996;10:97-108. 10. Nghiem DD, Lee HM. In situ hypothermic preservation of a renal allograft during resection of abdominal aortic aneurysm. Am Surg 1982;48:237-238. 11. Chacko KN, Ninan S, Jacob CK, Korula R. Transplant kidney protection during aortic aneurysm surgery. J Urol 1999; 161:891-892. 12. Lacombe M. Aortoiliac surgery in renal transplant patients. J Vasc Surg 1991;13:712-718. 13. Harris JP, May J. Successful aortic surgery after renal transplantation without protection of the transplanted kidney. J Vasc Surg 1987;5:457-461. 14. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491-499. 15. Kaplan DB, Kwon CC, Marin ML, Hollier LH. Endovascular repair of abdominal aortic aneurysms in patients with congenital renal vascular anomalies. J Vasc Surg 1999;30:407416. 16. Oliveira DB. Prophylaxis against contrast-induced nephropathy. Lancet 1999;15:1638-1639.
The coexistence of an abdominal aortic aneurysm (AAA) and a pelvic renal allograft is a unique clinical situation. Because of the increased susceptibility of the transplant kidney to ischemic injury, various approaches have been developed to minimize allograft ischemia during open aneurysm repair. Endovascular techniques have the potential advantage in this situation of greatly diminishing renal ischemia time. To our knowledge, this approach has not been reported in this situation. We report a case of a 61-year-old male with a 7.0-cm AAA and a functioning right pelvic transplant kidney. There was an adequate aneurysm neck below the level of the superior mesenteric artery with occluded renal arteries. Successful endovascular repair of the aneurysm was achieved using a bifurcated graft and bilateral iliac extensions. Perfusion to the renal allograft was maintained throughout the procedure except for short periods when the graft was expanded with a balloon. Short-term follow-up reveals successful aneurysm exclusion and no deterioration in renal function. This exciting new approach to this challenging clinical problem is reviewed along with other methods of minimizing renal allograft ischemia.
The presentation of an abdominal aortic aneurysm (AAA) in patients with a renal allograft is becoming more common with the improved outcomes after kidney transplantation. There are several reports of standard open repair of these aneurysms in the presence of a functioning renal allograft. Because of the recognized susceptibility of the transplant kidney to ischemic injury,1 various techniques have 1 Division of Vascular Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada. 2 Department of Radiology, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada.
Correspondence to: T.L. Forbes, MD, Division of Vascular Surgery, London Health Sciences Centre, University of Western Ontario, 375 South Street., Suite N380, London, Ontario, Canada, N6A 4G5, E-mail: [email protected]. Ann Vasc Surg 2001; 15: 586-590 DOI: 10.1007/s10016-001-0018-7 © Annals of Vascular Surgery Inc. Published online: August 23, 2001 586
been developed to minimize allograft ischemia during standard aneurysm repair. These include the use of temporary shunts,2-7 extracorporeal bypass,8 cold renal perfusion,9,10 or general hypothermia11 and alterations in open surgical technique.12 There are also reports of successful aneurysm repair without any adjunctive renal protective measures.13 With the development of endovascular techniques,14 aortic aneurysms can be repaired without aortic clamping and the risk of distal ischemia. This has definite advantages in the presence of a pelvic renal allograft. Although endovascular repair of an aortic aneurysm in a patient with a congenital solitary pelvic kidney has been reported,15 to our knowledge, there are no published reports of endovascular aneurysm repair in the presence of a pelvic transplanted kidney. We report our experience with successful endovascular aortic aneurysm repair with a functioning pelvic renal allograft receiv-
Vol. 15, No. 5, 2001
Fig. 1. Preoperative contrast-enhanced CT scan of the 7-cm AAA.
Case reports 587
Fig. 2. Preoperative aortogram showing the occluded left renal artery and a small right renal artery.
ing its arterial supply from the right external iliac artery.
CASE REPORT A 61-year-old male presented with a 7.0-cm asymptomatic AAA and a history of chronic renal failure secondary to hypertensive nephropathy. Nine years previously he had undergone a cadaveric right pelvic kidney transplant with the arterial supply originating from the right external iliac artery. The patient was taking appropriate immunosuppressants and his preoperative creatinine was 181 µmol/L. A preoperative computed tomography (CT) scan and aortogram revealed an infrarenal aneurysm involving both common iliac arteries (Figs. 1 and 2). The arterial supply to the transplanted kidney originated from the right external iliac artery well distal to the right common iliac bifurcation (Figs. 3 and 4). The endovascular repair took place in the operating room, under general anaesthesia. Bilateral femoral artery dissections were performed and a catheter positioned via the right common femoral artery marked the position of the superior mesenteric artery (SMA). Arteriotomies were made after anticoagulation with intravenous heparinization. There were no attempts at pharmacologic renal protection. The aortouniliac component of a 30 × 16-mm standard bifurcated Talent graft was introduced via the left common femoral artery and deployed with the bare metal stent at the level of the renal artery orifices. A 16-mm left iliac extension was placed to land in the distal common iliac artery. The right limb of the graft and a 16-mm iliac extension were inserted in a retrograde
Fig. 3. Preoperative contrast-enhanced CT scan showing the pelvic renal allograft.
fashion from the right common femoral artery such that the graft terminated in the distal common iliac artery. Proximal and distal fixation sites were secured by balloon fixation. Completion aortogram revealed good proximal fixation with perfusion of the SMA (Fig. 5) and excellent
588
Case reports
Fig. 4. Preoperative aortogram showing the renal allograft with its arterial supply from the right external iliac artery.
perfusion of the renal allograft in the right iliac fossa (Fig. 6). On delayed films there was faint filling of the aneurysm sac from patent lumbar arteries. This type II endoleak had resolved on the CT exams at 2 days and 1 month postoperatively. There were no complications and the patient was discharged home on the fourth postoperative day. He continued to do well and his creatinine level 1 month after aneurysm repair was 188 µmol/L.
DISCUSSION Given the solitary arterial supply and lack of collateralization of renal allografts, these allografts are more susceptible to ischemic injury than native kidneys. When a pelvic transplanted kidney exists with an aortic aneurysm, clamping of the aneurysm neck is always suprarenal. In this case, endovascular repair has the distinct advantage of limiting allograft ischemia to those short periods when the graft is being ballooned in place. Possible disadvantages of endovascular repair with a pelvic renal allograft include emboli to the kidney from dislodged atherosclerotic debris during device placement and manipulation. This should be no more common than atheroemboli to the lower extremities during endovascular repair of other aortic aneurysms, the occurrence of which, in our experience, is rare (2.5%). In the case described here, the aortouniliac component of the device, with the larger delivery
Annals of Vascular Surgery
system, was placed via the femoral artery contralateral to the renal allograft. The smaller uniliac limb was inserted through the ipsilateral artery. This potentially reduces the risk of direct trauma to the transplant arterial anastomosis and of embolization from the donor external iliac artery. The risk of contrast-induced nephropathy is also minimized by limiting contrast volume (70 cc of Omnipaque 350) and maintaining adequate hydration. Currently, there is insufficient evidence to support the use of pharmacologic protective measures to prevent contrast-induced nephropathy.16 Although various intraoperative techniques have been used to minimize allograft ischemia with standard repair, there are several reports of successful repair without adjunctive renal protective measures. Harris and May described a series of four patients who underwent aortic surgery without any allograft protective measures.13 No serious complications resulted, although half of the patients had a transient rise in serum creatinine levels in the early postoperative period. Hypothermia via both cold renal perfusion9,10 and external cooling11 has been used in an attempt to decrease the risk of ischemic injury. Nghiem and Lee described successful aneurysm repair using direct iliac artery perfusion with Ringer’s lactate cooled to 4°C.10 Panneton et al. described the Mayo Clinic experience with five patients undergoing elective infrarenal AAA repair.9 Three of the transplanted kidneys received cold perfusion while two were also exposed to topical cooling. They concluded that these patients do well with cold renal perfusion with or without topical cooling of the renal allograft. The most obvious method of protecting a renal allograft from an ischemic insult is to maintain perfusion during aneurysm repair. A variety of techniques have been described, including femoralfemoral bypass with a pump oxygenator. Wolf et al. described this method of maintaining renal perfusion during aortic cross-clamping.8 Perfusion pressure was maintained at 60-80 mmHg with a flow of 600-1000 mL/min during 40 min of aortic clamping. Temporary bypass procedures have also been deployed to maintain renal perfusion during standard aneurysm repair. Retrograde allograft perfusion has been successfully used in this setting via a temporary axillofemoral bypass graft.4 The supraceliac or proximal abdominal aorta has also been used as inflow for temporary bypasses to the common iliac artery,7 the external iliac artery,2 and the femoral artery6 to perfuse a pelvic transplant kidney during successful aneurysm repair. Temporary shunting procedures have also been reported.
Vol. 15, No. 5, 2001
Case reports 589
Fig. 5. Proximal fixation site of the bifurcated endovascular graft.
Fig. 6. Distal fixation site of the bifurcated endovascular graft showing preservation of renal allograft perfusion.
Kashyap and Quin˜ones-Baldrich described the use of two shunting procedures in patients with aneurysms and pelvic renal allografts deriving their arterial supply from the internal iliac artery.3 In the first patient, the juxtarenal aorta and the ipsilateral common femoral artery were exposed and cannulated with a shunt through purse-string sutures. In the second patient, an in-line shunt was fashioned by placing a chest tube through the ipsilateral limb of a bifurcated graft into the suprarenal aorta. It was secured in place by Rumel tourniquets around the infrarenal aorta and the ipsilateral common iliac artery. In both cases, the renal allograft produced urine during aneurysm repair and there were no adverse sequelae. Laborde et al. described a similar technique using a Pruitt-Inahara shunt.5 Following completion of the proximal anastomosis, the body of the graft is punctured, proximal to a clamp on the graft, and the shunt is inserted into the body of the graft and through the orifice of the ipsilateral iliac artery. With this technique, the allograft ischemia time is limited to the duration of the proximal anastomosis. Several variations of standard aneurysm repair
without the use of shunts or bypasses have been described. Lacombe has reported the largest series, consisting of 15 patients with pelvic renal allografts operated on for aneurysms (8 patients) or aortoiliac occlusive disease (7 patients).12 In the presence of an aneurysm the aortic neck is divided between two clamps and the proximal anastomosis is performed. Partial renal allograft perfusion is maintained via back-bleeding from the lumbar arteries, the inferior mesenteric artery, and the iliac arteries. Full allograft revascularization is achieved by anastomosis of the graft to the ipsilateral iliac artery or by reimplantation of the allograft artery into the graft. Intraoperative furosemide and dopamine were used routinely in this series. There were no permanent deteriorations in renal function.
CONCLUSIONS With improving outcomes after kidney transplantation, the occurrence of an aneurysm in these patients will become a more frequent clinical scenario. Many centers have had some experience with standard repair of these aneurysms. There is no stan-
590
Case reports
dard published renal protective protocol for aneurysm repair in transplant patients. Endovascular repair obviates the need for further renal protective measures, as the allograft ischemia time is limited to the brief time that the graft is ballooned into place. It is important to minimize contrast load and to avoid excessive manipulation of the donor artery during graft positioning and deployment. We have shown that endovascular repair of an AAA is a safe and useful technique in the presence of a functioning pelvic renal allograft. REFERENCES 1. Finn W. Prevention of ischemic injury in renal transplantation. Kidney Int 1990;37:171-182. 2. Sparks SR, Chock A, Seslar S, Bergan JJ, Owens EL. Surgical treatment of Takayasu’s arteritis: case report and literature review. Ann Vasc Surg 2000;14:125-129. 3. Kashyap VS, Quin˜ones-Baldrich WJ. Abdominal aortic aneurysm repair in patients with renal allografts. Ann Vasc Surg 1999;13:199-203. 4. Giulini SM, Maffeis R, Cangiotti L, Bonardelli S, Bertolini G, Caratozzolo E. Temporary axillo-femoral bypass graft for renal transplant protection during aortic aneurysm repair. J Cardiovasc Surg (Torino) 1996;37:575-578. 5. Laborde AL, Hoballah JJ, Sharp WJ, Kresowik TF, Corson JD. A simple technique of renal transplant preservation during aortic reconstruction. Ann Vasc Surg 1992;6:550-552.
Annals of Vascular Surgery
6. O’Mara CS, Flinn WR, Bergan JJ, Yao JS. Use of a temporary shunt for renal transplant protection during aortic aneurysm repair. Surgery 1983;94:512-515. 7. Sterioff S, Parks L. Temporary vascular bypass for perfusion of a renal transplant during abdominal aneurysmectomy. Surgery 1977;82:558-560. 8. Wolf W, Ayisi K, Ismail M, Kalmar P, Pokar H, Trautwein S. Abdominal aortic aneurysm repair after renal transplantation with extra corporeal bypass. Thorac Cardiovasc Surg 1991;39:384-385. 9. Panneton JM, Gloviczki P, Canton LG, et al. Aortic reconstruction in kidney transplant recipients. Ann Vasc Surg 1996;10:97-108. 10. Nghiem DD, Lee HM. In situ hypothermic preservation of a renal allograft during resection of abdominal aortic aneurysm. Am Surg 1982;48:237-238. 11. Chacko KN, Ninan S, Jacob CK, Korula R. Transplant kidney protection during aortic aneurysm surgery. J Urol 1999; 161:891-892. 12. Lacombe M. Aortoiliac surgery in renal transplant patients. J Vasc Surg 1991;13:712-718. 13. Harris JP, May J. Successful aortic surgery after renal transplantation without protection of the transplanted kidney. J Vasc Surg 1987;5:457-461. 14. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491-499. 15. Kaplan DB, Kwon CC, Marin ML, Hollier LH. Endovascular repair of abdominal aortic aneurysms in patients with congenital renal vascular anomalies. J Vasc Surg 1999;30:407416. 16. Oliveira DB. Prophylaxis against contrast-induced nephropathy. Lancet 1999;15:1638-1639.