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Rescue of kidney and pancreas grafts with complex vascular lesions
Rescue of Kidney and Pancreas Grafts With Complex Vascular Lesions U. Boggi, M. Ferrari, F. Vistoli, F. Sgambelluri, C. Vignali, R. Cioni, P. Petruzzi, M. Del Chiaro, R. Berchiolli, S. Signori, L. Coletti, F. Gremmo, G. Rizzo, and F. Mosca ABSTRACT Background. The organ shortage mandates that grafts with complex vascular lesions be considered for graft rescue. Methods. Surgical graft rescue was attempted in 8 patients bearing 8 kidneys and 2 pancreata that showed complex vascular lesions deemed not suitable for interventional radiology procedures. Results. All procedures but 1 were performed under elective conditions. Seven grafts were repaired in situ, while cooling the organ through retrograde venous perfusion, and 3 kidneys were explanted, repaired extracorporeally, and retransplanted. All vascular reconstructions remain patent after a mean follow-up period of 3.3 years (⫾2.1 years). Conclusions. Careful patient selection, multidisciplinary evaluation, and personalized surgical technique may allow the rescue of kidney and pancreas grafts with complex vascular lesions that, otherwise, would be lost.
T
HE DONOR SHORTAGE, the main factor limiting the number of all solid organ transplants,1–3 is particularly stringent for the kidney due to the prevalence of renal diseases and the high survival rates of extracorporeal dialysis.4 Moreover, when a kidney graft fails, patients may be listed for retransplantation, thus further exacerbating the graft shortage.1–3,5 Because it is generally accepted that the results of retransplantation are inferior to those achieved after primary transplantation,6 every effort should be made to salvage each graft at risk for failure due to technical reasons. Patients with diabetes who need a pancreas transplantation face similar difficulties and have even worse prospects for retransplantation.6 We herein report our experience with the rescue of kidney and pancreas grafts showing complex vascular lesions. MATERIALS AND METHODS Between May 1996 and March 2003, 13 patients were diagnosed with complex vascular lesions involving their kidney and/or pancreas grafts following comprehensive assessment and multidisciplinary evaluation to assess the possibility of graft rescue. Seven patients, with vascular lesions not suitable for interventional radiology treatment (Fig 1), were scheduled for elective surgical repair. One recipient of a pancreas-kidney transplantation was scheduled for simultaneous repair of vascular lesions involving both grafts. Another patient, with a history of failed percutaneous angioplas© 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 505⫺508 (2004)
ties, underwent extracorporeal repair of the renal arteries and retransplantation. The same patient, 6 years later, underwent in situ renal artery reconstruction due to aneurysm formation in the saphenous graft (Fig 2). Finally, 1 patient, initially scheduled for interventional radiology treatment, required urgent surgical repair following renal artery rupture. Overall, a total of 10 complex vascular lesions involving either the renal artery or the pancreas blood supply were treated surgically, including 9 elective procedures and 1 urgent operation.
Surgical Procedures All procedures were performed through a mid-line approach allowing good exposure and simultaneous access to all vascular pedicles. When the estimated in situ time for vascular reconstruction exceeded 20 minutes or when otherwise impossible, an extraFrom the Divisione di Chirurgia Generale e Trapianti (U.B., F.V., F.S., M.D.C., R.B., S.S., L.C., F.G., F.M.), Unita´ Operativa Chirurgia Vascolare (M.F.), Dipartimento Immagini (C.U., R.C., P.P.), Unita´ Operativa Nefrologia e Trapianti (G.R.) Azienda Ospedaliera Universitaria Pisana, Pisa, Italy. This work was supported by a grant from ARPA Foundation (www.fondazionearpa.it). Address reprint requests to Franco Mosca, MD, FACS, FRCSEd, Head, Divisione di Chirurgia Generale e Trapianti, Universita` di Pisa, Ospedale di Cisanello, via Paradisa 2-56124, Pisa, Italy. 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.02.015 505
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BOGGI, FERRARI, VISTOLI ET AL
Fig 1.
Conventional angiography demonstrating dual kidney supply and hilar aneurysm.
corporeal repair was planned including graft removal, cold graft perfusion, back-table vascular reconstruction, and retransplantation. Based on these criteria, vascular lesions in 3 grafts were reconstructed extracorporeally and 7 in situ. For the latter procedures hypothermic graft protection was achieved by continuous back perfusion of the graft with cold lactated Ringer’s solution through the vein (Fig. 3).
RESULTS
A total of 8 patients (mean age, 38.1 years ⫾ 9.4 years) was treated for complex vascular lesions involving either kidney or pancreas grafts after a mean period of 9.2 years (⫾5.6 years) after transplantation. At the time of repair, all grafts but 1 kidney, which required an urgent repair after a failed interventional angioplasty, were functioning well (mean serum creatinine level, 1.5 mg/dL ⫾ 0.5 mg/dL). Accord-
ingly, all patients but 1 were scheduled for elective vascular repair. Surgery was carried out as planned preoperatively in all but 1 vascular lesion involving the renal artery (8 of 9; 88.9%). This procedure, which started as an situ repair, had to be converted to an extracorporeal procedure. All grafts were successfully revascularized after a mean cold ischemia time of 26.2 minutes (⫾10.5 minutes) for in situ procedures and 98.6 minutes (⫾16.4 minutes) for ex vivo repairs. All grafts but 1 functioned immediately. No graft was removed later due to either infarction or intractable hypertension. All vascular reconstructions remain patent at the longest follow-up. After a mean follow-up period of 40.2 months (⫾25.7 months), 1 patient died of sudden death with functioning kidney and pancreas grafts. Kidney function was lost in 2
RESCUE OF GRAFTS
507
Fig 2. Computed tomography angiogram showing an enlarged saphenous graft 6 years after ex vivo reconstruction of the renal artery and retransplantation.
patients, including 1 with initial poor function undergoing urgent renal artery repair due to rupture. Endocrine pancreas function was lost in 1 patient. Actuarial 1-year and 5-year kidney survival rates are 88.9% and 63.5%, respectively. Three patients (37.8%) receiving anti-hypertensive drugs before vascular repair do not currently require any therapy. The remaining 5 patients (62.2%) are receiving reduced numbers and doses of anti-hypertensive medications compared with their pre-revascularization treatments. DISCUSSION
Our series shows that a considerable proportion of grafts with complex vascular lesions, otherwise not amenable to correction, may be rescued by aggressive surgical repair. However, although the technique for renal artery reconstruction has been clearly established for renovascular hypertension in native kidneys,7–11 there are no agreed surgical procedures for the treatment of kidney or pancreas grafts with complex vascular lesions not suitable for interventional radiology procedures. In our experience we found a multidisciplinary evaluation of each patient, involving the transplant surgeon, the vascular surgeon, the interventional radiologist, and the neph-
rologist to be extremely useful. From a technical point of view, we note that the transperitoneal approach, as obtained through a midline incision, is fundamental for both in situ and extracorporeal procedures. Although extracorporeal graft repair and retransplantation is clearly the safest option, it is technically demanding, requires repeat urological reconstruction, and entails a long procedure that may not be well tolerated by all patients. Therefore, we attempted to select patients for in situ procedures when we anticipated that the vascular lesion was easily amenable to repair, mainly by means of a by-pass with a very short period of vascular occlusion. However, it should be noted that in 1 case we had to quickly convert an in situ procedure to an extracorporeal one. Urgent graft explantation was difficult and, although no iatrogenic lesions were produced, it does not appear to be a safe procedure in a patient with a single kidney. Therefore, patients should be carefully selected for in situ procedures and, probably, some preliminary graft dissection, in preparation for possible conversion to an extracorporeal procedure, should be done anyway. In the case of an extracorporeal procedure, the excellent exposure minimizes the chance of bleeding, allowing vascular reconstructions to be performed easily and expedi-
508
BOGGI, FERRARI, VISTOLI ET AL
Fig 3. During in situ procedures, graft cooling was achieved through retrograde continuous perfusion obtained with an occlusionperfusion balloon inserted percutaneously in the femoral vein and threaded back to the iliac vein.
tiously. Therefore, it was not necessary to use any perfusion machine, as previously described for renovascular lesions of native kidneys.9 We conclude that careful patient selection, multidisciplinary evaluation, and personalized surgical technique may allow the rescue of a significant proportion of kidney and pancreas grafts that, otherwise, would be lost. REFERENCES 1. United Network for Organ Sharing: The critical organ shortage. Available at: http://www.unos.org. Accessed 2001 2. Rosengard BR, Feng S, Alfrey EJ, et al: Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor. Am J Transplant 2:701, 2002 3. Lopez-Navidad A, Caballero F: Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool. Clin Transplant 17:308, 2003 4. Vanholder R, Smet RD, Glorieux G, et al: Survival of hemodialysis patients and uremic toxin removal. Artif Organs 27:218, 2003
5. Gaston RS, Danovitch GM, Adams PL, et al: The report of a national conference on the wait list for kidney transplantation. Am J Transplant 3:775, 2003 6. Stratta RJ, Lowell JA, Sudan D, et al: Retransplantation in the diabetic patient with a pancreas allograft. Am J Surg 174:759, 1997 7. Mosca F, Brandi LS, Carmellini M, et al: Successful treatment of recurrent renovascular hypertension by solitary kidney autotransplantation. Ital J Surg Sci 13:311, 1983 8. Dubernard JM, Martin X, Mongin D, et al: Extracorporeal replacement of the renal artery: techniques, indications and longterm results. J Urol 133:13, 1985 9. Kent KC, Salvatierra O, Reilly LM, et al: Evolving strategies for the repair of complex renovascular lesions. Ann Surg 206:272, 1987 10. Novick AC, Jackson CL, Straffon RA: The role of renal autotransplantation in complex urological reconstruction. J Urol 143:452, 1990 11. Murray SP, Kent C, Salvatierra O, et al: Complex branch renovascular disease: management options and late results. J Vasc Surg 20:338, 1994
T
HE DONOR SHORTAGE, the main factor limiting the number of all solid organ transplants,1–3 is particularly stringent for the kidney due to the prevalence of renal diseases and the high survival rates of extracorporeal dialysis.4 Moreover, when a kidney graft fails, patients may be listed for retransplantation, thus further exacerbating the graft shortage.1–3,5 Because it is generally accepted that the results of retransplantation are inferior to those achieved after primary transplantation,6 every effort should be made to salvage each graft at risk for failure due to technical reasons. Patients with diabetes who need a pancreas transplantation face similar difficulties and have even worse prospects for retransplantation.6 We herein report our experience with the rescue of kidney and pancreas grafts showing complex vascular lesions. MATERIALS AND METHODS Between May 1996 and March 2003, 13 patients were diagnosed with complex vascular lesions involving their kidney and/or pancreas grafts following comprehensive assessment and multidisciplinary evaluation to assess the possibility of graft rescue. Seven patients, with vascular lesions not suitable for interventional radiology treatment (Fig 1), were scheduled for elective surgical repair. One recipient of a pancreas-kidney transplantation was scheduled for simultaneous repair of vascular lesions involving both grafts. Another patient, with a history of failed percutaneous angioplas© 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 505⫺508 (2004)
ties, underwent extracorporeal repair of the renal arteries and retransplantation. The same patient, 6 years later, underwent in situ renal artery reconstruction due to aneurysm formation in the saphenous graft (Fig 2). Finally, 1 patient, initially scheduled for interventional radiology treatment, required urgent surgical repair following renal artery rupture. Overall, a total of 10 complex vascular lesions involving either the renal artery or the pancreas blood supply were treated surgically, including 9 elective procedures and 1 urgent operation.
Surgical Procedures All procedures were performed through a mid-line approach allowing good exposure and simultaneous access to all vascular pedicles. When the estimated in situ time for vascular reconstruction exceeded 20 minutes or when otherwise impossible, an extraFrom the Divisione di Chirurgia Generale e Trapianti (U.B., F.V., F.S., M.D.C., R.B., S.S., L.C., F.G., F.M.), Unita´ Operativa Chirurgia Vascolare (M.F.), Dipartimento Immagini (C.U., R.C., P.P.), Unita´ Operativa Nefrologia e Trapianti (G.R.) Azienda Ospedaliera Universitaria Pisana, Pisa, Italy. This work was supported by a grant from ARPA Foundation (www.fondazionearpa.it). Address reprint requests to Franco Mosca, MD, FACS, FRCSEd, Head, Divisione di Chirurgia Generale e Trapianti, Universita` di Pisa, Ospedale di Cisanello, via Paradisa 2-56124, Pisa, Italy. 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.02.015 505
506
BOGGI, FERRARI, VISTOLI ET AL
Fig 1.
Conventional angiography demonstrating dual kidney supply and hilar aneurysm.
corporeal repair was planned including graft removal, cold graft perfusion, back-table vascular reconstruction, and retransplantation. Based on these criteria, vascular lesions in 3 grafts were reconstructed extracorporeally and 7 in situ. For the latter procedures hypothermic graft protection was achieved by continuous back perfusion of the graft with cold lactated Ringer’s solution through the vein (Fig. 3).
RESULTS
A total of 8 patients (mean age, 38.1 years ⫾ 9.4 years) was treated for complex vascular lesions involving either kidney or pancreas grafts after a mean period of 9.2 years (⫾5.6 years) after transplantation. At the time of repair, all grafts but 1 kidney, which required an urgent repair after a failed interventional angioplasty, were functioning well (mean serum creatinine level, 1.5 mg/dL ⫾ 0.5 mg/dL). Accord-
ingly, all patients but 1 were scheduled for elective vascular repair. Surgery was carried out as planned preoperatively in all but 1 vascular lesion involving the renal artery (8 of 9; 88.9%). This procedure, which started as an situ repair, had to be converted to an extracorporeal procedure. All grafts were successfully revascularized after a mean cold ischemia time of 26.2 minutes (⫾10.5 minutes) for in situ procedures and 98.6 minutes (⫾16.4 minutes) for ex vivo repairs. All grafts but 1 functioned immediately. No graft was removed later due to either infarction or intractable hypertension. All vascular reconstructions remain patent at the longest follow-up. After a mean follow-up period of 40.2 months (⫾25.7 months), 1 patient died of sudden death with functioning kidney and pancreas grafts. Kidney function was lost in 2
RESCUE OF GRAFTS
507
Fig 2. Computed tomography angiogram showing an enlarged saphenous graft 6 years after ex vivo reconstruction of the renal artery and retransplantation.
patients, including 1 with initial poor function undergoing urgent renal artery repair due to rupture. Endocrine pancreas function was lost in 1 patient. Actuarial 1-year and 5-year kidney survival rates are 88.9% and 63.5%, respectively. Three patients (37.8%) receiving anti-hypertensive drugs before vascular repair do not currently require any therapy. The remaining 5 patients (62.2%) are receiving reduced numbers and doses of anti-hypertensive medications compared with their pre-revascularization treatments. DISCUSSION
Our series shows that a considerable proportion of grafts with complex vascular lesions, otherwise not amenable to correction, may be rescued by aggressive surgical repair. However, although the technique for renal artery reconstruction has been clearly established for renovascular hypertension in native kidneys,7–11 there are no agreed surgical procedures for the treatment of kidney or pancreas grafts with complex vascular lesions not suitable for interventional radiology procedures. In our experience we found a multidisciplinary evaluation of each patient, involving the transplant surgeon, the vascular surgeon, the interventional radiologist, and the neph-
rologist to be extremely useful. From a technical point of view, we note that the transperitoneal approach, as obtained through a midline incision, is fundamental for both in situ and extracorporeal procedures. Although extracorporeal graft repair and retransplantation is clearly the safest option, it is technically demanding, requires repeat urological reconstruction, and entails a long procedure that may not be well tolerated by all patients. Therefore, we attempted to select patients for in situ procedures when we anticipated that the vascular lesion was easily amenable to repair, mainly by means of a by-pass with a very short period of vascular occlusion. However, it should be noted that in 1 case we had to quickly convert an in situ procedure to an extracorporeal one. Urgent graft explantation was difficult and, although no iatrogenic lesions were produced, it does not appear to be a safe procedure in a patient with a single kidney. Therefore, patients should be carefully selected for in situ procedures and, probably, some preliminary graft dissection, in preparation for possible conversion to an extracorporeal procedure, should be done anyway. In the case of an extracorporeal procedure, the excellent exposure minimizes the chance of bleeding, allowing vascular reconstructions to be performed easily and expedi-
508
BOGGI, FERRARI, VISTOLI ET AL
Fig 3. During in situ procedures, graft cooling was achieved through retrograde continuous perfusion obtained with an occlusionperfusion balloon inserted percutaneously in the femoral vein and threaded back to the iliac vein.
tiously. Therefore, it was not necessary to use any perfusion machine, as previously described for renovascular lesions of native kidneys.9 We conclude that careful patient selection, multidisciplinary evaluation, and personalized surgical technique may allow the rescue of a significant proportion of kidney and pancreas grafts that, otherwise, would be lost. REFERENCES 1. United Network for Organ Sharing: The critical organ shortage. Available at: http://www.unos.org. Accessed 2001 2. Rosengard BR, Feng S, Alfrey EJ, et al: Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor. Am J Transplant 2:701, 2002 3. Lopez-Navidad A, Caballero F: Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool. Clin Transplant 17:308, 2003 4. Vanholder R, Smet RD, Glorieux G, et al: Survival of hemodialysis patients and uremic toxin removal. Artif Organs 27:218, 2003
5. Gaston RS, Danovitch GM, Adams PL, et al: The report of a national conference on the wait list for kidney transplantation. Am J Transplant 3:775, 2003 6. Stratta RJ, Lowell JA, Sudan D, et al: Retransplantation in the diabetic patient with a pancreas allograft. Am J Surg 174:759, 1997 7. Mosca F, Brandi LS, Carmellini M, et al: Successful treatment of recurrent renovascular hypertension by solitary kidney autotransplantation. Ital J Surg Sci 13:311, 1983 8. Dubernard JM, Martin X, Mongin D, et al: Extracorporeal replacement of the renal artery: techniques, indications and longterm results. J Urol 133:13, 1985 9. Kent KC, Salvatierra O, Reilly LM, et al: Evolving strategies for the repair of complex renovascular lesions. Ann Surg 206:272, 1987 10. Novick AC, Jackson CL, Straffon RA: The role of renal autotransplantation in complex urological reconstruction. J Urol 143:452, 1990 11. Murray SP, Kent C, Salvatierra O, et al: Complex branch renovascular disease: management options and late results. J Vasc Surg 20:338, 1994