Papers Presented at the Peripheral Vascular Surgery Society
Aortic Reconstruction in Kidney Transplant Recipients Jean M. Panneton, MD, Peter Gloviczki, MD, Linda G. Canton, RN, BSN, Thomas C. Bower, MD, Matthew S.T. Chow, MD, Peter C. Pairolero, MD, Hartzell V. Schaff, MD, John W. Hallett, Jr., MD, and Kenneth J. Cherr)~ Jr., MD, Rochester, Minnesota
Renal transplantation has increased the longevity of patients with uremia. An increasing number undergo aortic reconstruction, which exposes the transplanted kidney to ischemic injury. To evaluate the risk for renal failure, loss of the transplant, and methods of renal protection, we reviewed our experience. Clinical data were reviewed for 10 consecutive patients (7 men, 3 women; mean age 52.7 years [range 32 to 75 years]) with a transplanted kidney who underwent aortic reconstruction between 1977 and 1994 at our institution. Mean interval between renal transplantation and aortic reconstruction was 5.9 years (range 1 month to 12.7 years). Seven patients required emergency repair because of dissection (2 patients), aneurysm rupture (4 patients), or symptomatic aneurysm (1 patient); three underwent elective repair. Reasons for reconstruction included aortic dissection (2 patients), aneurysm of the descending thoracic (2 patients), thoracoabdominal (1 patient), or abdominal aorta (3 patients), and aortoiliac occlusive disease (2 patients). Patients with thoracic or thoracoabdominal reconstructions underwent repair with atriofemoral, aortofemoral, or femorofemoral shunt placement or bypass. Of the five abdominal aortic reconstructions, the kidney was protected with aortofemoral shunt placement in one patient and cold renal perfusion in three. In two of them, topical cooling of the kidney also was used. One patient with acute aortic dissection died at 39 days as a result of respiratory failure. Loss of the recently transplanted kidney was caused by acute rejection. One patient had a transient increase in serum creatinine concentration. Eight had no worsening of renal function, and none of the nine survivors lost the transplanted kidney. We conclude that aortic reconstruction can be safely performed in kidney transplant recipients. Patients in whom thoracic or thoracoabdominal aortic reconstruction was required were protected with an atriofemoral or aortofemoral bypass or shunt. Patients undergoing abdominal aortic reconstruction did well when cold renal perfusion with or without local cooling of the transplant was used for renal protection. Transplanted kidneys appeared to tolerate ischemic injury similarly to native kidneys. (Ann Vasc Surg 1996;10:97-108.)
From the Division of Vascular Surgery and Division of Thoracic and Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn. Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995. Reprint requests: Peter Gloviczki, MD, Mayo Clinic, Division of Vascular Surgery, 200 1st St. SW, Rochester, MN 55905.
Chronic renal failure and long-term hemodialysis are known predisposing factors for development of accelerated atherosderosis.' Renal transplantation has increased the longevity of patients with uremia, and renal transplantation is now performed in older patients in their seventh and eighth decades. Consequently an increase in the prevalence of aortic atherosclerotic disease, either 97
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Table I. Aortic reconstruction in 10 kidney transplant recipients Patient-related variables Patient
1 2* 3 4 5 6 7 8 9 10
50/F 32/M 46/M 48/F 75/M 65/M 66/M 52/M 49/M 43/F
Associated risk factors HTN, HTN CAD, HTN, HTN, HTN, HTN, HTN HTN, HTN,
CAD PVD, CVD, CAD CAD, CAD,
DM DM CVD PVD
Cause of end-stage renal disease
Polycystic kidney SLE DM SLE CGN IgA n e p h r o p a t h y Unknown Polycystic kidney MPGN Reflux n e p h r o p a t h y
Cadaveric LRD LRD Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric Cadaveric LRD
EIA IIA IIA EIA EIA IIA EIA EIA EIA IIA
7.3 0.1 8.0 1.0 3.0 5.3 2.4 7.9 10.8 12.7
CAD = coronary artery disease; CGN = chronic glomemlonephritis; CVD = cerebrovascular disease; DM = diabetes mellitus; EIA = external iliac artery; HTN = hypertension; IgA = immunoglobulin A; IIA = internal iliac artery; LRD = living related donor; MPGN = membranoproliferative glomerulonephritis; PVD = peripheral vascular disease; SLE = systemic lupus erythematosus, *Previously reported case (see reference 2).
Table II. Aortic reconstruction in 10 kidney transplant recipients Treatment and outcome Patient 1 2 3 4 5 6 7 8 9 10
Acute type A dissection Acute type B dissection Severe AIOD
Atriofemoral Gott shunt A o r t o f e m o r a l Gott shunt None Femorofemoral ECC AortofemoraI Gott shunt Perfusion cooling
R u p t u r e d AAA R u p t u r e d dissecting DTAA R u p t u r e d type IV TAAA A n a s t o m o t i c AAA, severe AIOD Symptomatic DTAA R u p t u r e d AAA M o d e r a t e AIOD, severe RVH
Cross -clamp protection
Patient outcome Survived Died, 39 days
P e r f u s i o n cooling Perfusion cooling
AAA = abdominal aortic aneurysm; A1OD = aortoiliac occlusive disease; DTAA = descending thoracic aortic aneurysm; ECC = extracorporeat circulation; NA = not available; RVH = renovascular hypertension; TAAA = thoracoabdominat aortic aneurysm, *Nonfunctional transplant due to acute rejection that occurred before the aortic dissection and required a staged transplant nephrectomy 10 days after the aortic repair. tTransient elevation of creatinine concentration, from 3.1 mg/dl to 5,0 mg/dl.
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aneurysmal or occlusive, in kidney transplant recipients can be expected. Therefore aortic reconstruction in kidney transplant recipients will be needed more frequently in the future. The issue of kidney transplant protection from ischemic and reperfusion injury during aortic surgery will arise as a clinical management problem. To examine this problem we reviewed our surgical experience with aortic reconstruction in kidney transplant recipients. MATERIAL AND METHODS All kidney transplant recipients undergoing aortic reconstruction at the Mayo Clinic during the past 18 years were identified and their clinical data reviewed. Follow-up data were obtained from outpatient clinic records for all patients. The status of the kidney transplant, the occurrence of rejection, and change in the initial immunosuppressive therapy were determined. Transient postoperative renal dysfunction was defined as an increase in the relative creatinine concentration of more than 40% over preoperative values. RESULTS Ten consecutive patients, recipients of a transplanted kidney, underwent aortic reconstruction between January 1, 1977, and January 31, 1995. Seven patients were m e n and three were women. Their mean age was 52.7 years (range, 32 to 75 years). Associated risk factors for atherosclerosis included hypertension in nine patients, coronary artery disease in five, and peripheral vascular disease in three (Table I). Seven patients received cadaveric kidneys and three received a kidney from a living related donor. All but one (patient 6) were recipients of their first kidney transplant. The artery of the transplanted kidney was anastomosed to the external iliac artery in six patients and to the internal iliac artery in four. Two of the l0 patients had one episode of rejection and two others had more than one rejection episode. Immunosuppressive therapy included a combination of steroid plus azathioprine (7 patients), steroid plus cydosporine (2 patients), and triple-agent immunosuppressive therapy (1 patient). The mean interval between renal transplantation and aortic reconstruction was 5.9 years (range 1 month to 12.7 years). Seven patients required emergency repair because of acute aortic dissection (2 patients), aneurysm rupture (4 patients), and symptomatic aneu-
Aortic reconstruction in kidney transplantation
rysm (1 patient). Three patients underwent elective repair (Table II). Indications for aortic reconstruction included acute aortic dissection (type A and type B, 1 patient each), aneurysms of the descending thoracic or thoracoabdominal aorta (3 patients) (Fig. 1), abdominal aortic aneurysms ( 3 patients) (Fig. 2 ), and aortoiliac occlusive disease (2 patients) (Fig. 3). One of the patients with aortoiliac occlusive disease also had severe renovascular hypertension caused by stenosis of the iliac and transplanted renal arteries (Fig. 4). All i0 patients underwent aortic graft replacement. One patient also required aortic valve resuspension and coronary reimplantation. In another patient a bifurcated graft was used to replace the infrarenal aorta. In this patient the artery of the transplanted kidney was reimptanted into the right limb of the graft (see Fig. 4). Mean aortic cross-clamping time in the 10 patients was 46.3 minutes (range 25 to 64 minutes ). All patients with thoracic or thoracoabdominal aortic reconstruction underwent atriofemoral, aortofemoral, or femorofemoral shunt placement or bypass. Of the five abdominal aortic reconstructions, the transplanted kidney was protected by an aortofemoral Gott shunt in one patient and by perfusion cooling in three (Fig. 5). Two of them also underwent topical cooling of the kidney with ice. The perfusate was cold (4 ° C) lactated Ringer's solution with heparin (1000 U ~ ) and mannitot (12.5 gm/L). One patient had no protection. Intravenous infusion of mannitol and low-dose dopamine (2 b~g/kg/min) and injection of furosemide and heparin were used in various combinations in most patients. One death occurred (patient 2) after 39 days as a result of respiratory failure caused by cytomegalovirus pneumonia. This 32-year old patient had acute rejection of a living related donor transplant followed by acute type B aortic dissection. He underwent successful graft replacement of the descending thoracic aorta and required a staged transplant nephrectomy 10 days later. Of the nine survivors, only one with a ruptured dissecting descending thoracic aneurysm had a transient postoperative increase in the serum creatinine concentration, from 3.1 mg/dl to 5.0 mg/dl. None of the other eight patients had significant transient worsening of renal function (Fig. 6), and none of the survivors lost their transplanted kidney. Early patency of the renal artery was confirmed in four patients (see Figs. 2, C and 4, C). Postoperative complications developed in five patients. These included pneumonia in three paText continued on p. 104.
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Fig. 1. A, CT scan of a type IV thoracoabdominal aortic aneurysm. B, Aortogram of the same patient confirms the aortic aneurysm. C, Arteriogram from the level of the aortic bifurcation shows the transplanted kidney perfused through the left internal iliac artery.
Fig. 2. A, CT scan confirms a massive retroperitoneal hematoma from a ruptured abdominal aortic aneurysm. B, CT scan of a lower section shows the perfused transplanted kidney in the left iliac fossa surrounded by the hematoma. C, Intraoperative postreconstruction duplex ultrasound scan confirms patency of the transplanted renal artery (R.A) anastomosed to the left external iliac artery (EIA).
Fig. 3. Aortogram shows an aortoiliac graft with a stenosis at the origin of the right limb perfusing a transplanted kidney. The right external iliac artery is occluded. Also note severe narrowing at the origin of the left limb of the graft.
Fig. 4. A, Aortogram shows distal aortic plaque overhanging the origins of both common iliac arteries, with the transplanted kidney anastomosed to the right internal iliac artery. 13, Aortogram demonstrates the anastomotic stenosis of the transplanted renal artery and the severe stenosis at the origin of the right common itiac artery. C, Postoperative digital subtraction arteriogram confirms the technical adequacy and patency of the repair.
Left atfiofemoral bypass
1-\ ~ ) ~/J/~ ~-
Gott s h u n t ~ / ~ ~ / ~
.__---- Aortic clamp E ~ , Aortic clamp
Common lilac clamps Internal lilac clamp
External lilac clamp
Fig. 5. A, Atriofemoral bypass for repair of a type II thoracoabdominal aortic aneurysm provides distal perfusion and protection of the kidney transplant. B, Protection of a kidney transplant with a Gott shunt placed from the aorta to the femoral artery. (3, Perfusion cooling through the recipient iliac artery for kidney transplant protection.
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o~ -10. t-
-30-40 24 hr
® Fig, 6. Perioperative and follow-up renal function expressed as the percent change in preoperative serum
creatinine measurements after aortic reconstruction in 10 kidney transplant recipients. F/U = follow-up.
tients and myocardial infarction, atrial fibrillation, gastrointestinal bleeding, pancreatitis, and small bowel obstruction in one patient each. Mean intensive care unit stay was 4.7 days (range 1 to 20 days) and mean hospital stay was 18.1 days (range 8 to 39 days). Among the nine survivors, no change in immunosuppression therapy was required. The nine survivors were followed up for a mean of 4.1 years (range 4.0 months to 11.7 years). One (patient 1 ) experienced chronic transplant rejection caused by chronic tubulointerstitial nephritis after 2.5 years and required a second kidney transplant. Five patients with functioning transplants died during follow-up, at 4 months, I year, 3 years, 5 years, and 11 years, respectively, after aortic reconstruction. Causes of death were pulmonary embolism, sepsis, gastrointestinal bleeding, myocardial infarction, and diffuse atherosclerosis. The four remaining survivors have stable renal function.
DISCUSSION Aortic reconstruction in kidney transplant recipients has been reported rarely. A review of the literature from 1966 to 1994 revealed only 51 cases of aortic reconstruction performed in patients w h o previously underwent renal transplantation (Table III). 3-~° In a study in which routine arteriography was performed for pretransplanta-
tion evaluation of patients, 1.86% were found to have either aneurysmal or occlusive disease that required pretransplant aortoiliac reconstruction. 3~ Sehti et al. 3 were the first, in 1976, to repair a thoracic aorta in a renal transplant recipient because of a ruptured type B dissecting aneurysm. This was soon followed by two other case reports 4'5 on abdominal aortic aneurysm repair after kidney transplantation. None of these three initial patients survived (see Table III). Campbell et al. 6 reported the first successful abdominal aortic aneurysm repair in a kidney transplant recipient, with femorofemoral partial extracorporeal circulation. An accelerated atherosclerotic process has been well documented in patients with renal failure requiring long-term dialysis. 1'32 With improved long-term survival of patients after renal transplantation, complications of atherosclerosis such as occlusive or aneurysmal disease have become more prevalent. Atherosclerotic changes requiring surgical treatment occur much earlier in kidney transplant recipients than in most patients without renal failure. Mean age of our patients was 53 years, similar to the mean age of 48 years in the reported patients, w h o underwent aortic repair after renal transplantation (see Table III). The mean interval between renal transplantation and aortic repair in our series was 5.9 years. Seven of our 10 patients and 31% of the reported cases needed emergency repair. This no doubt is responsible for the high rate of postoperative complications and the prolonged hospitalization of these patients. The high prevalence of emergencies also supports the need for more careful follow-up of kidney transplant recipients to detect the presence and progression of aortic aneurysmal or occlusive disease. Aortic reconstruction in kidney transplant recipients raises the issue of protection of the transplanted kidney. The concept of direct perfusion of the transplanted kidney with an axillofemoral bypass graft or placement of a temporary shunt was introduced by Shons et al. 4 and Sterioff and Parks. ~ However, a decade later Lacombe 14 reported successful AAA repair in five kidney transplant recipients without any shunt or bypass. Three options are available to the surgeon for protection of the transplanted kidney: distal aortic perfusion with a shunt or bypass (see Fig. 5, A and B), perfusion cooling (Fig. 5, C), and topical cooling of the kidney with ice slush. The decision to choose one or a combination of these methods is influenced by several clinical factors
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Aortic reconstruction in kidney transplantation 105
Table III. Worldwide 1976 to 1994
i n 51 k i d n e y
Sehti et al. 3
F e m o r o f e m o r a l ECC
Died, 12 h r
S h o n s et al.*
Died, 64 days
Sterioff a n d Parks s
Died, 66 days
Campbell et al. 6
G i b b o n s et al. 7
P e r m a n e n t axillof e m o r a l graft Aortoiliac PVC shunt Femorofemoral ECC T e m p o r a r y axillof e m o r a l graft T e m p o r a r y axillof e m o r a l graft P e r f u s i o n cooling Aortofemoral Gott shunt Axillofemoral n o n heparinized shunt Atriofemoral ECC A o r t o f e m o r a l Gott shunt Femorofemoral ECC General hypothermia None None None None None None None None None Femorofemoral ECC P e r m a n e n t axillof e m o r a l graft Axillofemoral Gott shunt None None None None None None None None None
R u p t u r e d type III dissection S y m p t o m a t i c mycotic AAA S y m p t o m a t i c AAA
R u p t u r e d AAA
S y m p t o m a t i c AAA
Acute type I dissection AAA
AAA AAA AAA AAA AAA AAA AIOD AIOD AIOD S y m p t o m a t i c AAA S y m p t o m a t i c AAA
No No No No Yes No No No No Yes Yes
Survived Survived Survived Survived Survived Survived Survived Survived Survived Survived Survived
R u p t u r e d AAA
R u p t u r e d AAA
R u p t u r e d AAA S y m p t o m a t i c AAA AIOD AAA AAA AAA AAA AIOD Iatrogenic dissection
No No No No No No No No No
Survived Survived Survived Survived Survived Survived Survived Survived Survived
59/M N g h i e m a n d Lee s O ' M a r a et aL 9
N u s s a u m e et al. '°
Wolfe a n d Williams ~ H u g h e s et al. ~2
Hi_rage et al. '~
Harris a n d M a y '5
Bittard et al. ~6
27/M 52/M 56/M 46/M 63/M 37/M 44[F 38/F 55/1: 68//vl 45/M
Defraigne a n d Limet ~ Schwartz et a l ) s
Jivegard et a l ) 9
B o u d r e a u x et al. 2° Hopkins et al. 21 G o u n y et al. 22
1990 1990 1991
64/M 50/1: 37/M 62 63/M 50 42 44 26
AAA = abdominal aortic aneurysm; AIOD = aortoiliac occlusive disease; ECC = extracorporeal circulation; PVC = polyvinyl chloride, *Significant creatinine increase is defined as a relative increase of >40%. Three of the 51 patients could not be evaluated for the occurrence of postoperative renal failure: one because of early death 3 and two because of preoperative renal failure, n'3°
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T a b l e III. Worldwide e x p e r i e n c e w i t h aortic r e c o n s t r u c t i o n in 51 k i d n e y t r a n s p l a n t recipients from 1976 to 1 9 9 4 - c o n t ' d Author Lacombe 23
61 35 41 49 48 41 50 49 35/F 40/F
None None None None None None None None None None
No No No No No No No No Yes No
Survived Survived Survived Survived Survived Survived Survived Survived Survived Survived
Femorofemoral ECC Femorofemoral ECC None
AAA AIOD AIOD AIOD AIOD AIOD AIOD AIOD AIOD Chronic type III dissection AAA
Wright et al. 24
Evans et al. 2~
Wolf et al/~
Holm 27 Matley a n d Imm e l m a n 28 Stavri et al. 29 Tarantini a n d Tchekanov 3°
S y m p t o m a t i c AAA
Acute type III dissection
including the c o m p l e x i t y of the aortic repair, the e s t i m a t e d d u r a t i o n of aortic cross-clamping time and of renal ischemia, the technical limitations and complications associated w i t h extracorporeal bypass or s h u n t p l a c e m e n t , and the ischemia tolerance of the t r a n s p l a n t e d kidney. Review of the literature revealed that some f o r m of t r a n s p l a n t p r o t e c t i o n was used in only 19 of the 51 patients (37%) (Table IV). Distal aortic perfusion was used in 17 patients and included axillofemoral graft (4 patients), 4"7"~7 n o n h e p a r i n ized s h u n t p l a c e m e n t (2 patients), ~ ° Gott s h u n t p l a c e m e n t (4 patients), 9'~2'~8'29 a n d left atriofemoral bypass (7 patients).* A m o n g these patients, a 47% incidence of t r a n s i e n t creatinine increase occurred (7 of 15 patients). The rate of t r a n s i e n t renal failure was 10% (3 of 31 patients) a m o n g those in w h o m renal p r o t e c t i o n was not used. t The groups, however, are not comparable, because patients w i t h some f o r m of distal aortic perfusion appeared to be at h i g h e r surgical risk, u n d e r w e n t *References 3, 5, 11, 13, 16, 25, 26. ]References 14, 15, 19-24, 27, 28, 30.
m o r e c o m p l e x aortic reconstruction, and required e m e r g e n c y repair m o r e frequently. In our material significant t r a n s i e n t renal d y s f u n c t i o n developed in only o n e patient despite the use of extracorporeal circulation. This patient w i t h preexistent renal insufficiency was operated on because of a ruptured dissecting d e s c e n d i n g thoracic aortic aneurysm. A r g u m e n t s in favor of not using protective m e a s u r e s d u r i n g aortic repair are that either renal ischemia time is short or the residual distal aortic pressure is sufficient to m a i n t a i n filtration pressure in the k i d n e y t h r o u g h collaterals vessels? 3 Table IV reports the t r a n s p l a n t salvage rate of 51 case reports published previously. The early t r a n s p l a n t salvage rate in the 50 patients w h o s u t u r e d b e y o n d 24 h o u r s was 100%, w i t h a n overall early survival rate of 94%, similar to our o w n findings. Loss of the only k i d n e y in our series was caused by acute rejection, not renal ischemia. Renal d y s f u n c t i o n in one patient was transient, a n d no patient required postoperative dialysis. Because the n u m b e r of reported cases in the literature is low, w e m a y presume, however, that some u n s u c c e s s f u l cases r e m a i n unreported.
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Aortic reconstruction in kidney transplantation
T a b l e IV. Clinical overview of aortic reconstruction in 51 kidney transplant recipients from 1976 to I994 Clinical data Sex* Male Female Type of transplant-tCadaveric Living related d o n o r Aortic disease AAA AIOD Dissection Aortic surgery Elective Emergent Transplant protection Yes No Transplant revascularization yes No Transient creatinine increase~: Yes No Transplant salvage§ Yes No Patient survival Yes No
No, of patients
32 14 5
63 27 10
*Reported for 36 patients only. tReported for 38 patients only. #Significant creatinine increase is defined as a relative increase of >40%. Three of the 51 patients could not be evaluated for postoperative renal failure: one because of early death 3 and two because of preoperative renal failure. ~~° §One patient died too early to assess transplant salvage?
dominal aortic aneurysm repairs, postoperative dialysis was significantly more frequent among patients w h o did not receive cold renal perfusion?' The normothermic ischemic limit for a transplanted kidney is 30 minutes of w a r m ische m i a Y In a study by Florack et al., 38 after a 30-minute period of w a r m ischemia, none of their kidney transplants failed; however, 78% showed transient creatinine increase. After 1 hour of w a r m ischemia, only one kidney sur~ved. Renal ischemia time in our series averaged 46 minutes. Aortic occlusion time beyond 30 minutes with unpredictable distal aortic pressure appears to justify additional renal protective measures. Cerilli et a l ) 2 performed the first successful simultaneous renal transplantation and abdominal aortic aneurysm repair. Similar simultaneous aortic replacement with kidney transplantation has been safely performed subsequently in other patients. ='24'43'44 Combined aortic reconstruction with kidney transplantation, however, should be performed rarely and should be reserved for candidates at good risk.
CONCLUSION On the basis of our experience and review of the reported cases in the literature, we conclude that aortic reconstruction can be safely performed in kidney transplant recipients, with elevated morbidity but low mortality and an excellent rate of transplant salvage. The use of bypass or shunt placement during thoracic and thoracoabdominal aortic repair, in our experience, provides adequate renal protection. For abdominal aortic reconstruction, cold perfusion of the kidney and use of ice slush for topical cooling are safe and simple techniques to protect the transplanted kidney during aortic occlusion. Transplanted kidneys appear to tolerate the ischemic injury similarly to native kidneys. REFERENCES
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