Aortoiliac reconstruction in preparation for renal transplantation

Utility of a Simplified Iliac Artery Calcium Scoring System to Guide Perioperative Management for Renal Transplantation

Non-contrast computed tomography scans of the abdomen and pelvis (CTAP) are often obtained prior to renal transplant to evaluate the iliac arteries and help guide surgical implantation. The purpose of this study was to describe the association of iliac calcification scores with operative and clinical outcomes using a simplified scoring system. A retrospective review of 204 patients who underwent renal transplant from 1/2013 to 11/2014 and who had a CTAP within 3 years prior to transplant was performed. Data were collected from the electronic medical record. Common iliac artery (CIA) and external iliac artery (EIA) calcification on CTAP were assessed using a simple scoring system. Descriptive statistics, logistic regression, and survival analyses were performed. A total of 204 patients were included in the analysis. The mean age was 57.4 ± 11.2 years and 134/204 (66%) were men. Nineteen patients (9%) had a history of peripheral artery disease (PAD), 78 (38%) had coronary artery disease, and 22 (11%) had a previous cerebrovascular accident (CVA). Patients with severe right EIA plaque morphology were significantly more likely to require arterial reconstruction compared to those without severe plaque (3/14[21%] 4/153 [3%], p = 0.03). Eleven patients (5%) had one or more amputations (toe, foot, or transtibial) following transplant. In UV logistic regression, severe EIA plaque morphology (OR 8.1, CI 2.2–29.6, p = 0.002) and PAD (OR 10.7, CI 2.8–39.9, p = 0.0004) were associated with increased odds of amputation. In the MV model containing both variables, EIA plaque morphology (OR 4.4, CI 0.99–18.3, p = 0.04) and PAD (OR 6.3, CI 1.4–26.4, p = 0.01) remained independently associated with increased odds of amputation. Over a median follow up of 3.3 years (IQR 2.9–3.6), 21 patients (10%) had post-operative major adverse cardiac events (MACE, defined as myocardial infarction, coronary intervention, or CVA), and 23 patients died (11%). In unadjusted Kaplan Meier analysis, CIA plaque (p = 0.00081) and >75% CIA length calcification (p = 0.0015) were significantly associated with MACE. Plaque burden in the EIA is associated with increased need for intra-operative arterial reconstruction and post-operative lower extremity amputations, while CIA plaque is associated with post-operative MACE. Assessment of CIA and EIA calcification scores on pre-transplant CT scans in high risk patients may guide operative strategy and perioperative management to improve clinical outcomes.

External iliac artery polytetrafluoroethylene graft interposition: An effective rescuer for kidney transplant in progressive intimal dissection of external iliac artery

AIMS AND OBJECTIVE

The aim of this study is to highlight the use of polytetrafluoroethylene (PTFE) interposition graft as an important salvage procedure in case of irreparable intimal injury of external iliac artery during renal transplant recipient surgery.

MATERIALS AND METHODS

Since 1987, we encountered irreparable intimal dissection of external iliac artery in five cases just after opening the clamp. It was successfully managed by PTFE interposition graft with subsequent end to side anastomosis of donor renal artery to the vascular graft.

RESULTS

No patient had bleeding or infective complications related to the graft and three patients had immediate diuresis. Normal immediate graft function was present in three patients while the other two had delayed graft function.

CONCLUSION

Polytetrafluoroethylene interposition graft is a successful procedure to salvage the kidney and lower limb in case of progressive intimal dissection of external iliac artery during renal transplant surgery.

Pertinent issues in pretransplant recipient workup

Renal transplantation is recognized as the treatment of choice in most patients with end-stage renal disease. The evaluation of the candidate for kidney transplantation has been the recent subject of clinical practice guidelines published by the European Renal Association- European Dialysis Transplant Association and the American Society of Transplantation. The purpose of this article is to review the current literature for urological evaluation and treatment of patients prior to renal transplantation. In India, urologists are involved in evaluating not only the genitourinary problems but also vascular access and, vascular anatomy and pathology especially related to major pelvic vessels. Hence, evaluation of the transplant recipient should include assessment of vascular access for hemodialysis, access for peritoneal dialysis, assessment of pelvic vessels to which renal allograft vessels need to be anastomosed and genitourinary system. In addition, review of the serological tests for infective viral diseases like hepatitis and human immunodeficiency viruses should always be done before starting clinical evaluation. A note of the evaluation performed by other specialists like nephrologist, cardiologist, endocrinologist, pulmonologist, anesthetist etc. should always be reviewed.