Aortoiliac bypass in a renal transplant patient using a new technique

Renal Function after Elective Infrarenal Aortic Aneurysm Repair in Patients with Pelvic Kidneys

Pelvic kidneys complicate aortic reconstructions because of increased risk of renal ischemia. Strategies for protection include shunting, cooling, and reliance on collaterals. A review identified two congenital pelvic kidney (not solitary) and five transplanted kidney patients who underwent elective abdominal aortic aneurysm repair. For congenital pelvic kidneys, topical cooling was used in one patient while no preservation was performed for the other patient. Three transplanted kidney patients were shunted, and one had endovascular repair. Postoperative creatinine values were compared to preoperative values. The two congenital pelvic kidney patients had no significant elevation of creatinine postoperatively. The transplanted kidney patient who underwent endovascular repair had no increase in creatinine postoperatively. All transplanted kidney patients who had open repair had significant but transient increase in creatinine postoperatively. Three patients who were shunted intraoperatively had normalization of creatinine. The patient who had persistent elevation of creatinine at discharge was not shunted. Aortorenal shunting or endovascular repair in transplanted pelvic kidney patients maintains renal function. For patients with congenital pelvic kidneys and adequate collaterals, cooling and collateral perfusion is usually sufficient. Though experience is limited, endovascular repair is likely to be superior to open repair in minimizing renal ischemia.

Aortic reconstruction in patients with functioning renal allografts

Patients with functioning renal allografts requiring aortic reconstruction pose a considerable challenge to the vascular surgeon. A variety of strategies for renal allograft preservation during intervention have been described including hypothermia, indwelling shunts, cold renal perfusion, axillofemoral bypass, and endovascular stent-grafting. Reported here are two cases of successful aortic reconstruction utilizing standard open surgical techniques designed simply to minimize warm renal ischemia. The first case was that of a 55 year-old patient with a functional renal allograft originating from the right external iliac artery, who presented acutely with large symptomatic aortic and bilateral iliac artery aneurysms. He was treated with aorto-right femoral/left iliac bypass grafting. The right femoral anastomosis was performed first so that warm renal ischemia was limited to the 34 min required to perform the proximal end-to-end aortic anastomosis. The second case was that of a 44-year-old patient also with a transplanted kidney originating from the right external iliac artery. He presented with worsening hypertension, decreasing renal function, claudication, and severe aortoiliac occlusive disease. He was treated with aorto-left femoral bypass grafting via a retroperitoneal approach, followed by femorofemoral crossover bypass for retrograde perfusion of the kidney (total warm ischemia time 20 min). Both patients recovered uneventfully without a decrement in renal function and remain well on follow-up. It is concluded that standard open surgery without adjunctive shunts or bypasses remains a viable treatment option for these patients, provided warm renal ischemia can be minimized.