Kidney transplantation following iliac revascularization in severe atherosclerosis: a comparative study

A novel technique for external iliac artery reconstruction in renal transplant patients with extensively atherosclerotic lower limb vasculature

We describe a 54-year-old man with type 2 diabetes mellitus, ischemic myopathy, pulmonary hypertension, and end-stage renal disease who was admitted for heart failure and listed for a dual cardiac-renal transplantation. Extensive calcification in the iliac arteries prevented clamping. Proximal endovascular balloon control of the left iliac artery was achieved using contralateral access; distal control was established by passing a Fogarty catheter distally through an iliac arteriotomy, later used for anastomosis of the cadaveric conduit. Postoperative Doppler imaging confirmed adequate renal perfusion. The patient was discharged in stable condition. This report presents a novel one-stage intravascular occlusion method for calcified arteries.

Kidney graft directly implanted on endovascular stent in external iliac artery: A preliminary experience

With an increasingly aging population, both end-stage renal disease and peripheral artery disease become more prevalent. Peripheral artery disease is increasingly treated with endovascular procedures. Endovascular stenting of the external iliac artery is often considered a contraindication for kidney transplantation, as clamping of the artery could result in possible injury to the stent. In this study, we describe our first 2 cases of kidney transplantation with a graft placed on a self-expandable metal stent and a covered stent as part of an endovascular repair of the aortic bifurcation, using endovascular balloon occlusion to occlude the proximal side of the external iliac artery. Six months after transplantation, both recipients have good kidney function without any signs of ischemia of the ipsilateral limb. This study shows that it is feasible to place a kidney graft on an endovascular stent.

Orthotopic Robot-assisted Kidney Transplantation: Surgical Technique and Preliminary Results

BACKGROUND AND OBJECTIVE

Orthotopic kidney transplantation (KT) has been proposed as an option for patients ineligible for heterotopic KT. In this scenario, orthotopic robot-assisted KT (oRAKT) represents a novel, minimally invasive alternative to the open approach. Here we describe the largest oRAKT series of patients, with a focus on the surgical technique, perioperative surgical outcomes, and functional results.

METHODS

We queried prospectively maintained databases from three referral centers to identify patients who underwent oRAKT and evaluated surgical and functional outcomes.

KEY FINDINGS AND LIMITATIONS

Overall, 16 oRAKT procedures were performed between January 2020 and August 2023. These involved four donors after cardiovascular death, five donors after brain death, and seven living donors. All oRAKT procedures were carried out in the left renal fossa. The indication for oRAKT was extensive calcification of the external iliac vessels (100%), frequently associated with prior KT (31%). The median operative time was 295 min (interquartile range [IQR] 268-360) and the median rewarming time 48 min (IQR 40-54). Conversion to open surgery occurred in two cases (12%), and delayed graft function was observed in two cases (12%). Postoperative complications occurred in 11 patients (69%) and three (18%) experienced Clavien-Dindo grade >II complications. At median follow-up of 9 mo (IQR 7-17), 14 patients had a functioning graft and median creatinine of 1.49 mg/dl (IQR 1.36-1.72).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Although oRAKT is a challenging procedure, it represents a feasible option for individuals ineligible for heterotopic KT and yields favorable perioperative and mid-term functional outcomes.

PATIENT SUMMARY

We evaluated outcomes of orthotopic robot-assisted kidney transplantation (KT), in which the native kidney is removed and the donor kidney is transplanted into its place, in patients who are not eligible for heterotopic KT, in which the native kidney is left in place and the donor kidney is transplanted into a new location. We found that robot-assisted surgery is a safe and feasible alternative to traditional open surgery for orthotopic KT.

Safety and efficacy of kidney transplantation in patients with aortoiliac stenosis: a retrospective cohort study

BACKGROUND

The impact of aortoiliac occlusive disease on kidney transplantation remains unclear. This study aims to investigate the clinical outcomes of kidney transplant patients with aortoiliac atherosclerotic stenosis.

METHODS

Retrospective data from our transplant center were used to identify patients undergoing kidney transplantation between January 2010 and December 2020. Aortoiliac atherosclerotic stenosis was screened and stratified by the Trans-Atlantic Inter-Society Consensus (TASC) II classification. The primary outcome was patient survival. Secondary outcomes were 90-day mortality, death-censored graft survival, graft function, and arterial complications. Propensity score matching was used to match all patients in the stenosis group with patients without stenosis sharing similar characteristics.

RESULTS

The analysis included 655 patients, 524 without stenosis and 131 with aortoiliac stenosis (95 with TASC A/B stenosis and 36 with TASC C/D stenosis). Recipient age [median (IQR), 66 (60-70) vs. 66 (59-71) years; P =0.47], sex [male: 87 (66%) vs. 355 (68%), P =0.85], and comorbidities were comparable between the stenosis and no-stenosis groups. Forty-six (35%) patients with stenosis were symptomatic. Patient survival was significantly lower in the stenosis group compared with the no-stenosis group (TASC A/B: 30.6% vs. no-stenosis: 44.1%, P =0.013; TASC C/D: 11.4% vs. no-stenosis: 44.1%, P <0.001). The incidence rates of artery dissection, lower extremity ischemia, and acute thrombosis were significantly higher in the stenosis group ( P <0.001). However, death-censored graft survival (TASC A/B: 73.6% vs. no-stenosis: 72.9%, P =0.62; TASC C/D: 58.1% vs. no-stenosis: 72.9%, P =0.16) and graft function were comparable between the groups.

CONCLUSIONS

Aortoiliac atherosclerotic stenosis significantly impacts patient survival but not graft survival. Our analyses suggest that patients with TASC A/B stenosis have prolonged survival and enhanced quality of life through kidney transplantation. However, for patients with TASC C/D stenosis, kidney transplantation improves quality of life without bringing survival benefits.