External iliac artery dissection causing early renal transplant dysfunction

Rescue of an asymptomatic arterial occlusion after kidney transplant

Arterial injury leading to vascular occlusion is a rare complication of kidney transplantation that requires urgent intervention to salvage the kidney and prevent graft loss. Occasionally, the recipient iliac vessels may be injured, resulting in acute ischaemia of the lower extremity in addition to loss of blood flow to the kidney transplant. In the case presented here, a 58-year-old man with chronic kidney disease secondary to IgA nephropathy underwent pre-emptive deceased donor renal transplantation complicated by an external iliac artery (EIA) dissection proximal to the transplant anastomosis. However, as a result of retrograde blood flow from collateral vessels, perfusion of the kidney and right lower extremity was initially preserved and early diagnosis was made after post-transplant ultrasound. This report reviews the aetiology, clinical features and therapeutic options for arterial injuries post-transplant. This case also highlights the importance of post-transplant vigilance and the value of routine postoperative ultrasound imaging.

Dissection of External Iliac Artery During Pediatric En bloc Kidney Transplant: Successful Rescue and Reimplant

En bloc kidney transplant is a surgical treatment option that increases available donor organs and has excellent graft survival for patients with end-stage renal disease. Herein, we report a case of dissection of the external iliac artery that occurred during en bloc kidney transplant in an adult recipient. The en bloc kidneys were removed, flushed, and then reimplanted after restoring the blood flow to the lower limb. To our knowledge, this is the first case of dissection of the external iliac artery managed successfully during en bloc kidney transplant.

Unexpected presentation and surgical salvage of transplant renal artery dissection caused by vascular clamping: a case report

Background

Transplant renal artery dissection is a rare and serious event that can cause allograft dysfunction and activation of the renin–mediated renovascular hypertension. Most cases are induced by percutaneous transluminal angioplasty, arteriosclerotic disease, or fibromuscular dysplasia. We observed a case of transplant renal artery dissection induced by unusual causes during kidney transplantation.

Case presentation

A 35-year-old woman, whose mother donated a kidney to her, underwent ABO-incompatible living kidney transplantation. The allograft had one renal artery and vein that were anastomosed to the internal iliac artery and external iliac vein, respectively. Although careful handling was performed in all procedures including vascular clamping, Doppler ultrasonography (US) immediately after reperfusion showed an increase in the systolic blood velocity and urine output was not observed. Arterial anastomotic stenosis was suspected, but upon exploration, a renal artery dissection was detected in the middle portion of the donor artery. The part of the transplant renal artery was resected, and cold reflux was started again. At the resected part of transplant renal artery, dissection was identified. After re-anastomosis, Doppler US revealed that the blood flow of the renal artery was adequate without an increase in the systolic blood velocity, and sufficient blood flow was observed throughout the allograft. Urine output was also observed as soon as blood flow returned, and serum creatinine level decreased to 0.95 mg/dL after surgery. The cause of injury might have been vascular clamping in order to drain the air and check bleeding at the anastomosis.

Conclusions

Our case reaffirmed that careful handling is needed in all procedures, including donor nephrectomy, cannulation for transplant perfusion, vascular clamping, and anastomosis, even without any evidence of arteriosclerosis. Kidney transplant recipients commonly have atherosclerosis and hypertension, which are risk factors for arterial dissection. Early diagnosis and intervention can lead to the prevention of allograft dysfunction. Therefore, close monitoring of allograft blood flow by Doppler US during surgery should be considered.

Arterial reconstruction with donor iliac vessels during kidney transplantation in a patient with severe atherosclerosis

Atherosclerosis is common in patients with end-stage renal disease. Severe calcification of the iliac vessels is expected in the growing pool of kidney transplant candidates. Thus, transplant surgeons must constantly develop alternative operative strategies to deal with the technical challenges that this condition confers. This case report aims to highlight a reconstructive vascular technique to salvage a completely calcified recipient external iliac artery using a deceased donor's arterial iliac allograft from the same donor as the renal allograft in a 59-year-old man, as an effective method to decrease vascular complications.

External Iliac Artery Dissection During Renal Transplantation: A Case Report and Literature Review

Iliac artery dissection in the setting of renal transplant is a rare but potentially catastrophic event that may result in loss of kidney and lower extremity perfusion. We report a right external iliac artery dissection in a 45-year-old man with end-stage renal disease, diabetes, and hypertension who underwent a renal transplant at our institution. An external iliac artery dissection was diagnosed intraoperatively after completion of the arterial anastomosis given the mottled appearance of the kidney and loss of Doppler signal. The dissection was repaired via open endarterectomy, intimal tacking, bovine patching, and re-anastomosis of the kidney to a proximal site on the external iliac artery. To date, 23 cases of transplant-related iliac artery dissection have been described in the literature. Predisposing risk factors include atherosclerosis and hypertension combined with trauma from vascular clamps or suturing. There is a slight male predominance. Only one group utilized an open endarterectomy approach similar to ours, whereas others used synthetic vascular grafts (12 of 23), endovascular stents (4 of 23), donor iliac artery grafts (4 of 23), or saphenous vein grafts (2 of 23). In the absence of long-term outcomes data, the optimal repair mechanism is yet to be established.