Kidney Autotransplantation for Renal Artery Aneurysm: Case Series and a Systematic Review.

OBJECTIVES: Renal artery aneurysm (RAA) is a rare vascular disease. Kidney autotransplantation (KAT) is the treatment option when endovascular approach is not available. However, the evidence on KAT for RAA is mostly limited to small case series or reports. Here, we describe our 2 center experience of KAT for RAA, and provide the results of our systematic literature review to evaluate the outcomes. METHODS: A retrospective 2 center study was conducted in patients undergoing KAT for RAA between 2010 and 2018. Moreover, a systematic review was performed on medical databases to evaluate the outcomes of KAT for RAA. RESULTS: Nine patients were surgically treated at our institutions: eight with laparoscopic nephrectomy (LN), and 1 with open followed heterotopic KAT. All RAAs were ex-vivo reconstructed, and in 3 cases a vein graft was used for reconstruction. There were 2 postoperative major complications including 1 graft loss. In the systematic review, 102 studies with 355 patients were included. In 35 patients (9.9%) a minimal invasive approach was performed. The incidence of postoperative major complications and graft loss was 9.4% and 4.1%. CONCLUSIONS: Our experiences showed that laparoscopic approach for nephrectomy followed heterotopic KAT was feasible with good postoperative outcomes. KAT is an effective treatment for RAA when endovascular approach is not feasible for interpretation of the outcomes, the quality and sample size of the evidence should be taken into consideration.

Outcomes of Small Renal Artery Targets in Patients Treated by Fenestrated-Branched Endovascular Aortic Repair.

OBJECTIVE: The aim was to evaluate renal related outcomes in patients who had incorporation of a small (<4.0 mm) renal artery (RA) during fenestrated-branched endovascular aortic repair (F-BEVAR). METHODS: A total of 215 consecutive patients enrolled in a prospective F-BEVAR trial were reviewed. Computed tomography angiography centreline of flow reconstruction was used to measure mean RA diameter. Patients who had at least one <4.0 mm main or accessory RA incorporated by fenestration or directional branch (study group) were compared with patients who had incorporation of two ≥5.0 mm RAs (control group). Endpoints were technical success of RA incorporation, RA rupture and kidney loss, primary and secondary RA patency, RA branch instability and re-interventions, and renal function deterioration. RESULTS: Twenty-four patients with 28 <4.0 mm RAs (16 accessory and 12 main RAs) were compared with 144 patients with 288 ≥5.0 mm incorporated RAs. Study group patients were significantly younger than controls (72 ± 8 vs. 75 ± 8 years, p = .04) and more often females (46% vs. 21%, p = .018); there were no differences in cardiovascular risk factors and aneurysm extent. Technical success was 92% for <4.0 mm and 99% for ≥5.0 mm RA incorporation (p = .05). Inadvertent RA rupture occurred in three patients in the study group (13%) and in one (1%) in the control group (p = .009) resulting in kidney loss in two study group patients (8%) and one (1%) control group patient (p = .05). At one year, primary patency was 79 ± 9% vs. 94 ± 1% (p < .001) and secondary patency was 84 ± 8% vs. 97 ± 1% (p < .001) for study vs. control group; freedom from branch instability was 79 ± 9% vs. 93 ± 2% (p = .005), respectively. There were no differences in re-intervention rates and renal function deterioration between the groups. The mean follow up time was 21 ± 14 months. CONCLUSION: Incorporation of <4.0 mm RAs during F-BEVAR is associated with lower technical success, higher risk of arterial disruption and kidney loss, and lower patency rates at one year.

Retrospective evaluation of the endovascular repair of the anastomotic pseudoaneurysm of the transplanted renal artery using the snorkel technique.

OBJECTIVE: To evaluate the endovascular repair of the transplanted renal artery anastomotic pseudoaneurysm using the snorkel technique. METHODS: From April 2012 to December 2017, we performed endovascular repair in six patients, who were diagnosed with transplanted renal artery anastomotic pseudoaneurysm, using the snorkel technique. The "snorkel" stent and the "parallel" stent were placed in the transplanted kidney and the external iliac artery, respectively. Another covered stent was implanted at the proximal end of the external iliac artery to match the diameter of the iliac artery.Result and conclusion: Of the six patients, three patients recovered. Two patients experienced pseudoaneurysm rupture due to infection, and one patient developed stent thrombosis; all three patients underwent graft nephrectomy. The endovascular treatment of transplanted renal artery anastomotic pseudoaneurysm with the snorkel technique is a feasible method but needs to comply with certain indications.

Endovascular Treatment for a True Aneurysm of the Transplant Renal Artery using Noncovered Stent-Assisted Coil Embolization.

True degenerative aneurysms involving the donor renal artery after kidney transplantation are rather rare. The indications for operation and optimal therapy to combat this vascular complication are still not clear. Surgical revision has been used as a potential treatment: nonetheless, it has been associated with high risk of complications. In the present study, we report on a 31-year-old woman with a true aneurysm located at a transplant renal artery after transplantation which was successfully managed with stent-assisted coil embolization, resulting in occluded aneurysm sac and well-preserved renal function without any complication. We present technical details of this endovascular procedure, which may be useful for transplant renal artery aneurysm repair in high-risk surgical patients.

Renovascular hypertension: results in adulthood of renal autotransplantation performed in children.

BACKGROUND: This study describes the long-term results of renal autotransplantation for renovascular hypertension performed in children who are now 21 years of age or older. METHODS: Sixteen children (4 boys, 12 girls) with a mean age of 11.2 years at the time of the procedure underwent ex-vivo surgery at the university hospital of Saint-Etienne between 1992 and 2008. Acetylsalicylic acid was used for antiplatelet therapy in the postoperative period, without routine anticoagulation. The mean follow-up period was 15 years. The clinical course of these patients was retrospectively reviewed in adulthood and the results analyzed. RESULTS: The children were treated with a mean of 2.37 drugs per patient, and the mean preoperative blood pressure of the entire patient population was 151/89 mmHg. Mean preoperative creatinine clearance was 80 ml/min/1.73 m2. There was no postoperative death. One patient experienced a thrombosis immediately after the surgery, leading to a redo surgery. In this patient diuresis was restarted, but without efficient concentration and filtration, ultimately leading the patient to have a renal transplant after 1 year. At the end of the follow-up period, eight of the 16 patients (50%) were cured and the others were improved. At the last follow-up the mean blood pressure was 127/70 mmHg, and the mean number of drugs per patient was 0.68. The mean creatinine clearance at last follow-up was 104.3 ml/min/1.73 m2. Three patients had secondary procedures, with two undergoing percutaneous angioplasty (at postoperative months 9 and 12, respectively) and one having an hepatorenal bypass at postoperative year 4. Primary patency was 12/16 (75%); primary assisted patency was 15/16 (94%); secondary patency was 16/16 (100%). CONCLUSION: This study shows that renal autotransplantation has good and stable long-term results and is an effective conservative strategy for treating renovascular hypertension in children, thus avoiding nephrectomy.

[Treatment of ureteral fistula and stricture following renal transplantation with Boari flap].

OBJECTIVE: To estimate the incidence rate of ureteral fistula and stricture after kidney transplantation, and to evaluate the effect of bladder flap (Boari flap) on ureteral complication of the transplanted kidney. 
 Methods: The clinical data and risk factors from 270 recipients of renal transplantation, who came from the Centre of Organ Transplantation, Xiangya Hospital, Central South University from January 2010 to January 2015, were retrospectively analyzed. The surgical management included Boari flap for ureteral reconstruction, neoureterocystostomy and endoscopic therapy with double-J (DJ) stent placement. Surgical proceeding and the effectiveness were evaluated.
 Results: The incidence rate of ureteral fistula following renal transplantation was 3.3%. The risk factors for ureteral fistula included elder donor age (P<0.05), delayed graft function (P<0.01), bladder spasm (P<0.05), and multiple renal arteries in allograft (P<0.01). Four cases were recovered after conservative treatment, and the other 5 cases were recovered after the treatment with Boari flap for ureteric reconstruction. The incidence rate of ureteral stricture was 4.4%. The risk factors for ureteral stricture included elder donor age (P<0.05), delayed graft function (P<0.05), cystospasm (P<0.05), ureteral fistula (P<0.01) and multiple renal arteries in allograft (P<0.01). Four cases underwent endoscopic therapy, 2 of them carried out percutaneous nephrostomy followed by antegrade DJ stent placement and the other 2 patients by retrograde DJ stent placement under ureteroscopy. Eight patients underwent surgery, 6 of them was treated by Boari flap for ureteral reconstruction and 2 patients were treated by neoureterocystostomy. All the patients recovered after surgical management.
 Conclusion: The ureteral complications after renal transplantation include ureteral fistula and stricture. Although the total incidence is low, the complications can result in adverse effects to the graft function and the life quality of the recipients. The risk factors for ureteral complication include elder donor age, delayed graft function, cystospasm, and multiple renal arteries in allograft. Ureteral fistula is the risk factor for ureteral fracture. Boari flap for ureterial reconstruction is an effective method in the treatment of the ureteral fistula and stricture.

Complex renal artery aneurysm managed with hand-assisted laparoscopic nephrectomy, ex vivo repair, and autotransplantation.

A 58-year-old woman had an incidentally found complex right renal artery aneurysm (RAA) during a clinical work-up for diverticulitis. The aneurysm measured 2.5 cm in diameter and was located at the right renal artery bifurcation. She was hospitalized and underwent hand-assisted laparoscopic nephrectomy with ex vivo repair of the RAA and autotransplantation into the right iliac fossa. The same incision was used to remove the kidney from the retroperitoneum as was used to transplant into the right lower quadrant. She tolerated the procedure well. Her postoperative course was uncomplicated. Hand-assisted laparoscopic nephrectomy with ex vivo repair of a complicated RAA and autotransplantation is feasible and safe.

Renal allograft implantation on prosthetic vascular grafts: short- and long-term results.

BACKGROUND: Arterial anastomosis in transplant patients with severe aortic and iliac atheromatosis is technically challenging and may jeopardize the success of the transplantation procedure. The aim of this retrospective study was to report short- and long-term results of a consecutive series of kidney transplant patients in whom the renal artery was implanted on a prosthetic vascular graft. MATERIALS AND METHODS: Medical charts and outpatient clinical records of patients who had undergone renal artery implantation on a prosthetic graft were reviewed. Data on patient characteristics, indications for transplantation, prior vascular procedures, surgical technique, and postoperative and long-term outcome were collected. RESULTS: The renal artery was implanted on a prosthetic graft in the course of 27 kidney transplantation procedures. Patients were divided into three groups according to the timing of the vascular intervention in relation to the transplantation. In group A (n = 22), the vascular prosthesis was implanted before kidney transplantation, in group B (n = 2), prosthetic iliac artery replacement and kidney transplantation were performed simultaneously, while in group C (n = 3), the vascular prosthesis was implanted after kidney transplantation. After a median follow-up of 50.5 months, one case of early arterial thrombosis was observed (3.7 %). Infectious complications occurred in two patients (7.4 %) related to mycotic pseudoaneurysms. One hematoma and one evisceration were also encountered, but no late arterial thrombosis nor stenosis were noted. Mean creatinine levels at 1 and 5 years of follow-up were 1.32 ± 0.36 and 1.27 ± 0.56 mg/dl, respectively. Five-year patient and graft survival rates were 85.2 and 74 %, respectively. CONCLUSIONS: Grafting of the renal artery to a vascular prosthesis is feasible and yields good results, despite the technical difficulties involved. We stress the importance of good teamwork.

Endovascular repair of a para-anastomotic pseudoaneurysm after renal autotransplantation: an alternative to open reconstruction.

Renal artery anastomotic pseudoaneurysms are rare after renal transplantation. The etiology tends to be technical, infectious, or degenerative, and repair is difficult with a high postsurgical complication rate. We report the first case of a complex autotransplant renal artery pseudoaneurysm repaired with kissing covered stents. A 52-year-old woman presented with severe left lower quadrant abdominal pain 6 years after a renal autotransplant for ureteral stenosis and recurrent pyelonephritis. A computed tomographic angiography (CTA) scan revealed a bilobed aneurysm arising at the anastomosis between the renal and common iliac arteries. Kissing covered stents were placed within the common iliac artery proximally and extending into the transplant renal artery and external iliac artery. Postdeployment angiography confirmed complete exclusion of the pseudoaneurysm and excellent flow into the transplant kidney and left lower extremity. A follow-up CTA scan at 1 month revealed continued stent-graft patency and complete exclusion of the pseudoaneurysm. An endovascular approach to transplant anastomotic pseduoaneurysms using kissing covered stents is a viable option to exclude aneurysmal changes and preserve flow to the transplanted organ in carefully selected patients.

Kidney transplant with multiple renal artery grafts from deceased donors: are long-term graft and patient survival compromised?

BACKGROUND: Kidneys with multiple arteries are often transplanted. However, the long-term outcome of such kidneys recovered exclusively from deceased donors is not clear. OBJECTIVE: To determine whether use of renal grafts with multiple arteries affects long-term graft survival and function. METHODS: The outcomes of 259 consecutive kidney transplants between 1996 and 2000 were retrospectively reviewed. Patients were divided into 2 groups, multiple renal artery graft recipients (n = 70) and single renal artery graft recipients (n = 189). Short-term complications and long-term outcomes (survival rates, blood pressure after transplant, creatinine clearance, and proteinuria levels at 1, 3, 5, and 7 years after transplant) were compared between the 2 groups. RESULTS: Early vascular complications were more common (P = .02) in multiple artery graft recipients (18.6%) than in single artery graft recipients (7.9%), mainly because of occlusion of a polar artery in grafts with multiple renal arteries (7.1%). Urologic complications were no more frequent in one group than in the other (5.7% vs 5.3%; P = .89). The 2 groups did not differ significantly (P = .33) in long-term graft survival, with a median follow-up of 9.05 years (range, 0.1-12.7 years). Mean (SD) for creatinine clearance (59.4 [22.6] vs 55.9 [20.3] mL/min; P = .47), proteinuria (0.77 [2.1] vs 0.4 [0.8] g/24 h; P = .19), and systolic blood pressure (133.6 [14.5] vs 133.7 [17.5] mm Hg; P = .85) did not differ significantly between the 2 groups 7 years after transplant. CONCLUSIONS: Kidney transplant with grafts containing multiple renal arteries rather than grafts with a single renal artery does not significantly influence patient and graft outcomes.

Early outcomes of laparoscopic donor nephrectomy with multiple renal arteries.

PURPOSE: We evaluated our experience with laparoscopic donor nephrectomy in patients with multiple renal arteries, comparing operative outcomes and early graft function with patients with a single renal artery. MATERIALS AND METHODS: From January 2003 to February 2009, 130 patients underwent laparoscopic donor nephrectomy at our institution, 108 (83 %) with a single renal artery and 22 (17 %) with multiple arteries. Donor and recipient outcomes for single artery and multiple arteries allografts were compared. RESULTS: The LDN operative time was similar between the single artery and multiple arteries groups (162 vs 163 min, respectively, p = 0.87). Allografts with multiple arteries had significantly longer warm ischemia time (3.9 vs 4.9 min, p = 0.05) and cold ischemia time (72 vs 94 min, p < 0.001) than those with single artery. The conversion rate was similar between single and multiple arteries groups (6 % vs 4.5 %, respectively, p = 0.7). Multiple arteries grafts had a non statistically significant higher rate of poor graft function when compared to single artery grafts (23 % vs 12 %, respectively, p = 0.18). Five patients in the single artery group (4.6 %) and one patient in the multiple arteries group (4.5 %) needed dialysis during the first postoperative week. Overall, recipient complication rates were similar between single and multiple arteries groups (12.9 % vs 18.1 %, respectively, p = 0.51). CONCLUSION: Laparoscopic donor nephrectomy with multiple arteries was associated with a non statistically significant higher rate of poor early graft function. The procedure appears to be safe in patients with multiple arteries, with similar complications rates. Multiple arteries should not be a contraindication for laparoscopic donor nephrectomy.

External Iliac Artery Anastomosis and Internal Iliac Artery Anastomosis for Artery anastomosis in Deceased-donor Kidney Transplantation and Multifactorial Analysis of Graft Survival.

OBJECTIVE: To determine the effects of surgical techniques applied to arterial anastomosis for kidney transplantation on the graft outcome. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Organ Transplantation Center, Ataturk University Research Hospital and School of Medicine, Erzurum, Turkey, from January 2010 to January 2020. METHODOLOGY: In total, 143 consecutive patients who underwent deceased-donor-donor kidney transplantation during a 10-years period were retrospectively analysed. All patients were divided into two groups according to the vascular anastomosis techniques (end-to side external iliac and end-to-end internal iliac). The two groups were compared in terms of urine volume on postoperative days 1 and 7; blood creatinine levels on postoperative days 1, 2, and 7; complications; and graft survival. RESULTS: The mean patient age was 42.04 ± 11.1 years. No significant difference was observed between creatinine values ​​and urine amounts for both surgical techniques (p >0.05). Only the amount of urine on the postoperative 7th day had a significant effect on graft survival (p <0.05). There was no significant difference between the two anastomosis techniques in terms of graft survival (p >0.05). CONCLUSION: Both surgical techniques can be used safely in renal transplantation and arterial anastomosis. Also, decreased urine volume during follow-up can be considered as an early indicator of graft loss in the long-term. KEY WORDS: Kidney transplantation, Surgical anastomosis, Delayed graft function, Graft survival.

Successful Endovascular Repair of Infectious External Iliac Artery Anastomotic Pseudoaneurysm With Graft Preservation Post-Kidney Transplantation: Case Report and Review of Literature.

BACKGROUND: Allograft artery-infected pseudoaneurysm (PA) represents a rare but life-threatening complication of kidney transplantation (KT). A review of the literature, showed that nearly all these cases ended resulted in graft loss. We presented a case of post-KT-infected external iliac artery anastomotic PA successfully managed by endovascular stenting with graft preservation. Additionally, we reviewed the pertinent literature. METHOD: In this article, we described a hypertensive, 47-year-old man who presented 1 month post-cadaveric KT with acute kidney injury and gram-negative bacteremia secondary to a large infectious anastomotic PA of the external iliac artery. RESULTS: Because of favorable anatomy, successful arterial angio-stent fixation of the main renal artery PA, sparing the lower polar artery, was performed after 1 week of antibiotic and fungal coverage. CONCLUSION: Patient was discharged after 2 weeks with functioning graft. Graft function was stable after 3 months.

Predictive Model of Ureteral Obstruction of Allograft Kidney Following Living Donor Kidney Transplantation.

BACKGROUND: Ureteral obstruction is one of the most frequent urologic complications of kidney transplantation. This study aimed to analyze independent factors that contribute to ureteral obstruction following kidney transplantation and develop predictive models form those factors. METHODS: As many as 545 kidney transplantations were analyzed. Patients underwent transplantation between January 2014 and December 2018. Logistic regression analysis was used to develop the predictive model. Both donor and recipient demographic characteristics and operative parameters were analyzed and presented. RESULTS: There were 37 (6.8%) subjects who developed ureteral obstruction. The independent risk factors for ureteral obstruction were multiple allograft renal arteries, older donor ages (>38 years), and older recipient age (>60 years). From the receiver operating characteristic (ROC) curve analysis, the area under the ROC curve of the predictive model was 0.843 (P < .001). Subjects with >2 renal allograft arteries, recipient age >60 years, and donor age >38 years had 83.8% probability of developing ureteral stenosis after kidney transplantation. CONCLUSION: Donor age, recipient age, and multiple renal arteries were independent risk factors of graft ureteral obstruction. Probability of developing ureteral obstruction should be considered pre-operatively in our population, using the proposed predictive model.

Transplant Renal Artery Stenosis: A Case Report of Functional Recovery Six Months After Angioplasty.

Transplant renal artery stenosis (TRAS) is a common vascular complication after kidney transplantation, leading to worsening or refractory hypertension, deterioration in renal function, and possible cause of graft loss. Early diagnosis and an appropriate treatment are crucial for organ preservation. Endovascular treatment, including percutaneous transluminal angioplasty and stent implantation, is considered the first-line therapy for TRAS. Here we report the case of a 69-year-old woman with end-stage renal disease for chronic kidney disease not biopsy proven, who underwent a kidney transplant from expanded criteria donors on December 2018. Postoperative course was characterized by delayed graft function. Doppler ultrasonography (US) showed an increase of peak systolic velocity at the origin of the renal artery, and parvus-tardus waveform in periferic graft arteries and an abdominal computed tomography scan confirmed a stenosis at the origin of the main renal artery (TRAS). The patient underwent a percutaneous transluminal angioplasty. It was not possible to place a stent at the particular location of the stenosis at the anastomosis. Despite the improvement of the graft's perfusion, monitored with Doppler US, the patient showed a very poor improvement in renal function and remained on hemodialysis for months. A percutaneous needle biopsy reported a normal renal parenchyma and excluded acute rejection. During this period, the patient received immunosuppressive therapy. About 6 months after the transplant, the patient had an unexpected and slow renal function recovery until she was weaned completely from hemodialysis.

Orthostatic Renal Transplant Compression Following Weight Gain Leading to Acute Kidney Injury.

BACKGROUND: We present a first case of orthostatic renal graft compression and acute kidney injury following weight gain. CASE REPORT: A 61-year-old male with a second cadaveric transplant presented with acute kidney injury - creatinine rise from 80 to 210 µmol/L (0.90 to 2.38 mg/dL). His medical history included diabetes, hypertension, ischemic heart disease, and obesity despite bariatric surgery. Renal biopsy was consistent with acute tubular necrosis. Serial renovascular duplex studies showed absence of diastolic flow and reduced renal perfusion despite a patent renal transplant artery and vein. Raising the fatty apron cephalad normalized renal blood flow with resistive indices throughout the kidney. Subsequent laparascopy ruled out adhesional obstruction and carbon dioxide angiogram confirmed normal transplant vessels, anastomotic sites, and intrarenal branches. He was treated with bedrest and an abdominal support belt with improvement of creatinine to 100 to 110 µmol/L (1.1-1.2 mg/dL). CONCLUSIONS: Transplant physicians and surgeons need to be aware of positional renal graft compression from an enlarged bulky omentum and fatty apron. Diagnosis requires positional sonography.

[Treatment of a complex renal artery aneurysm by renal autotransplantation]. / Traitement d'un anévrisme complexe de l'artère rénale par autotransplantation rénale.

Renal artery aneurysm (AAR) is rare and usually asymptomatic; rupture, thromboembolism are aneurysmal complications that can then lead to renal infarction. AAR is often found fortuitously when exploring other diseases. Renal autotransplantation (RAT) is an alternative treatment for complex AAR, with satisfactory outcomes described in the literature.

Laparoscopic procurement of single versus multiple artery kidney allografts: Meta-analysis of comparative studies.

Laparoscopic donor nephrectomy has become the standard procedure to procure kidney graft. Transplantation using multiple arteries allograft is technically more challenging and still controversial with respect to renal transplantation outcomes. The objective of this study was to examine the transplantation outcome in both donor and recipient outcome of multiple arteries allograft kidney compared with single renal artery kidney. Eligible studies were identified from electronic databases: PubMed, Cochrane CENTRAL, Science Direct, and CINAHL as of October 2016. Relevant parameters explored using Review Manager V5.2 included donor and recipient outcomes. Twenty-four studies were included in this meta-analysis. Compared with SA, MA kidneys were associated with a longer donor operative time. There was no difference between donor length of stay, intraoperative blood loss, hospital stay, first warm ischemic time (WIT-I), and donor surgical complications in donors with multiple arteries compared with single. There was an increased risk of one-year graft loss (OR 1.57, 95% CI 1.09 to 2.26, p = 0.016), recipient vascular complications and recipient ureteral complications in multiple arteries compared with single artery allografts. Kidney transplantation with multiple arteries is relatively as safe as single artery in terms of donor outcomes. However, transplantation with multiple arteries allograft had several potential negative impacts on the recipient outcomes.

Salvage of hyperacute renal transplant hypoperfusion with stent placement: a case report.

The authors report on a patient who underwent renal artery stent placement 6 hours after transplantation due to acute hypoperfusion of the transplant, which was diagnosed with intraoperative Doppler ultrasonography. Extensive atherosclerotic disease of the cadaveric transplant renal artery necessitated endarterectomy before creation of the anastomosis, and no further surgical options were considered feasible by the transplant surgeon. Six hours after the transplantation, percutaneous transluminal renal angioplasty and stent placement were performed, resulting in restoration of normal arterial flow and rescue of allograft function.