Successful aortic surgery aftcr renal transplantation without protection of the transplanted lddncy

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1 Successful aortic surgery aftcr renal transplantation without protection of the transplanted lddncy John Preston Harris, M.S., F.R.C.S., F.RoA.C.S., and James May, M.S., F.R.A.C,S., Sydney, Australia When renal transplant recipients undergo aortic surgery, blood supply to the renal graft is interrupted while the aorta is damped. Several innovative ways of using shunts have been described to preserve blood flow to the transplanted kidney during such surgery on the assumption that temporary warm ischemia of the renal transplant is poorly tolerated. We have performed aortic surgery in four renal transplant recipients without the use of any form of graft protection. One patient underwent urgent operation to treat an expanding aortic aneurysm and the other three had elective surgery for aortoiliac occlusive disease. Ischemic times ranged from 30 to 4 minutes. Two of the four patients had a temporary rise in serum creatinine levels. No patient required hemodialysis. We conclude that in selected renal transplant recipients, aortic surgery can be safely undertaken without graft protection. (J VAsc SUR~ 1987;:47-61.) Several authors have anticipated that an increasing number of renal transplant recipients will require surgical intervention to treat atherosclerotic arteries. la Not only may prolonged hemodialysis accelerate the atherosclerotic process, 4 but also more elderly and diabetic patients undergo renal transplantation. Femorodistal arterial surgical therapy in renal transplant recipients can be done without affecting the blood supply to the transplanted kidney. However, there is concern that the transplanted kidney may suffer ischemic damage during aortic surgery as the blood supply to the renal graft is interrupted, bile the aorta is clamped. 2 Several ingenious methods have been devised to protect the kidney during aortic surgery (Table I). 1-a,sq All have been derived from the assumption that temporary warm ischemia of the renal transplant is poorly tolerated. This article reports our experience with four patients who have undergone successful aortic operation without any form of protection for the transplanted kidney. CASE REPORTS Case 1. A 44-year-old female patient had renal failure as a result of chronic pyetonephritis and received a cadaveric allograft in Five years later she complained of severe claudication in the left lower limb. Arteriography showed atherosclerosis affecting the abdominal aorta and tight stenoses of both common iliac arteries. Aortoiliac bypass From the Department of Surgery, Royal Prince Alfred Hospital, University of Sydney. Reprint requests: J, May, Department of Surgery, Blackburn Building, University of Sydney, NSW 2006, Australia. Fig. 1. Bifurcated graft anastomosed between infrarenai aorta and common iliac bifurcations. was done with a bifurcated woven Dacron graft from the aorta below her native renal arteries to the lilac bifurcations (Fig. 1). Blood supply to the renal transplant was interrupted for 40 minutes. The serum creatinine level rose from 4,7

2 48 Harris and May lournal of VASCULAR SURGERY Table I. Previous reports of renal transplant recipients undergoing aortic surgery Year No. of published Authors patients Method 1976 Shons et al.s 1 Permanent axillofemoral bypass 1977 Sterioff and Parkes 6 1 Temporary polyvinyl shunt 1978 Cox and Sabiston 7 1 Temporary mxillofemoral shunt 1981 Campbell et al.8 1 Pump oxygenator 1981 Gibbons et al.9 2 Temporary axiltofemoral bypass 1982 Nghiem and Lee 1 1 Cold perfusion 1983 O'Mara et al. 2 1 Heparin-bonded shunt 198 Hughes et al.s 1 Heparin-bonded shunt 1986 Lacombe 1 1 General hypothermia 1986 Lacombe 1 No protection 1987 Present series 4 No protection Table II. Summary of aortic operations in four renal transplant recipients Cases Age (yr)/sex Renal disease 44/F Pyelonephritis 38/F Analgesic ne- /F Pyelonephritis phropathy Months on dialysis Years posttransplant Indication for aortic Claudication 3 Claudication; 19 Claudication; operation hypertension hypertension Aortic graft Bifurcated Bifurcated Bifurcated Ischemic time (rain) Blood pressure Unchanged Reduced to Reduced to normal normal Serum creatinine Temporary Reduction to 1.3 Unchanged elevation mg/dl Survival (yr) Cause of death Long-term rejection Myocardial infarction Alive 68/M Glomerulonephritis 72 Aortic aneurysm Straight 38 Unchanged Temporary elevauon 2 Thoracic dissection 3.6 mg/dl preoperatively to a maximum of 4.3 mg/dl before falling to the preoperative level by the tenth postoperative day. Blood pressure remained unchanged at 10/100 mm Hg. Claudication was relieved up to the patient's death 2 years later after long-term rejection. Case 2. A 38-year-old female patient had renal failure caused by chronic pyelonephritis and analgesic nephropathy. She received a cadaveric renal graft in 197. Three years later she had claudication in the right lower limb and uncontrolled hypertension. The serum creatinine level was 2.3 mg/dl. Aortography showed atherosclerotic stenoses of the right common iliac artery and of the right intcrual iliac artery, which supplied the transplanted kidney. A bifurcated Dacron graft (16 mm/8 ram) was used for the aortic reconstruction. The origin of the graft was from the infrarenal abdominal aorta. The right limb of the bifurcated graft was anastomosed to the transplanted renal artery, divided immediately beyond the stenotic segment. The left limb was anastomosed to the right common femoral artery (Fig. 2). The transplanted kidney was ischcmic for 40 minutes. After this operation, claudication was rclicved and the creatinine level fell to 1.2 mg/dl. A/though the patient was normotensive in the immediate postoperative period, she later required antihypettensive medication to contr,~! high blood pressure. She remained in good health until her death 4 years later from myocardial infarction. Case 3. A -year-old woman had renal failure caused by pyelonephritis and hydronephrosis. In 1966 she underwent cadaveric renal transplantation but lost this graft from chronic rejection. She received a second cadaveric transplant in This graft was placed in the left iliac fossa, with the renal artery anastomosed end to side to the external iliac artery. In 198 the patient was admitted with uncontrolled hypertension and bilateral thigh and calfclaudication. Plain x-ray films of the abdomen and an aortogram showed heavy calcification of the aortoiliac segment together with tight stenoses of both common iliac arteries. On three separate occasions, attempts were made to dilate the left common iliac stenosis and there was one attempt to dilate the right iliac stenosis. Despite temporary relief of the claudication and control of blood pressure, symptoms recurred. Aortic reconstruction was then undertaken because the longest period of improvement was only 3 months. The serum creatinine level was 0,9 mg/dl

3 Volume Number 3 March i987 Aortic surety after renal transplantation 49,\ Fig. 2. Bifurcated graft with its origin from infrarenal aorta below the native renal arteries. Right limb of graft joined to renal transplant artery and left limb to right common femoral artery. At operation the infrarenat aorta was heavily calcified and rigid. The supraceliac abdominal aorta was relatively 'ree of disease. This portion of the aorta was used for the origin of the aortic graft to avoid the hazards of clamping the calcified infrarenal aorta and the prolonged ischemic times anticipated if endarterectomy of the infrarenal aorta was attempted. The graft was placed behind the stomach and pancreas. The left limb was anastomosed to the divided left external iliac artery above the transplanted kidney. The right limb was anastomosed to the right external iliac artery (Fig. 3). Blood supply to the transplanted kidney was interrupted for 4 minutes. Better control of blood pressure was obtained postoperatively although the patient still required antihypertension medication. The serum creatinine level was unchanged. Thigh claudication was relieved but right calf claudication persisted until a right femoropopliteal bypass was performed 4 months after the aortic operation. The patient was alive and well at follow-up i ycar later. Fig. 4 shows the postoperative angiogram. Case 4. A 68-year-old man had renal failure because of glomevalonephritis. He underwent hemodialysis for 6 years before receiving a cadaveric renal transplant in Five years later he was admitted complaining of sudden, i!, Fig. 3. Bifurcated graft with its origin from supracdiac abdominal aorta. Right limb of graft anastomosed end to side to right external iliac artery, left limb placed end to end to left external iliac artery above origin of renal transplant artery, which is patched to left external iliac artery. severe pain in the abdomen and back. At operation an edematous, 6 cm infrarenal aortic aneurysm was found but free rupture of the aneurysm had not occurred. The aorta was replaced with a 22 mm straight woven Dacron graft (Fig. ). Ischemic times for the transplanted kidney was 3 minutes. Good urine output was maintained perioperatively; however, the serum creatinine level rose to 2.4 mg/dl before returning to the preoperative level of 1.4 mg/ dl by the fifth postoperative day. Blood pressure was unchanged at 10/90 mm Hg. The patient remained in good health for 2 years before dying of a dissecting thoracic aneurysm in 198. Table II summarizes data from all the case reports. DISCUSSION The methods &scribed to perfusc the transplanted kidney during aortic surge~ have been dc-

4 460 Harris and dvsay Journal of VASCULAR SURGERY ii~; iiill Fig. 4. Postoperatwe angiogram shows bifurcated graft between supraceliac aorta and right external lilac artery and left external iliac artery, supplying renal transplant in left iliac fossa. veloped on the assumption that the transplanted kidney does not tolerate temporary warm ischemia. This assumption is probably incorrect. As Lacombe 1 has pointed out, the transplanted kidney is not completely ischemic and is still partially perfused, albeit at a low pressure, while the aorta is clamped. Lacombe found that aortic back pressure after crossclamping above an aortic aneurysm is usually greater than 3 man Hg and Morris, Heider, and Moyer 1~ have shown experimentally that kidneys perfused at 2 mm Hg remain viable. Certainly aortic occlusion proximal to native kidneys is generally well tolerated, particularly if there is no preexisting impairment of renal function. We have reported our experience with patients in whom the supraceliac aorta was clamped from 1 to 4 minutes. ~2 A temporary rise in creatinine level occurred in 14 of the patients but only one patient, with preexisting renal disease and a preoperative creatinine level of.7 mg/dl, required permanent hemodialysis. The relationship between aortic occlusion time Fig.. Straight graft replaces infrarenal abdominal aortic aneurysm. and renal function after resection of thoracoabdominal aortic aneurysms provides supportive evidence that partially perfused kidneys can tolerate significant periods of warm ischemia. In an analysis of 132 patients, Crawford and Schuessler 13 found that o.nl.y 4 of 49 patients showed any rise in serum creannn**, values when the aortic occlusion time was from 1 to 3 minutes. Similarly, only 2 of 68 patients showed any elevation of serum creatinine levels when the occlusion time was from 3 to minutes. One patient in each of the above-mentioned groups required hemodialysis. When the aortic occlusion time was from to 10 minutes, postoperative serum creatinine levels were elevated in of 1 patients, four of whom required hemodialysis. Lacombe 1 modified the technique of aortic aneurysm resection in renal transplant recipients by dividing the aorta above the aneurysm. He completed the proximal aortic anastomosis without opening the aneurysm, leaving the lumbar collateral vessel undisturbed and saving time. The distal anastomosis is then done, which restores blood flow to the transplanted kidney. Finally the aneurysm is opened, its contents evacuated and the operation completed in

5 Volume Number 3 March 1987 Aortic surety after renal transplantation 461 the usual way by enveloping the aneurysmal sac around the aortic graft. We consider that this modification complicates the aortic surgery and is probably unnecessary. The proximal aortic anastomosis would be awkward above a large aneurysm with a risk of embolization of the aneurysmal content from inadvertent manipulation of the aneurysm while the iliac arteries are unclamped and anastomoses are being completed. The aortic aneurysm described in case 4 was opened after the aorta and common lilac arteries were clamped. The lumbar arteries were oversewn and a straight graft was then inserted in the usual way. End-to-side proximal aortic anastomoses, in those renal transplant recipients undergoing aortic t--:pass operations in the treatment of occlusive disease, have the advantage that blood flow is restored to the transplanted kidney after the proximal aortic anastomosis is completed. This would not be so if the proximal anastomosis was done in an end-to-end fashion. Our experience of successful aortic surgery in four renal transplant recipients, without protection of the transplanted kidney, is similar to that reported by Lacombe. 1 He described six renal transplant recipients undergoing aortic aneurysmectomy in whom five of the transplanted kidneys had no form of protection. Postoperative renal function remained normal in all patients after aneurysmectomy except for one who had a temporary rise in serum creatinine level. We conclude that aortic reconstruction may be safely undertaken in renal transplant recipients, without protection of the transplanted kidney, pro-. ;ded that the ischemic time is not excessive and there is no significant preexisting impairment of renal function. REFERENCES 1. Nghiem DD, Lee HM. In situ hypothermic preservation of a renal allograft during resection of abdominal aortic aneurysm. Am Surg 1982;48: O'Mara CS, Flinn WR, Bergan JJ, Yao ~ST. Use of a temporary shunt for renal transplant protection during aortic aneu~sm repair. Surgery 1983;94: Hughes JD, Milfeld DJ, Shield III CF. Renal transplajnt perfusion during aortoiliac aneurysmectomy. J VAsc SURG 198;2: Lindner A, Charra B, Sherrard DJ, Scribner BH. Accelerated atherosclerosis in prolonged maintenance hemodiatysis. N Engl J Med 1974;290: Shons AR, DeShazo CS, Rattazzi L, Najarian JS. Renal transplantation with blood supply by axillofemoral bypass graft. Am J Surg 1976;132: Sterioff S, Parks L. Temporary vascular bypass for perfusion of a renal transplant during abdominal aneurysmectomy. Surgery 1977;82: Cox JL, Sabiston Jr DC. The use of heparin-bonded shunts for perfusion of the renal artery during resection of complex abdominal aortic anemtsm. Surg Gynecol Obstet 1978; 147: Campbell Jr DA, Lorber MI, Arneson WA, Kirsh MM, Turcorte JG, Stanley JC. Renal transplant protection during abdominal aortic aneurysmectomy with a pump-oxygenator. Surgery 1981;90: Gibbons GW, Madras PN, Wheelock FC, Sahyoun AI, Monaco AP. Aortoiliac reconstruction following fermi transplantation. Surgery 1982;91: Lacombe M. Abdominal aortic aneurysmectomy in renal transplant patients. Ann Surg 1986;203: Morris Jr GC, Heider CF, Moyer JH. The protective effect of subfiltration arterial pressure on the kidney. Surg Forum 196;6: May I, Harris JP. Use of the supraceliac abdominal aorta for repeat aortic surgery. In: Bergan JL Yao IST, eds. Reoperative arterial surgery. Orlando: Gnme& Stratton, inc, 1986: Crawford ES, Schuessler JS. Thoracoabdominal and abdominal aortic aneurysms involving celiac, superior mesenteric, and renal arteries. World J Surg 1980;4:643-2.