Failure of endovascular abdominal aortic aneurysm graft limb in a kidney transplant patient: a case report.

Abstract

Kidney transplantation after endovascular aneurysm repair (EVAR) has been reported only once in the literature with a good outcome (1). We reported a similar but unsuccessful case in which the renal transplant was performed 18 months after EVAR. The patient was a 55-year-old man with end-stage renal disease secondary to glomerular nephropathy and infrarenal abdominal aortic aneurysm (diameter: 5.5 cm) who underwent endovascular insertion of a first-generation bifurcated stent graft (Vanguard Endovascular Aortic Graft, Meadox/Boston Scientific Vascular, Natick, MA). Eighteen months later, the patient underwent left pelvic renal transplantation; the renal artery was anastomosed to the left external iliac artery distally to the stent graft. The patient experienced no operative complications. Twelve months after the kidney transplant, the patient acutely developed dramatic left limb ischemia and became anuric. Angiography disclosed occlusion of the endograft left limb, proximal to the renal transplant. The pelvic kidney was poorly supplied by reversal flow of left limb collateral vessels. The patient was treated with an extra-anatomic femorofemoral bypass ensuring limb and renal perfusion by reversal flow through the external iliac artery. Despite the results of the angiography, the patient experienced left limb intermittent claudication. Reduced urine production after prolonged walking was mainly noted, which resolved at rest. On the basis of these clinical indications, a steal phenomenon of the kidney from the inferior limb during walking was detected by exercise renography using a bicycle ergometer (2). In consideration of the renal ischemia caused by the vascular steal, a potential threat of transplanted kidney loss, the patient underwent endograft removal and bilateral aortoiliac bypass graft (Fig. 1a) without any form of kidney protection. The patient experienced no postoperative complications. At 12-months follow-up, a magnetic resonance scan revealed no vascular defects of the pelvic kidney or inferior limbs, and the patient’s creatinine level was 1.2 mg/dL. Figure 1: (a) A patent femorofemoral bypass graft (black arrow) furnishing blood flow to the left limb and pelvic kidney (white arrow). (b) A magnetic resonance scan at 12 months follow-up reveals a patent aortoiliac vascular graft without vascular defects of pelvic kidney or inferior limbs.In conclusion, kidney transplantation in patients with endoluminal bifurcated aortic stent graft can be hazardous because of unpredictable complications of EVAR. In patients with prior EVAR, renal transplantation should be performed after 3 years of event-free complications. In uremic candidates for renal transplantation, it is advisable to undertake endovascular repair of concomitant aortoiliac lesions only in patients unfit for open surgery. The number of patients requiring both aortoiliac reconstruction and kidney transplantation is increasing. Recently, the feasibility of EVAR and the short-term benefits of this approach compared with conventional open surgery has led to successful endovascular treatment in association with kidney transplantation (3). Nevertheless, the crucial and as yet unresolved problem of EVAR concerns its efficacy in the long-term. At midterm follow-up, EVAR may present two major complications. The first complication is the persistent pressurization of the aneurysm (with or without endoleaks), which is responsible for an annual rupture rate of 1% (4). The second complication, occurring at longer follow-up, concerns geometric changes in aortic endograft and morphologic alterations of the aneurysm sac that may induce later limb thrombosis. Kramer et al. (5), studying geometric changes in aortic endografts during a 2-year observation period, concluded that aortic endografts are exposed to a significant amount of movement after insertion, but that the resulting changes are inhomogeneous, unpredictable, and ongoing even after 2 years. Michele Mirelli Tiziano Curti Gabriele Testi Massimo D’Addato Maria Piera Scolari Giovanni Liviano D’arcangelo Sergio Stefoni