Multicentric Long-Term Results of Aorto Bi Femoral Bypasses Performed Before Kidney Transplantation

Abstract

Introduction - Kidney recipients are increasingly older, leading to extended aorto iliac calcifications that can contra-indicate transplantation in absence of previous procedure to get a safe and suitable access even in asymptomatic patients. We aimed to describe the results of aorto bi femoral bypasses performed as a preparation for kidney transplantation. Methods - This retrospective multicentric study included 89 patients (76 men) over 11university centers, mean age of 55.9 (27-76), who underwent revascularization from 1984 to 2016 by transperitoneal (n=75), retroperitoneal (n=11) and 3 times coelioscopic approaches. Vascular prosthesis was PET (n=84) or PTFE (n=5). Nineteen have had previous kidney transplantation, 79 were on dialysis at time of surgery. A subgroup analysis was performed depending on Rutherford class: 36 class 0 and 1 were included in group I (GI) and 53 class 2 to 6 in group II (GII). Results - Overall major complications after bypass surgery were 14/89 (15.7%): 2 infections, 6 ischemia (2 mesenteric, 1 medullar, 3 limb occlusions), 4 hemorrhages and 2 myocardial infarctions. The latest were responsible of a 30-day mortality of 2/89 (2.2%), 2.8% in GI (1/36) and 1.9% in GII (1/53). There was no lost of follow-up with a mean duration of 6.3 years. According to Kaplan-Meier analysis, at 1 and 5 years, survival was respectively 92.7% and 75.7% for overall population, 97% and 92.9% for GI, 93.5% and 69.6% for GII. Survival was significantly higher in GI (log-rank p=0.044). Five-year primary patency was 88.4% without significant difference between GI and GII (96.3% vs 81.8%). In GI, 13 patients had secondary procedures (5 limb occlusions, 2 infections, 6 run-off impairment) vs 16 in GII (8 limb occlusions, 5 infections, 3 run-off impairment). In the overall population, 47 patients underwent kidney transplantation (52.8%), 20 in GI (55.6) and 27 in GII (51%). Overall mean time from waiting list inscription to kidney transplantation was 26±29 months, significantly shorter in GI (1.2±0.9 vs 2.8±2.9, p=0.038). Eleven patients among 89 (12.4%) died before transplantation, 3 in GI (8.3%) vs 8 (15.1%). Fourteen remain on waiting list, 2 (5.6%) in GI vs 12 (21.4%). Seventeen patients (19.1%) are currently under temporary contra-indication, 10 (27.8%) in GI vs 7 (13.2%). At time of transplantation, arterial anastomosis was performed on the vascular prosthesis in 46 of the 47 cases. Mean warm ischaemia duration was 66±34 min. Overall 30-Day mortality after transplantation was 2.1% (1/47) solely in GI. At discharge, mean creatinine clearance was 35.9±19.4 ml/min/1.73 m2. Graft loss occurred in 17% (8/47) and at last follow up mean creatinine clearance was 43.6±17.7 ml/min/1.73 m2. Conclusion - In end stage renal disease patients, aorto bi femoral bypass is an effective strategy to prepare kidney transplantation. It provides acceptable long-term results despite a high rate of secondary arterial reinterventions. This strategy poses a life-threatening risk in initially asymptomatic patients without any guarantee to undergo transplantation. This could be considered as an ethical key-point.