Papers Presented at the Peripheral Vascular Surgery Society Aortic Reconstruction in Kidney Transplant Recipients Jean M. Panneton, MD, Peter Gloviczki, MD, Linda G. Canton, RN, BSN, Thomas C. Bower, MD, Matthew S.T. Chow, MD, Peter C. Pairolero, MD, Hartzell V. Schaff, MD, John W. Hallett, Jr., MD, and Kenneth J. Cherr)~ Jr., MD, Rochester, Minnesota Renal transplantation has increased the longevity of patients with uremia. An increasing number undergo aortic reconstruction, which exposes the transplanted kidney to ischemic injury. To evaluate the risk for renal failure, loss of the transplant, and methods of renal protection, we reviewed our experience. Clinical data were reviewed for 10 consecutive patients (7 men, 3 women; mean age 52.7 years [range 32 to 75 years]) with a transplanted kidney who underwent aortic reconstruction between 1977 and 1994 at our institution. Mean interval between renal transplantation and aortic reconstruction was 5.9 years (range 1 month to 12.7 years). Seven patients required emergency repair because of dissection (2 patients), aneurysm rupture (4 patients), or symptomatic aneurysm (1 patient); three underwent elective repair. Reasons for reconstruction included aortic dissection (2 patients), aneurysm of the descending thoracic (2 patients), thoracoabdominal (1 patient), or abdominal aorta (3 pa- tients), and aortoiliac occlusive disease (2 patients). Patients with thoracic or thoracoabdomi- nal reconstructions underwent repair with atriofemoral, aortofemoral, or femorofemoral shunt placement or bypass. Of the five abdominal aortic reconstructions, the kidney was protected with aortofemoral shunt placement in one patient and cold renal perfusion in three. In two of them, topical cooling of the kidney also was used. One patient with acute aortic dissection died at 39 days as a result of respiratory failure. Loss of the recently transplanted kidney was caused by acute rejection. One patient had a transient increase in serum creatinine concen- tration. Eight had no worsening of renal function, and none of the nine survivors lost the transplanted kidney. We conclude that aortic reconstruction can be safely performed in kidney transplant recipients. Patients in whom thoracic or thoracoabdominal aortic reconstruction was required were protected with an atriofemoral or aortofemoral bypass or shunt. Patients undergoing abdominal aortic reconstruction did well when cold renal perfusion with or without local cooling of the transplant was used for renal protection. Transplanted kidneys appeared to tolerate ischemic injury similarly to native kidneys. (Ann Vasc Surg 1996;10:97-108.) From the Division of Vascular Surgery and Division of Thoracic and Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn. Presented at the Twentieth Annual Meeting of the Periph- eral Vascular Surgery Society, New Orleans, La., June 10, 1995. Reprint requests: Peter Gloviczki, MD, Mayo Clinic, Divi- sion of Vascular Surgery, 200 1st St. SW, Rochester, MN 55905. Chronic renal failure and long-term hemodialysis are known predisposing factors for development of accelerated atherosderosis.' Renal transplanta- tion has increased the longevity of patients with uremia, and renal transplantation is now per- formed in older patients in their seventh and eighth decades. Consequently an increase in the prevalence of aortic atherosclerotic disease, either 97
Transcript
Papers Presented at the Peripheral Vascular Surgery Society
Aortic Reconstruction in Kidney Transplant Recipients
Jean M. Panneton, MD, Peter Gloviczki, MD, Linda G. Canton, RN, BSN, Thomas C. Bower, MD, Matthew S.T. Chow, MD, Peter C. Pairolero, MD, Hartzell V. Schaff, MD, John W. Hallett, Jr., MD, and Kenneth J. Cherr)~ Jr., MD, Rochester, Minnesota
Renal transplantation has increased the longevity of patients with uremia. An increasing number undergo aortic reconstruction, which exposes the transplanted kidney to ischemic injury. To evaluate the risk for renal failure, loss of the transplant, and methods of renal protection, we reviewed our experience. Clinical data were reviewed for 10 consecutive patients (7 men, 3 women; mean age 52.7 years [range 32 to 75 years]) with a transplanted kidney who underwent aortic reconstruction between 1977 and 1994 at our institution. Mean interval between renal transplantation and aortic reconstruction was 5.9 years (range 1 month to 12.7 years). Seven patients required emergency repair because of dissection (2 patients), aneurysm rupture (4 patients), or symptomatic aneurysm (1 patient); three underwent elective repair. Reasons for reconstruction included aortic dissection (2 patients), aneurysm of the descending thoracic (2 patients), thoracoabdominal (1 patient), or abdominal aorta (3 pa- tients), and aortoiliac occlusive disease (2 patients). Patients with thoracic or thoracoabdomi- nal reconstructions underwent repair with atriofemoral, aortofemoral, or femorofemoral shunt placement or bypass. Of the five abdominal aortic reconstructions, the kidney was protected with aortofemoral shunt placement in one patient and cold renal perfusion in three. In two of them, topical cooling of the kidney also was used. One patient with acute aortic dissection died at 39 days as a result of respiratory failure. Loss of the recently transplanted kidney was caused by acute rejection. One patient had a transient increase in serum creatinine concen- tration. Eight had no worsening of renal function, and none of the nine survivors lost the transplanted kidney. We conclude that aortic reconstruction can be safely performed in kidney transplant recipients. Patients in whom thoracic or thoracoabdominal aortic reconstruction was required were protected with an atriofemoral or aortofemoral bypass or shunt. Patients undergoing abdominal aortic reconstruction did well when cold renal perfusion with or without local cooling of the transplant was used for renal protection. Transplanted kidneys appeared to tolerate ischemic injury similarly to native kidneys. (Ann Vasc Surg 1996;10:97-108.)
From the Division of Vascular Surgery and Division of Thoracic and Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn.
Presented at the Twentieth Annual Meeting of the Periph- eral Vascular Surgery Society, New Orleans, La., June 10, 1995.
Reprint requests: Peter Gloviczki, MD, Mayo Clinic, Divi- sion of Vascular Surgery, 200 1st St. SW, Rochester, MN 55905.
Chronic renal failure and long-term hemodialysis are known predisposing factors for development of accelerated atherosderosis.' Renal transplanta- tion has increased the longevity of patients with uremia, and renal transplantation is now per- formed in older patients in their seventh and eighth decades. Consequently an increase in the prevalence of aortic atherosclerotic disease, either
97
Annals of 98 Panneton et al. Vascular Surgery
Table I. Aortic reconstruction in 10 kidney transplant recipients
Patient-related variables
Associated risk Cause of end-stage Interval Patient Age/sex factors renal disease Transplant Recipient vessel (yr)
10 Modera te AIOD, Elective 45 Perfusion cooling Yes Survived
severe RVH
AAA = abdominal aortic aneurysm; A1OD = aortoiliac occlusive disease; DTAA = descending thoracic aortic aneurysm; ECC = extracorporeat circulation; NA = not available; RVH = renovascular hypertension; TAAA = thoracoabdominat aortic aneurysm, *Nonfunctional transplant due to acute rejection that occurred before the aortic dissection and required a staged transplant nephrectomy 10 days after the aortic repair. tTransient elevation of creatinine concentration, from 3.1 mg/dl to 5,0 mg/dl.
aneurysmal or occlusive, in kidney transplant recipients can be expected. Therefore aortic recon- struction in kidney transplant recipients will be needed more frequently in the future. The issue of kidney transplant protection from ischemic and reperfusion injury during aortic surgery will arise as a clinical management problem. To examine this problem we reviewed our surgical experience with aortic reconstruction in kidney transplant recipients.
MATERIAL A N D M E T H O D S
All kidney transplant recipients undergoing aortic reconstruction at the Mayo Clinic during the past 18 years were identified and their clinical data reviewed. Follow-up data were obtained from outpatient clinic records for all patients. The sta- tus of the kidney transplant, the occurrence of rejection, and change in the initial immunosup- pressive therapy were determined. Transient post- operative renal dysfunction was defined as an increase in the relative creatinine concentration of more than 40% over preoperative values.
RESULTS
Ten consecutive patients, recipients of a trans- planted kidney, underwent aortic reconstruction between January 1, 1977, and January 31, 1995. Seven patients were men and three were women. Their mean age was 52.7 years (range, 32 to 75 years). Associated risk factors for atherosclerosis included hypertension in nine patients, coronary artery disease in five, and peripheral vascular disease in three (Table I). Seven patients received cadaveric kidneys and three received a kidney from a living related donor. All but one (patient 6) were recipients of their first kidney transplant. The artery of the transplanted kidney was anas- tomosed to the external iliac artery in six patients and to the internal iliac artery in four. Two of the l0 patients had one episode of rejection and two others had more than one rejection episode. Im- munosuppressive therapy included a combination of steroid plus azathioprine (7 patients), steroid plus cydosporine (2 patients), and triple-agent immunosuppressive therapy (1 patient). The mean interval between renal transplantation and aortic reconstruction was 5.9 years (range 1 month to 12.7 years).
Seven patients required emergency repair be- cause of acute aortic dissection (2 patients), aneu- rysm rupture (4 patients), and symptomatic aneu-
rysm (1 patient). Three patients underwent elec- tive repair (Table II). Indications for aortic reconstruction included acute aortic dissection (type A and type B, 1 patient each), aneurysms of the descending thoracic or thoracoabdominal aorta (3 patients) (Fig. 1), abdominal aortic aneu- rysms ( 3 patients) (Fig. 2 ), and aortoiliac occlusive disease (2 patients) (Fig. 3). One of the patients with aortoiliac occlusive disease also had severe renovascular hypertension caused by stenosis of the iliac and transplanted renal arteries (Fig. 4). All i0 patients underwent aortic graft replacement. One patient also required aortic valve resuspension and coronary reimplantation. In another patient a bifurcated graft was used to replace the infrarenal aorta. In this patient the artery of the transplanted kidney was reimptanted into the right limb of the graft (see Fig. 4). Mean aortic cross-clamping time in the 10 patients was 46.3 minutes (range 25 to 64 minutes ).
All patients with thoracic or thoracoabdominal aortic reconstruction underwent atriofemoral, aortofemoral, or femorofemoral shunt placement or bypass. Of the five abdominal aortic recon- structions, the transplanted kidney was protected by an aortofemoral Gott shunt in one patient and by perfusion cooling in three (Fig. 5). Two of them also underwent topical cooling of the kid- ney with ice. The perfusate was cold (4 ° C) lactated Ringer's solution with heparin (1000 U~) and mannitot (12.5 gm/L). One patient had no protection. Intravenous infusion of mannitol and low-dose dopamine (2 b~g/kg/min) and injec- tion of furosemide and heparin were used in various combinations in most patients.
One death occurred (patient 2) after 39 days as a result of respiratory failure caused by cytomeg- alovirus pneumonia. This 32-year old patient had acute rejection of a living related donor transplant followed by acute type B aortic dissection. He underwent successful graft replacement of the descending thoracic aorta and required a staged transplant nephrectomy 10 days later. Of the nine survivors, only one with a ruptured dissecting descending thoracic aneurysm had a transient postoperative increase in the serum creatinine concentration, from 3.1 mg/dl to 5.0 mg/dl. None of the other eight patients had significant tran- sient worsening of renal function (Fig. 6), and none of the survivors lost their transplanted kid- ney. Early patency of the renal artery was con- firmed in four patients (see Figs. 2, C and 4, C). Postoperative complications developed in five pa- tients. These included pneumonia in three pa-
Text continued on p. 104.
Annals of 100 Panneton et aL Vascular Surgery
A
B C
Fig. 1. A, CT scan of a type IV thoracoabdominal aortic aneurysm. B, Aortogram of the same patient confirms the aortic aneurysm. C, Arteriogram from the level of the aortic bifurcation shows the transplanted kidney perfused through the left internal iliac artery.
A
B
C
Fig. 2. A, CT scan confirms a massive retroperitoneal hematoma from a ruptured abdominal aortic aneurysm. B, CT scan of a lower section shows the perfused transplanted kidney in the left iliac fossa surrounded by the hematoma. C, Intraoperative postreconstruction duplex ultrasound scan confirms patency of the transplanted renal artery (R.A) anastomosed to the left external iliac artery (EIA).
Fig. 3. Aortogram shows an aortoiliac graft with a steno- sis at the origin of the right limb perfusing a transplanted kidney. The right external iliac artery is occluded. Also note severe narrowing at the origin of the left limb of the graft.
A
B C
Fig. 4. A, Aortogram shows distal aortic plaque overhanging the origins of both common iliac arteries, with the transplanted kidney anastomosed to the right internal iliac artery. 13, Aortogram demonstrates the anastomotic stenosis of the transplanted renal artery and the severe stenosis at the origin of the right common itiac artery. C, Postoperative digital subtraction arteriogram confirms the technical adequacy and patency of the repair.
Fig. 5. A, Atriofemoral bypass for repair of a type II thoracoabdominal aortic aneurysm provides distal perfusion and protection of the kidney transplant. B, Protection of a kidney transplant with a Gott shunt placed from the aorta to the femoral artery. (3, Perfusion cooling through the recipient iliac artery for kidney transplant protection.
C
Annals of 104 Panneton et al. Vascular Surgery
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Fig, 6. Perioperative and follow-up renal function ex- pressed as the percent change in preoperative serum creatinine measurements after aortic reconstruction in 10 kidney transplant recipients. F/U = follow-up.
tients and myocardial infarction, atrial fibrilla- tion, gastrointestinal bleeding, pancreatitis, and small bowel obstruction in one patient each. Mean intensive care unit stay was 4.7 days (range 1 to 20 days) and mean hospital stay was 18.1 days (range 8 to 39 days). Among the nine survivors, no change in immunosuppression therapy was required.
The nine survivors were followed up for a mean of 4.1 years (range 4.0 months to 11.7 years). One (patient 1 ) experienced chronic transplant rejec- tion caused by chronic tubulointerstitial nephritis after 2.5 years and required a second kidney transplant. Five patients with functioning trans- plants died during follow-up, at 4 months, I year, 3 years, 5 years, and 11 years, respectively, after aortic reconstruction. Causes of death were pul- monary embolism, sepsis, gastrointestinal bleed- ing, myocardial infarction, and diffuse atheroscle- rosis. The four remaining survivors have stable renal function.
D I S C U S S I O N
Aortic reconstruction in kidney transplant recipi- ents has been reported rarely. A review of the literature from 1966 to 1994 revealed only 51 cases of aortic reconstruction performed in pa- tients who previously underwent renal transplan- tation (Table III). 3-~° In a study in which routine arteriography was performed for pretransplanta-
tion evaluation of patients, 1.86% were found to have either aneurysmal or occlusive disease that required pretransplant aortoiliac reconstruction. 3~ Sehti et al. 3 were the first, in 1976, to repair a thoracic aorta in a renal transplant recipient be- cause of a ruptured type B dissecting aneurysm. This was soon followed by two other case re- ports 4'5 on abdominal aortic aneurysm repair after kidney transplantation. None of these three initial patients survived (see Table III). Campbell et al. 6 reported the first successful abdominal aortic an- eurysm repair in a kidney transplant recipient, with femorofemoral partial extracorporeal circu- lation.
An accelerated atherosclerotic process has been well documented in patients with renal failure requiring long-term dialysis. 1'32 With improved long-term survival of patients after renal trans- plantation, complications of atherosclerosis such as occlusive or aneurysmal disease have become more prevalent. Atherosclerotic changes requiring surgical treatment occur much earlier in kidney transplant recipients than in most patients with- out renal failure. Mean age of our patients was 53 years, similar to the mean age of 48 years in the reported patients, who underwent aortic repair after renal transplantation (see Table III). The mean interval between renal transplantation and aortic repair in our series was 5.9 years.
Seven of our 10 patients and 31% of the re- ported cases needed emergency repair. This no doubt is responsible for the high rate of postop- erative complications and the prolonged hospital- ization of these patients. The high prevalence of emergencies also supports the need for more careful follow-up of kidney transplant recipients to detect the presence and progression of aortic aneurysmal or occlusive disease.
Aortic reconstruction in kidney transplant re- cipients raises the issue of protection of the trans- planted kidney. The concept of direct perfusion of the transplanted kidney with an axillofemoral bypass graft or placement of a temporary shunt was introduced by Shons et al. 4 and Sterioff and Parks. ~ However, a decade later Lacombe 14 re- ported successful AAA repair in five kidney trans- plant recipients without any shunt or bypass. Three options are available to the surgeon for protection of the transplanted kidney: distal aor- tic perfusion with a shunt or bypass (see Fig. 5, A and B), perfusion cooling (Fig. 5, C), and topical cooling of the kidney with ice slush. The decision to choose one or a combination of these methods is influenced by several clinical factors
T a b l e I I I . W o r l d w i d e e x p e r i e n c e w i t h a o r t i c r e c o n s t r u c t i o n i n 51 k i d n e y t r a n s p l a n t r e c i p i e n t s f r o m
Sehti et al. 3 1976 38/M Femorofemora l ECC Ruptured type III NA Died, 12 hr d issec t ion
Shons et al.* 1976 32/F P e r m a n e n t axillo- Symptoma t i c mycot ic Yes Died, 64 days femora l graf t AAA
Sterioff and Parks s 1977 54/M Aortoil iac PVC Symptoma t i c AAA No Died, 66 days s h u n t
Campbel l et al. 6 1981 34/M Femorofemora l AAA Yes Survived ECC
Gibbons et al. 7 1982 51/F Temporary axillo- AIOD No Survived femora l graf t
59/M Temporary axillo- Rup tu red AAA No Survived femora l graf t
48 /M Per fus ion cooling AAA No Survived 56/M Aor tofemora l Got t AAA No Survived
s h u n t 44 /M Axi l lofemoral n o n - Symptoma t i c AAA Yes Survived
hepar in ized s h u n t 42/M Atr io femora l Acute type I dis- NA Survived
ECC sect ion 59/M Aor tofemora l Gott AAA No Survived
s h u n t 35/M Femorofemora l AAA No Survived
ECC 27/M Genera l h y p o t h e r m i a AAA No Survived 52/M None AAA No Survived 56/M None AAA No Survived 46/M None AAA No Survived 63/M None AAA Yes Survived 37/M None AAA No Survived 44[F None AIOD No Survived 38/F None AIOD No Survived 55/1: None AIOD No Survived 68//vl None Symptoma t i c AAA Yes Survived 45 /M Femorofemora l Symptoma t i c AAA Yes Survived
ECC 59/M P e r m a n e n t axillo- Ruptured AAA No Survived
femora l graf t 53/M Axil lofemoral Got t Rup tu red AAA Yes Survived
s h u n t 64/M None Rup tu red AAA No Survived 50/1: None Symptoma t i c AAA No Survived 37/M None AIOD No Survived 62 None AAA No Survived 63/M None AAA No Survived 50 None AAA No Survived 42 None AAA No Survived 44 None AIOD No Survived 26 None Ia t rogenic dis- No Survived
sect ion
Ngh iem and Lee s 1982 O 'Mara et aL 9 1983
N u s s a u m e et al. '° 1983
Wolfe and 1984 Wil l iams ~
Hughes et al. ~2 1985
Hi_rage et al. '~ 1986
Lacombe ~* 1986
Harris and May '5 1987
Bit tard et al. ~6 1987
Defraigne and 1987 Limet ~
Schwartz et a l ) s 1988
J ivegard et a l ) 9 1989
Boudreaux et al. 2° 1990 Hopkins et al. 21 1990 Gouny et al. 22 1991
AAA = abdominal aortic aneurysm; AIOD = aortoiliac occlusive disease; ECC = extracorporeal circulation; PVC = polyvinyl chloride, *Significant creatinine increase is defined as a relative increase of >40%. Three of the 51 patients could not be evaluated for the occurrence of postoperative renal failure: one because of early death 3 and two because of preoperative renal failure, n'3°
Continued,
Annals of 106 Panneton et al. Vascular Surgery
T a b l e III. Worldwide exper ience wi th aortic recons t ruc t ion in 51 k idney t ransplant recipients f rom 1976 to 1 9 9 4 - c o n t ' d
61 None AAA No Survived 35 None AIOD No Survived 41 None AIOD No Survived 49 None AIOD No Survived 48 None AIOD No Survived 41 None AIOD No Survived 50 None AIOD No Survived 49 None AIOD No Survived
Wright et al. 24 1991 35/F None AIOD Yes Survived 40/F None Chronic type III dis- No Survived
section Evans et al. 2~ 1991 52/F Femorofemoral AAA No Survived
ECC Wolf et al/~ 1991 51/M Femorofemoral AAA
ECC Jivegard and 1992 None AAA
Holm 27
Matley and Im- 1992 61/M m e l m a n 28
Stavri et al. 29 1993 56/M
Tarantini and 1994 42/F Tchekanov 3°
Yes Survived
No Survived
None Symptomat ic AAA No Survived
Ruptured AAA Yes Survived AxiIlofemoral Gott shun t
None Acute type III dis- NA Survived section
including the complexi ty of the aortic repair, the es t imated dura t ion of aortic cross-clamping t ime and of renal ischemia, the technical l imitat ions and complicat ions associated wi th ext racorporeal bypass or shun t p lacement , and the ischemia tolerance of the t ransp lan ted kidney.
Review of the l i terature revealed that some form of t ransp lan t pro tec t ion was used in only 19 of the 51 pat ients (37%) (Table IV). Distal aortic perfus ion was used in 17 pat ients and included axi l lofemoral graft (4 pat ients) , 4"7"~7 nonhepa r in - ized shun t p lacement (2 pat ients) , ~° Gott shun t p lacement (4 pat ients) , 9'~2'~8'29 and left a t r iofemo- ral bypass (7 patients) .* Among these patients , a 47% incidence of t rans ient creat in ine increase occurred (7 of 15 pat ients) . The rate of t rans ient renal failure was 10% (3 of 31 pat ients) amo n g those in w h o m renal pro tec t ion was not used. t The groups, however, are not comparable, because pa- t ients wi th some form of distal aortic perfus ion appeared to be at h igher surgical risk, u n d e r w e n t
more complex aortic reconstruct ion, and required emergency repair more frequently. In our mater ia l significant t rans ient renal dysfunc t ion developed in only one pat ient despite the use of extracorpo- real circulation. This pat ient wi th preexis tent renal insuff iciency was opera ted on because of a rup- tured dissecting descending thoracic aortic aneu- rysm. Arguments in favor of not using protective measures dur ing aortic repair are that e i ther renal i schemia t ime is short or the residual distal aortic pressure is sufficient to ma in ta in fi l tration pres- sure in the k idney th rough collaterals vessels? 3
Table IV reports the t ransplant salvage rate of 51 case reports publ ished previously. The early t ransp lan t salvage rate in the 50 pat ients w ho s u t u r e d beyond 24 hours was 100%, wi th an overall early survival ra te of 94%, similar to our o w n findings. Loss of the only k idney in our series was caused by acute rejection, not renal ischemia. Renal dys func t ion in one pat ient was t ransient , and no pat ient required postoperat ive dialysis. Because the n u m b e r of reported cases in the l i terature is low, we ma y presume, however, tha t some unsuccessfu l cases remain unreported.
Table IV. Clinical overview of aortic reconstruction in 51 kidney transplant recipients from 1976 to I994
Clinical data No, of patients Percent
Sex* Male 26 72 Female 10 28
Type of transplant-t- Cadaveric 27 71 Living related donor 11 29
Aortic disease AAA 32 63 AIOD 14 27
Dissection 5 10 Aortic surgery
Elective 35 69 Emergent 16 31
Transplant protect ion Yes i9 37 No 32 63
Transplant revascular- ization yes 11 22 No 39 78
Transient creatinine increase~: Yes 10 21 No 38 79
Transplant salvage§ Yes 50 100
No 0 Patient survival
Yes 48 94 No 3 6
*Reported for 36 patients only. tReported for 38 patients only. #Significant creatinine increase is defined as a relative increase of >40%. Three of the 51 patients could not be evaluated for postoperative renal failure: one because of early death 3 and two because of preoperative renal failure. ~~° §One patient died too early to assess transplant salvage?
Our current approach is to provide some form of distal aortic perfusion when aortic reconstruc- tion involves the thoracic or thoracoabdominal aorta. When aortic repair is limited to the ab- dominal aorta, perfusion cooling of the trans- planted kidney 8 is a simple, safe, and efficacious method to prevent renal dysfunction and salvage the kidney transplant. The protective effect of hypothermia has been established by man]," inves- tigators. 34-37 Both topical and perfusion cooling are effective to decrease renal cortical tempera- ture and increase the ischemia tolerance of the kidney. 3s-4° In our experience with 181 thoracoab-
dominal aortic aneurysm repairs, postoperative dialysis was significantly more frequent among patients who did not receive cold renal perfu- sion?' The normothermic ischemic limit for a transplanted kidney is 30 minutes of warm isch- emiaY In a study by Florack et al., 38 after a 30-minute period of warm ischemia, none of their kidney transplants failed; however, 78% showed transient creatinine increase. After 1 hour of warm ischemia, only one kidney sur~ved. Renal ischemia time in our series averaged 46 minutes. Aortic occlusion time beyond 30 minutes with unpredictable distal aortic pressure appears to justify additional renal protective measures.
Cerilli et a l ) 2 performed the first successful simultaneous renal transplantation and abdomi- nal aortic aneurysm repair. Similar simultaneous aortic replacement with kidney transplantation has been safely performed subsequently in other patients. ='24'43'44 Combined aortic reconstruction with kidney transplantation, however, should be performed rarely and should be reserved for can- didates at good risk.
C O N C L U S I O N
On the basis of our experience and review of the reported cases in the literature, we conclude that aortic reconstruction can be safely performed in kidney transplant recipients, with elevated mor- bidity but low mortality and an excellent rate of transplant salvage. The use of bypass or shunt placement during thoracic and thoracoabdominal aortic repair, in our experience, provides adequate renal protection. For abdominal aortic reconstruc- tion, cold perfusion of the kidney and use of ice slush for topical cooling are safe and simple techniques to protect the transplanted kidney during aortic occlusion. Transplanted kidneys ap- pear to tolerate the ischemic injury similarly to native kidneys. REFERENCES
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