Renal Transplantation After Thoracic Endovascular Repair of Type B Aortic DissectiondA Case Report lua, V. Turunça,*, T. S¸enerb, B. Tabandehc, T. Orug c, T. Gürold, A. Aydınd, and B. Güvena A. Erog a Organ Transplantation Center, Goztepe Medical Park Hospital, Istanbul, Turkey; bDepartment of Cardiovascular Surgery, Goztepe Medical Park Hospital, Istanbul, Turkey; cDepartment of General Surgery, Bahcesehir University, Istanbul, Turkey; and dDepartment of Cardiology, Bahcesehir University, Istanbul, Turkey
ABSTRACT Because of the strong association between uremia and atherosclerosis, incidence of aortic aneurysms is increasing among renal failure patients awaiting renal transplantation (RT). Successful RTs have been performed in these patients after surgical repair of the aneurysms. Since Parodi et al introduced endovascular aortic aneurysm repair (EVAR) in patients with high risk for conventional surgery, a new era has begun. The 1st successful RT after EVAR was published in 2001. Herein we report the 1st successful RT after thoracic EVAR (TEVAR) reported to date. We performed RT in a 54-year-old man with end-stage renal failure due to diabetic nephropathy, who had undergone TEVAR for type B aortic dissection (TBAD) 6 months earlier. The postoperative period was uneventful and the patient was discharged from the hospital at postoperative day 6 with a serum creatinine of 0.9 mg/dL. At follow-up examination at postoperative 6 months, graft function was stable. Because of its advantages over open surgery, including low mortality and morbidity, TEVAR is becoming more common among renal failure patients with thoracic aortic aneurysms and TBAD. Our case shows that successful RT can be performed in renal failure patients who have undergone TEVAR.
B
ECAUSE of the strong association between uremia and atherosclerosis, incidence of aortic aneurysms is increasing among renal failure patients awaiting renal transplantation (RT) [1,2]. Successful RTs have been performed in these patients after surgical repair of the aneurysms [3,4]. When Parodi et al reported endovascular aortic aneurysm repair (EVAR) in patients with high risk for conventional surgery, a new era began [5]. The first successful RT after EVAR was reported in 2001 [6]. There are 3 other cases reported from 2001 to date [7e9]. In all of these cases, endovascular repair of abdominal aorta was performed. As far as we know, the present case is the 1st successful RT after thoracic EVAR (TEVAR) reported to date.
(Stanford type B) in another hospital and TEVAR was performed (Fig 1). In his physical examination, right femoral pulse was not palpable, but there was no sign of arterial ischemia in his right lower extremity. Left femoral pulse was palpable. We did coronary and aortoperipheral angiography for further evaluation. There was no significant problem in his coronary arteries and no evidence of endoleaks (Fig 2). The right iliac artery was occluded. The arterial perfusion of the right lower extremity was via collaterals. There was no pathology in the left iliac artery (Fig 3). We performed RT in the left iliac fossa with end-to-side anastomosis to the external iliac artery and vein. The surgery was done without complications, and the postoperative period was uneventful. Graft function began immediately and serum creatinine decreased to 1.1 mg/dL at postoperative day 5. In Doppler ultrasonography, peak systolic flow velocity of the renal artery was 75 cm/s, and resistive indexes obtained from intraparenchymal, interlobar, and arcuate arteries were 0.70. The patient was discharged from the hospital at
CASE REPORT A 54-year-old man with end-stage renal failure due to diabetic nephropathy undergoing hemodialysis for 2 years was admitted to our transplant center for living-related RT. He also had a history of hypertension. Six months before, he was diagnosed with aortic dissection involving descending aorta distal to the subclavian artery
*Address correspondence to Volkan Turunç, Organ Transplantation Center, Goztepe Medical Park Hospital, Merdivenkoy Mh E5 Uzeri 23 Nisan Sk. No: 17 Kadıkoy, 34732, Istanbul, Turkey. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.04.031
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1522
Transplantation Proceedings, 47, 1522e1524 (2015)
RENAL TX AFTER THORACIC ENDOVASCULAR REPAIR
Fig 1. Computerized tomographic image of endovascular stent graft (arrow).
postoperative day 6 with normal serum creatinine (0.9 mg/dL). His immunosuppressive regimen consisted of tacrolimus (0.1 mg/kg/ d divided into 2 doses), mycophenolate mofetil (2 g/d divided into 2 doses), and prednisolone (20 mg/d). At follow-up examination at postoperative 6 months, graft function was stable with a serum creatinine of 0.8 mg/dL.
DISCUSSION
Chronic renal failure and hemodialysis are predisposing factors for atherosclerosis [10]. RT has become the criterion standard therapy for end-stage renal failure. As the number of patients awaiting RT increases, diagnoses of atherosclerotic vascular disease and aortic aneurysms among these patients is also increasing.
Fig 2. Endovascular stent graft in angiogram.
1523
Fig 3. Aortoperipheral angiogram (right iliac artery can not be visualized).
EVAR has become more common in abdominal aortic aneurysm (AAA) repair compared with standard open procedure owing to less morbidity and mortality, shorter operative time, and shorter hospital stay [11,12]. EVAR has been performed with low morbidity and mortality in RT recipients with AAA [13,14]. There are also a few published cases of RT performed after EVAR [6e9]. Like EVAR in AAAs, TEVAR has become the preferred treatment option in thoracic aortic aneurysms (TAAs) and type B aortic dissection (TBAD) especially in past decade, owing to the same advantages over standard open surgery [15e17]. There are some differences between EVAR and TEVAR patients. Whereas the majority of patients who undergo EVAR have aneurysms, TEVAR patients have a wider range of pathologies, including aortic dissection, intramural hematoma, penetrating ulcer, aneurysms, pseudoaneurysms, and trauma [18]. Hughes et al have shown that TEVAR had lower mortality than open surgery (3.6% vs 4.6%) in their study comparing 712 cases of TEVAR and 8,255 cases of open surgery performed in the United States of America from 1998 to 2007 in patients with TAA. In the same study, they have shown that postoperative neurologic, cardiac, and respiratory complication rates were significantly lower in the TEVAR group [19]. Steuer et al have shown that mortality was 3% and 5-year survival was 87% in 60 patients with TBAD who were treated with TEVAR [20]. There are a few cases of TEVAR reported in RT recipients [21,22]. In these cases, there was a mild graft dysfunction in some patients, but no patient needed renal replacement therapy. Morbidity and mortality rates were low. Because of its advantages, TEVAR is recommended in RT recipients with TAA/TBAD. No cases of RT performed after TEVAR has been reported before. To our knowledge, the case we present here is the 1st report of RT performed after TEVAR. We can not
1524
comment on long-term outcomes, because the patient was in post-transplantation month 6 when this article was written, but the early postoperative period was uneventful. In conclusion, because of its advantages over open surgery, including low mortality and morbidity, TEVAR is becoming more common among renal failure patients with TAA/TBAD. Our case shows that successful RT can be performed in renal failure patients who have undergone TEVAR before.
REFERENCES [1] Port FK, Merion RM, Finley MP, et al. Trends in organ donation and transplantation in the United States, 1997-2006. Am J Transplant 2008;8:911e21. [2] Merion RM, Pelletier SJ, Goodrich N, et al. Donation after cardiac death as a strategy to increase deceased donor liver availability. Ann Surg 2006;244:555e62. [3] Piquet P, Berland Y, Coulange C, et al. Aortoiliac reconstruction and renal transplantation: staged or simultaneous. Ann Vasc Surg 1989;3:251e6. [4] Brekke IB, Lien B, Sodal G, et al. Aortoiliac reconstruction in preparation for renal transplantation. Transpl Int 1993;6:161e3. [5] Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491e9. [6] George P, Tan HP, Beebe H, et al. Successful renal transplantation after endovascular bifurcated stent graft repair of an abdominal aortic aneurysm. Transplantation 2001;72:533e5. [7] Machado R, Almeida P, Loureiro L, Almeida R. Renal transplantation after endovascular aortic aneurysm repair: case report and literature review. Transplant Proc 2011;43:150e2. [8] Abou-Jaoudé MM, Al Beteddini OS. Kidney transplantation in a patient with aortic bi-iliac endovascular graft: case report and literature review. Int Surg 2010;9:305e8. [9] Shrestha BM, McKane WS, Raftery AT. Renal transplantation after endovascular repair of abdominal aortic aneurysm. Transplant Proc 2007;39:1670e2. [10] Linder A, Charra B, Sherrard DJ, et al. Accelerated atherosclerosis in prolonged maintenance hemodialysis. N Engl J Med 1974;290:697e701.
EROGLU, TURUNÇ, S¸ENER ET AL [11] Sicard GA, Zwolak RM, Sidawy AN, et al. Endovascular abdominal aortic aneurysm repair: long-term outcome measures in patients at high-risk for open surgery. J Vasc Surg 2006;44:229e36. [12] Aarts F, van Sterkenburg S, Blankensteijn JD. Endovascular aneurysm repair versus open aneurysm repair: comparison of treatment outcome and procedure-related reintervention rate. Ann Vasc Surg 2005;19:699e704. [13] Ailawadi G, Bedi A, Williams DM, et al. Endovascular treatment of aortic aneurysms in patients with renal transplants. J Vasc Surg 2003;37:693e6. [14] Karkos CD, McMahon G, Fishwick G, et al. Endovascular abdominal aortic aneurysm repair in the presence of a kidney transplant: therapeutic considerations. Cardiovasc Intervent Radiol 2006;29:284e8. [15] Scali ST, Goodney PP, Walsh DB, et al. National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice. J Vasc Surg 2011;53:1499e505. [16] Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg 2008;85: S1e41. [17] Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation 2008;118:808e17. [18] Feezor RJ, Huber TS, Martin TD, et al. Perioperative differences between endovascular repair of thoracic and abdominal aortic diseases. J Vasc Surg 2007;45:86e9. [19] Hughes K, Guerrier J, Obirieze A, et al. Open versus endovascular repair of thoracic aortic aneurysms: a nationwide inpatient sample study. Vasc Endovascular Surg 2014;48:383e7. [20] Steuer J, Eriksson MO, Nyman R, et al. Early and long-term outcome after thoracic endovascular aortic repair (TEVAR) for acute complicated type B aortic dissection. Eur J Vasc Endovasc Surg 2011;41:318e23. [21] da Rocha M, Zarka ZA, Riambau VA. Endovascular treatment of thoracic aortic pathology in renal transplant recipients: early and intermediate-term results. Interact Cardiovasc Thorac Surg 2009;9:947e50. [22] Yanase Y, Muraki S, Koyanagi T, et al. Thoracic endovascular aortic repair and off-pump coronary artery bypass grafting after renal transplantation: a case report. Ann Thorac Cardiovasc Surg 2011;17:603e6.
ABSTRACT Because of the strong association between uremia and atherosclerosis, incidence of aortic aneurysms is increasing among renal failure patients awaiting renal transplantation (RT). Successful RTs have been performed in these patients after surgical repair of the aneurysms. Since Parodi et al introduced endovascular aortic aneurysm repair (EVAR) in patients with high risk for conventional surgery, a new era has begun. The 1st successful RT after EVAR was published in 2001. Herein we report the 1st successful RT after thoracic EVAR (TEVAR) reported to date. We performed RT in a 54-year-old man with end-stage renal failure due to diabetic nephropathy, who had undergone TEVAR for type B aortic dissection (TBAD) 6 months earlier. The postoperative period was uneventful and the patient was discharged from the hospital at postoperative day 6 with a serum creatinine of 0.9 mg/dL. At follow-up examination at postoperative 6 months, graft function was stable. Because of its advantages over open surgery, including low mortality and morbidity, TEVAR is becoming more common among renal failure patients with thoracic aortic aneurysms and TBAD. Our case shows that successful RT can be performed in renal failure patients who have undergone TEVAR.
B
ECAUSE of the strong association between uremia and atherosclerosis, incidence of aortic aneurysms is increasing among renal failure patients awaiting renal transplantation (RT) [1,2]. Successful RTs have been performed in these patients after surgical repair of the aneurysms [3,4]. When Parodi et al reported endovascular aortic aneurysm repair (EVAR) in patients with high risk for conventional surgery, a new era began [5]. The first successful RT after EVAR was reported in 2001 [6]. There are 3 other cases reported from 2001 to date [7e9]. In all of these cases, endovascular repair of abdominal aorta was performed. As far as we know, the present case is the 1st successful RT after thoracic EVAR (TEVAR) reported to date.
(Stanford type B) in another hospital and TEVAR was performed (Fig 1). In his physical examination, right femoral pulse was not palpable, but there was no sign of arterial ischemia in his right lower extremity. Left femoral pulse was palpable. We did coronary and aortoperipheral angiography for further evaluation. There was no significant problem in his coronary arteries and no evidence of endoleaks (Fig 2). The right iliac artery was occluded. The arterial perfusion of the right lower extremity was via collaterals. There was no pathology in the left iliac artery (Fig 3). We performed RT in the left iliac fossa with end-to-side anastomosis to the external iliac artery and vein. The surgery was done without complications, and the postoperative period was uneventful. Graft function began immediately and serum creatinine decreased to 1.1 mg/dL at postoperative day 5. In Doppler ultrasonography, peak systolic flow velocity of the renal artery was 75 cm/s, and resistive indexes obtained from intraparenchymal, interlobar, and arcuate arteries were 0.70. The patient was discharged from the hospital at
CASE REPORT A 54-year-old man with end-stage renal failure due to diabetic nephropathy undergoing hemodialysis for 2 years was admitted to our transplant center for living-related RT. He also had a history of hypertension. Six months before, he was diagnosed with aortic dissection involving descending aorta distal to the subclavian artery
*Address correspondence to Volkan Turunç, Organ Transplantation Center, Goztepe Medical Park Hospital, Merdivenkoy Mh E5 Uzeri 23 Nisan Sk. No: 17 Kadıkoy, 34732, Istanbul, Turkey. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.04.031
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1522
Transplantation Proceedings, 47, 1522e1524 (2015)
RENAL TX AFTER THORACIC ENDOVASCULAR REPAIR
Fig 1. Computerized tomographic image of endovascular stent graft (arrow).
postoperative day 6 with normal serum creatinine (0.9 mg/dL). His immunosuppressive regimen consisted of tacrolimus (0.1 mg/kg/ d divided into 2 doses), mycophenolate mofetil (2 g/d divided into 2 doses), and prednisolone (20 mg/d). At follow-up examination at postoperative 6 months, graft function was stable with a serum creatinine of 0.8 mg/dL.
DISCUSSION
Chronic renal failure and hemodialysis are predisposing factors for atherosclerosis [10]. RT has become the criterion standard therapy for end-stage renal failure. As the number of patients awaiting RT increases, diagnoses of atherosclerotic vascular disease and aortic aneurysms among these patients is also increasing.
Fig 2. Endovascular stent graft in angiogram.
1523
Fig 3. Aortoperipheral angiogram (right iliac artery can not be visualized).
EVAR has become more common in abdominal aortic aneurysm (AAA) repair compared with standard open procedure owing to less morbidity and mortality, shorter operative time, and shorter hospital stay [11,12]. EVAR has been performed with low morbidity and mortality in RT recipients with AAA [13,14]. There are also a few published cases of RT performed after EVAR [6e9]. Like EVAR in AAAs, TEVAR has become the preferred treatment option in thoracic aortic aneurysms (TAAs) and type B aortic dissection (TBAD) especially in past decade, owing to the same advantages over standard open surgery [15e17]. There are some differences between EVAR and TEVAR patients. Whereas the majority of patients who undergo EVAR have aneurysms, TEVAR patients have a wider range of pathologies, including aortic dissection, intramural hematoma, penetrating ulcer, aneurysms, pseudoaneurysms, and trauma [18]. Hughes et al have shown that TEVAR had lower mortality than open surgery (3.6% vs 4.6%) in their study comparing 712 cases of TEVAR and 8,255 cases of open surgery performed in the United States of America from 1998 to 2007 in patients with TAA. In the same study, they have shown that postoperative neurologic, cardiac, and respiratory complication rates were significantly lower in the TEVAR group [19]. Steuer et al have shown that mortality was 3% and 5-year survival was 87% in 60 patients with TBAD who were treated with TEVAR [20]. There are a few cases of TEVAR reported in RT recipients [21,22]. In these cases, there was a mild graft dysfunction in some patients, but no patient needed renal replacement therapy. Morbidity and mortality rates were low. Because of its advantages, TEVAR is recommended in RT recipients with TAA/TBAD. No cases of RT performed after TEVAR has been reported before. To our knowledge, the case we present here is the 1st report of RT performed after TEVAR. We can not
1524
comment on long-term outcomes, because the patient was in post-transplantation month 6 when this article was written, but the early postoperative period was uneventful. In conclusion, because of its advantages over open surgery, including low mortality and morbidity, TEVAR is becoming more common among renal failure patients with TAA/TBAD. Our case shows that successful RT can be performed in renal failure patients who have undergone TEVAR before.
REFERENCES [1] Port FK, Merion RM, Finley MP, et al. Trends in organ donation and transplantation in the United States, 1997-2006. Am J Transplant 2008;8:911e21. [2] Merion RM, Pelletier SJ, Goodrich N, et al. Donation after cardiac death as a strategy to increase deceased donor liver availability. Ann Surg 2006;244:555e62. [3] Piquet P, Berland Y, Coulange C, et al. Aortoiliac reconstruction and renal transplantation: staged or simultaneous. Ann Vasc Surg 1989;3:251e6. [4] Brekke IB, Lien B, Sodal G, et al. Aortoiliac reconstruction in preparation for renal transplantation. Transpl Int 1993;6:161e3. [5] Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491e9. [6] George P, Tan HP, Beebe H, et al. Successful renal transplantation after endovascular bifurcated stent graft repair of an abdominal aortic aneurysm. Transplantation 2001;72:533e5. [7] Machado R, Almeida P, Loureiro L, Almeida R. Renal transplantation after endovascular aortic aneurysm repair: case report and literature review. Transplant Proc 2011;43:150e2. [8] Abou-Jaoudé MM, Al Beteddini OS. Kidney transplantation in a patient with aortic bi-iliac endovascular graft: case report and literature review. Int Surg 2010;9:305e8. [9] Shrestha BM, McKane WS, Raftery AT. Renal transplantation after endovascular repair of abdominal aortic aneurysm. Transplant Proc 2007;39:1670e2. [10] Linder A, Charra B, Sherrard DJ, et al. Accelerated atherosclerosis in prolonged maintenance hemodialysis. N Engl J Med 1974;290:697e701.
EROGLU, TURUNÇ, S¸ENER ET AL [11] Sicard GA, Zwolak RM, Sidawy AN, et al. Endovascular abdominal aortic aneurysm repair: long-term outcome measures in patients at high-risk for open surgery. J Vasc Surg 2006;44:229e36. [12] Aarts F, van Sterkenburg S, Blankensteijn JD. Endovascular aneurysm repair versus open aneurysm repair: comparison of treatment outcome and procedure-related reintervention rate. Ann Vasc Surg 2005;19:699e704. [13] Ailawadi G, Bedi A, Williams DM, et al. Endovascular treatment of aortic aneurysms in patients with renal transplants. J Vasc Surg 2003;37:693e6. [14] Karkos CD, McMahon G, Fishwick G, et al. Endovascular abdominal aortic aneurysm repair in the presence of a kidney transplant: therapeutic considerations. Cardiovasc Intervent Radiol 2006;29:284e8. [15] Scali ST, Goodney PP, Walsh DB, et al. National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice. J Vasc Surg 2011;53:1499e505. [16] Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg 2008;85: S1e41. [17] Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation 2008;118:808e17. [18] Feezor RJ, Huber TS, Martin TD, et al. Perioperative differences between endovascular repair of thoracic and abdominal aortic diseases. J Vasc Surg 2007;45:86e9. [19] Hughes K, Guerrier J, Obirieze A, et al. Open versus endovascular repair of thoracic aortic aneurysms: a nationwide inpatient sample study. Vasc Endovascular Surg 2014;48:383e7. [20] Steuer J, Eriksson MO, Nyman R, et al. Early and long-term outcome after thoracic endovascular aortic repair (TEVAR) for acute complicated type B aortic dissection. Eur J Vasc Endovasc Surg 2011;41:318e23. [21] da Rocha M, Zarka ZA, Riambau VA. Endovascular treatment of thoracic aortic pathology in renal transplant recipients: early and intermediate-term results. Interact Cardiovasc Thorac Surg 2009;9:947e50. [22] Yanase Y, Muraki S, Koyanagi T, et al. Thoracic endovascular aortic repair and off-pump coronary artery bypass grafting after renal transplantation: a case report. Ann Thorac Cardiovasc Surg 2011;17:603e6.
