[MP-16] Renal artery stenting to mitigate vascular injury in the transplanted kidney
Introduction
Iatrogenic injury to native vessel during vascular surgery is a potential threat to long term patency of the anastomosis. Transplant renal artery stenosis with dissection is the likely cause for 8.3% of renal graft dysfunction. During a living donor renal transplant there was inadvertent iatrogenic dissection to the external iliac artery at the anastomotic site, managed with primary repair. In the first week post-operatively, the transplant failed to function as expected. Duplex USS was performed and demonstrated haemodynamically significant stenosis of the renal artery anastomosis from a residual dissection flap.
Methods
We reviewed the published literature relevant to stenting of renal artery stenosis after transplantation for all causes.
Results
Endovascular intervention is the accepted initial approach for hemodynamically significant transplant renal artery stenosis. Transplanted renal artery plasty and stenting is most commonly performed for post-transplant hypertension, fluid overload and graft injury or loss secondary to renal artery stenosis. Either drug eluting or bare metal stents are used, depending on artery size. The overall re-stenosis rate is lower for stenting compared to angioplasty. There is a 10% risk of contrast nephropathy, which does not have significant long term impact. Progression to end stage renal failure after endovascular intervention is associated with rejection or the original disease process, not re-stenosis of the artery. Revision open surgery is reserved for failed endovascular approach, due to the high rate of graft loss and urethral injury.
Conclusion
Our patient underwent renal artery stenting on post-operative day 3 with bare metal stent from contralateral CFA approach. She was later discharged with improvement in renal flows demonstrated on USS duplex and normalisation of the glomerular filtration rate, maintained at 4 month follow up. This rare complication (0.01%) can be safely and effectively managed by endovascular techniques.
Iatrogenic injury to native vessel during vascular surgery is a potential threat to long term patency of the anastomosis. Transplant renal artery stenosis with dissection is the likely cause for 8.3% of renal graft dysfunction. During a living donor renal transplant there was inadvertent iatrogenic dissection to the external iliac artery at the anastomotic site, managed with primary repair. In the first week post-operatively, the transplant failed to function as expected. Duplex USS was performed and demonstrated haemodynamically significant stenosis of the renal artery anastomosis from a residual dissection flap.
Methods
We reviewed the published literature relevant to stenting of renal artery stenosis after transplantation for all causes.
Results
Endovascular intervention is the accepted initial approach for hemodynamically significant transplant renal artery stenosis. Transplanted renal artery plasty and stenting is most commonly performed for post-transplant hypertension, fluid overload and graft injury or loss secondary to renal artery stenosis. Either drug eluting or bare metal stents are used, depending on artery size. The overall re-stenosis rate is lower for stenting compared to angioplasty. There is a 10% risk of contrast nephropathy, which does not have significant long term impact. Progression to end stage renal failure after endovascular intervention is associated with rejection or the original disease process, not re-stenosis of the artery. Revision open surgery is reserved for failed endovascular approach, due to the high rate of graft loss and urethral injury.
Conclusion
Our patient underwent renal artery stenting on post-operative day 3 with bare metal stent from contralateral CFA approach. She was later discharged with improvement in renal flows demonstrated on USS duplex and normalisation of the glomerular filtration rate, maintained at 4 month follow up. This rare complication (0.01%) can be safely and effectively managed by endovascular techniques.