Endovascular treatment of thoracic aortic pathology in renal transplant recipients: early and intermediate-term results

Marcio Da Rocha 0 Zaki Anas Zarka 0 Vicente A. Riambau 0 0 Division of Vascular Surgery, Thorax Institute, Hospital Clinic, University of Barcelona , Villarroel 170, 08036 Barcelona, Spain Endovascular correction of aorta thoracic pathology in renal transplant patients is a challenge. The aim of this study is to review early and intermediate-term results of endovascular repair of thoracic aorta pathology in patients with functioning previous renal transplant. The records of 81 patients submitted to a thoracic endograft between 2003 and 2008 were reviewed. Five patients with six previous renal transplants were submitted to six thoracic endografting. Two were women. The mean age was 55.4 years (range, 43-75 years). There were two patients with type B aortic dissection, one penetrating ulcer, one aneurysm of the aortic arch and one descending thoracic aorta aneurysm. Three patients underwent hybrid procedures: two total supra-aortic transpositions and one partial transposition of visceral trunks. Three patients presented postoperative complications. There were two cases of pneumonia, one acute limb ischemia and a stroke, with an early death. The mean follow-up was 16.2 months (range, 1-40 months). In this period all patients sustained renal function without any related complication. Despite the fact that it is a small series, in our clinical experience, endovascular thoracic aortic surgery can be performed as an alternative to open correction, in high-risk patients with a previous working renal transplant. 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. 1. Introduction The prevalence of end-stage renal disease (ESRD) has increased in the last years throughout the world w1x. Renal transplantation (RT) is the best option of treatment for this serious health problem. Renal replacement increases survival and is done even in patients over 65 years old w2, 3x. Renal transplanted patients (RTP) may develop thoracic aorta disease (Fig. 1) because of associated arteriosclerosis risk factors, or prolonged use of steroid and other immunosuppressant therapy w4x. They may need endovascular repair lifelong. The traditional open surgery of thoracic aorta aneurysms is associated with a high rate of morbidity and mortality, and is performed with aortic cross-clamping. Nowadays, endovascular surgery of thoracic aorta aneurysms has shown promising results. In this group of patients, with a working renal transplant, it is very important to carefully plan thoracic aorta endografting. The presence of a renal graft imposes some concerns and technical considerations. There is no reported series in the bibliography about the endovascular treatment of thoracic aorta lesions in renal transplant patients. No previous reports concerning thoracic endografting of RT patients have been found in English peer reviewed bibliography. Open graft replacement includes aortic cross-clamp as a major technical risk factor for these patients; however, *Corresponding author. Tel.: q34 932275515; fax: q34 932275749. E-mail address: (V.A. Riambau). 2009 Published by European Association for Cardio-Thoracic Surgery endovascular repair has also a great risk factor, especially in this subgroup of patients: in fact, contrast enhancing agent is used during the procedure and may be necessary in some circumstances in the follow-up period. The objective of this work is to report the early and intermediate term results of endovascular treatment of thoracic aorta diseases in patients with working previous renal transplant, over a period of five years. 2. Methods The prospective records of the patients who underwent endovascular treatment of thoracic aorta pathologies were retrospectively reviewed, between April 2003 and April 2008. Eighty-two thoracic endograftings were performed in 81 patients. Six endovascular thoracic aorta procedures were performed in five patients with working renal transplant, two females and three males. The mean age was 55.4 years (range, 4375 years). These patients were referred to our institution to be evaluated for endovascular correction of thoracic aorta pathology in a context of multiple comorbidities (Table 1). They were deemed risk patients for traditional open surgery. The etiologies of ESRD in this series were glomerulonephritis, followed by polycystic kidney disease, nephroangiosclerosis and ischemic nephropathy (Table 2). Four transplants were from cadaveric donors. One was an auto transplant to the pelvis and the other was of a living related donor, in a patient previously operated for an aorta bifemoral bypass for atherosclerotic obstructive disease. M. Da Rocha et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 947950 Fig. 1. Aneurysm of the aortic arch in a patient with renal transplant. Detail of the anastomosis of the renal artery with the right external iliac artery (arrow). SVS/ISCVS, Society for Vascular Surgery/International Society for Cardiovascular Surgery. Glomerulonephrits Polycystic kidney Nephroangiosclerosis Ischemic nefropathy ESRD, end-stage renal disease. One patient had two renal transplants, the second one nineteen years later. The external iliac artery was the donor artery in five cases, and in one case the renal artery was anastomosed to a branch of a previous aorta bifemoral bypass. All patients were on immunosuppression therapy and continued the medication after surgery. Kidneys transplanted to the iliac vessels were located in the iliac fossa. They were working at the moment of the surgery. The mean RT follow-up of this cohort was 64.5 months (range, 11205 months). In this series, one patient presented with penetrating aortic ulcer in the descending aorta, another presented with a descending thoracic aortic aneurysm involving celiac trunk, a third had an aortic arch aneurysm (Figs. 1 and 2) involving supra-aortic trunks. Two patients presented type B aortic dissection treated because of persistent pain. In these two cases the dissection did not involve iliac arteries. Four years later one of them required thoracic aorta stenting, to treat a re-entry tear and false lumen, next to the subclavian artery. In three of six patients, hybrid procedure was necessary. Two total supraaortic transpositions and one partial transposition of the visceral trunks (celiac trunk and superior mesenteric artery) were performed. All hybrid interventions were done in two stages. General anesthesia was used in all six patients, including in the second stage of hybrid intervention. Insertion of the endograft was performed via femoral artery, contra-lateral to the side of the kidney graft, in five instances. In both cases of debranching of the arch, the thoracic endografts were implanted in zone 0 w6x. A temporary iliac conduit, contra-lateral to the renal graft was necessary in one woman. The Gore TAG (W.L. Gore & Associates, Flagstaff, AZ, USA) endoprosthesis was used in two cases and Relay (Bolton Medical, Sunrise, FL (...truncated)