Aortic reconstruction in patients with functioning renal allografts

Patients with functioning renal allografts requiring aortic reconstruction pose a considerable challenge to the vascular surgeon. A variety of strategies for renal allograft preservation during intervention have been described including hypothermia, indwelling shunts, cold renal perfusion, axillofemoral bypass, and endovascular stent-grafting. Reported here are two cases of successful aortic reconstruction utilizing standard open surgical techniques designed simply to minimize warm renal ischemia. The first case was that of a 55 year-old patient with a functional renal allograft originating from the right external iliac artery, who presented acutely with large symptomatic aortic and bilateral iliac artery aneurysms. He was treated with aorto-right femoral/ left iliac bypass grafting. The right femoral anastomosis was performed first so that warm renal ischemia was limited to the 34 min required to perform the proximal end-to-end aortic anastomosis. The second case was that of a 44-year-old patient also with a transplanted kidney originating from the right external iliac artery. He presented with worsening hypertension, decreasing renal function, claudication, and severe aortoiliac occlusive disease. He was treated with aorto-left femoral bypass grafting via a retroperitoneal approach, followed by femorofemoral crossover bypass for retrograde perfusion of the kidney (total warm ischemia time 20 min). Both patients recovered uneventfully without a decrement in renal function and remain well on follow-up. It is concluded that standard open surgery without adjunctive shunts or bypasses remains a viable treatment option for these patients, provided warm renal ischemia can be minimized.