AJR 2003; 180:759-763
© American Roentgen Ray Society
Early Posttransplantation Renal Allograft Perfusion Failure Due to Dissection: Diagnosis and Interventional Treatment
Masahide Takahashi1,2,
Ulrich Humke3,
Matthias Girndt4,
Bernhard Kramann1 and
Michael Uder1
1 Department of Diagnostic Radiology, The Saarland University Hospital,
Kirrberger Str. 1, D-66421 Homburg (Saar), Germany.
2 Present address: Department of Radiology, Tsukuba-Gakuen Hospital, 2573-1
Kamiyokoba, Tsukuba, Ibaraki 305-0854, Japan.
3 Department of Urology, Julius-Maximilians University, Josef-Schneider Str. 2,
D-97080 Wuerzburg, Germany.
4 Department of Nephrology, The Saarland University Hospital, D-66421 Homburg
(Saar), Germany.
Received May 28, 2002;
accepted after revision August 27, 2002.
Address correspondence to M. Takahashi.
Abstract
OBJECTIVE. The aim of our study was to describe the role of
interventional radiology, especially in the use of vascular stents, in early
renal perfusion failure after transplantation.
CONCLUSION. Angiography revealed intimal dissection of the graft
artery and graft venous thrombosis, which were successfully treated with stent
angioplasty and thromboaspiration. For early vascular complication after
transplantation, timely use of angiography and subsequent intervention should
be recognized as potentially effective and safe treatment techniques.
Introduction
Impairment of renal allograft perfusion in the early postoperative period
is usually associated with acute transplant rejection. However, vascular
complications such as transplant renal artery stenosis or graft venous
thrombosis are rare but critical causes
[1,2,3,4,5].
Sudden oliguria is often the initial symptom of decreased graft perfusion and
indicates the need for immediate imaging evaluation. For this purpose, Doppler
sonography is usually the first diagnostic procedure
[1]. Although Doppler
examination readily measures the organ perfusion itself and may identify flow
levels in the main renal vessels including the anastomotic region, the exact
anatomic cause of perfusion failure cannot necessarily be identified.
Therefore, in such challenging cases, the necessity for angiography should be
well recognized because it allows not only diagnosis but also the option of
immediate correction of vascular complications. The usefulness of percutaneous
transluminal angioplasty for transplant renal artery stenosis in the later
postoperative period has been well documented
[6,
7], whereas the role of
interventional radiology in the early period after transplantation has rarely
been discussed [4,
5]. In this small series, we
present three cases of acute allograft perfusion failure associated with
transplant renal artery stenosis due to intimal dissection, for which stent
angioplasty was technically successful. In one patient, catheter
thromboaspiration was also required for treating graft venous thrombosis.
Subjects and Methods
Three men (age range, 58-76 years) were referred for emergency angiography
in the early posttransplantation period (days 2-7) after undergoing cadaveric
renal transplantation. Indication for angiography was the sudden onset of
oligoanuria. The allografts had been anastomosed end-to-side to the right
external iliac artery. The cold ischemia time ranged between 10 and 15 hr. The
stumps of graft arteries in the first and the second patients presented marked
atherosclerotic change and had to be resected further at the time of graft
preparation. In all cases, color Doppler sonography revealed global allograft
perfusion failure of unknown origin.
In the first patient, the transplanted kidney was functional immediately,
and the early postsurgical status was uneventful. On the second day after
transplantation, the patient developed anuria.
In the second patient, delayed graft function made hemodialysis necessary
on the first day after transplantation, but the daily urine output had
improved gradually to 1770 mL/day by the third day after transplantation. On
day 7 after transplantation, hourly diuresis suddenly dropped from 100 to 10
mL. Although Doppler sonography revealed an increased resistive index of
0.82-0.86 compared with 0.73-0.76 on postoperative day 5, no postrenal
obstruction, including venous thrombosis, could be identified.
In the third patient, the transplanted kidney regained normal color at the
end of transplantation. Nevertheless, the initial postoperative course was
complicated by delayed graft function with a poor diuresis of 50 mL/day, and
the patient underwent dialysis on the first postoperative day. However, both
resistive index (0.73-0.78) and perfusion of the transplanted kidney were
unremarkable. On day 3 after transplantation, sudden anuria appeared with a
preshock status.
Conventional digital subtraction angiography was performed on a standard
angiography unit (Polytron; Siemens Medical Systems, Erlangen, Germany). All
patients gave their written informed consent before angiography. The
examination was initiated with nonselective pelvic arteriography so that
ipsilateral proximal atherosclerotic iliac stenosis could be ruled out. Then
for angioplasty, an ipsilateral femoral approach with a 5-French short sheath
(in patients 1 and 2; Terumo Europe, Leuven, Belgium) or a 7-French short
sheath (Terumo Europe) combined with 7-French guiding catheter (in patient 3;
Veripath-RDC, Guidant Europe, Diegem, Belgium) was used, followed by an
injection of 5000 IU of heparin. The graft artery was selectively catheterized
with either a 4-French small J-Curve catheter (Optitorque; Terumo Europe) or a
5-French Cobra-2 catheter (Tempo-5; Cordis Europe, LJ Roden, The Netherlands).
Thereafter, a soft-tipped half-rigid 0.014-inch guidewire (Hi-Torque
Spartacore 14; Guidant Europe) was carefully advanced as far peripherally as
possible without resistance. To definitely avoid a subintimal dilatation,
confirmation angiography was routinely performed through the sheath or guiding
catheter with the wire in place. For balloon dilatation, the catheter was
changed to a 5 x 20 mm (diameter x length) balloon catheter (Rx
Viatrac 14; Guidant Europe). Balloon inflation time was 30 sec. The balloon
was used mainly as a reference for renal artery sizing and also for
predilatation before the stent placement. Stent angioplasty was attempted with
a premounted monorail system (Rx Herculink 14; Guidant Europe). As routine
prophylaxis after stent implantation, low-dose aspirin (100 mg/day) was
given.
Results
In all three patients, angiography showed intimal dissection of the graft
renal artery. For stabilization of the intimal flap, every procedure required
stent placement and was technically successful with the ipsilateral approach.
Neither residual strictures nor complications were observed. In one patient,
catheter thromboaspiration successfully cleared graft venous thrombosis. Two
patients showed immediate and lasting improvements of graft function. Although
one allograft was lost because of the preexisting infarction, no
procedure-related graft loss was recorded.
Figure
1A,1B
shows the angiograms for the first patient. In this patient, percutaneous
transluminal angioplasty resulted in an incomplete stabilization of the flap.
Hence a 5.5 x 18 mm stent was placed. The stent angioplasty was
technically successful (Fig.
1B), followed by an immediate brisk diuresis. The serum creatinine
level was stabilized at 1.3 mg/dL after 3 weeks and around 1.5 mg/dL after
half a year.
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Fig. 1A. —76-year-old man with intimal dissection of renal allograft
artery on day 2 after transplantation. Right iliac arteriogram obtained with
contralateral approach shows intimal flap (arrows) severely narrowing
graft artery.
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Fig. 1B. —76-year-old man with intimal dissection of renal allograft
artery on day 2 after transplantation. Arteriogram shows that after stent
angioplasty with ipsilateral approach, complete repair of dissection is
seen.
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Figure
2A,2B,2C,2D,2E,2F
shows the angiograms for the second patient. An incomplete stabilization of
the flap after percutaneous transluminal angioplasty
(Fig. 2B) was successfully
corrected with a 5 x 8 mm stent (Fig.
2C). After this procedure, findings of a prolonged parenchymal
stain of the graft and poor visualization of the graft vein
(Fig. 2D) prompted direct
venography. Selective venography disclosed a fresh thrombosis in the graft
vein and also in the external iliac vein
(Fig. 2E). Thrombi in the graft
vein were withdrawn into the iliac vein by the Fogarty maneuver with a 7
x 20 mm balloon catheter (Smash; Boston Scientific International, La
Garenne-Colombes Cedex, France). Declotting and the Fogarty maneuver in the
iliac vein were also performed with a 8 x 20 mm balloon catheter (Smash,
Boston Scientific International), combined with thromboaspiration through a
6-French sheath (Terumo Europe). Immediately after the intervention, hourly
diuresis returned to normal and remained stable. To avoid recurrence of graft
venous thrombosis, heparinization (1000-1500 IU/hr for 3 days) was performed
in addition to routine aspirin prophylaxis. On the next day, Doppler
sonography indicated regression of the resistive index to 0.71-0.76. The serum
creatinine level was stable at approximately 2.0 mg/dL 6 months after
transplantation.
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Fig. 2A. —60-year-old man with intimal dissection of renal allograft
artery and graft venous thrombosis on day 7 after transplantation. Right
external iliac arteriogram obtained through ipsilateral vascular sheath shows
short-segment intimal flap (arrow) at proximal portion of graft
artery with approximately 50% stenosis.
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Fig. 2B. —60-year-old man with intimal dissection of renal allograft
artery and graft venous thrombosis on day 7 after transplantation.
Arteriorgram shows that after percutaneous transluminal angioplasty,
persistent flap and stenosis are seen.
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Fig. 2C. —60-year-old man with intimal dissection of renal allograft
artery and graft venous thrombosis on day 7 after transplantation.
Arteriorgram shows that after stent placement, no residual stenosis is
present.
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Fig. 2D. —60-year-old man with intimal dissection of renal allograft
artery and graft venous thrombosis on day 7 after transplantation. Venous
phase of selective allograft arteriogram shows prolonged parenchymal stain and
outflow stenosis (arrow).
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Fig. 2E. —60-year-old man with intimal dissection of renal allograft
artery and graft venous thrombosis on day 7 after transplantation. Direct
venogram of graft vein shows multiple thrombi in renal and iliac veins.
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Fig. 2F. —60-year-old man with intimal dissection of renal allograft
artery and graft venous thrombosis on day 7 after transplantation. Direct
venogram of graft vein shows that after thromboaspiration, venous outflow is
almost cleared of thrombus. Some small thrombi may remain.
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In the third patient, angiography revealed a high-grade stenosis of the
graft artery and significantly impaired distal circulation (Figs.
3A and
3B). The recipient's external
iliac artery contained extensive atherosclerotic plaques
(Fig. 3A). Although it was
difficult to traverse the stenosis with a 0.014-inch guidewire, we finally
guided the wire to a narrow lumen. After balloon dilatation, the stenosis and
distal filling of the graft artery were improved to some degree
(Fig. 3C). However, a filling
defect at the anastomotic site of the artery seemed to be an intimal flap.
Therefore, a decision to perform stent angioplasty was made. An incomplete
stabilization of the flap (Fig.
3D) after the first stent (6 x 13 mm) placement was
successfully corrected with an additional distal stent (5 x 18 mm)
(Fig. 3E). Nevertheless, the
poor peripheral perfusion did not improve. On the next day, the patient's
general condition worsened with signs of sepsis, and the transplanted kidney
was removed. Pathologic exploration of the allograft disclosed extensive fresh
hemorrhagic arterial infarctions with no evidence of rejection or graft venous
thrombosis.
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Fig. 3A. —58-year-old man with intimal dissection of renal allograft
and extensive renal infarction on day 3 after transplantation. Right external
iliac arteriogram obtained through ipsilateral vascular sheath shows graft
artery with severe stricture (arrow). Note extensive atherosclerosis
of iliac arteries and total occlusion of internal iliac artery
(arrowhead).
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Fig. 3B. —58-year-old man with intimal dissection of renal allograft
and extensive renal infarction on day 3 after transplantation. Later phase of
right external iliac arteriogram (A) shows significantly diminished
graft perfusion.
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Fig. 3C. —58-year-old man with intimal dissection of renal allograft
and extensive renal infarction on day 3 after transplantation. Selective
allograft arteriogram obtained through guiding catheter after percutaneous
transluminal angioplasty shows flat filling defect at origin of renal
artery.
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Fig. 3D. —58-year-old man with intimal dissection of renal allograft
and extensive renal infarction on day 3 after transplantation. Selective
allograft arteriogram obtained through guiding catheter after first stent
placement shows remaining intimal flap (arrow).
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Fig. 3E. —58-year-old man with intimal dissection of renal allograft
and extensive renal infarction on day 3 after transplantation. Selective
allograft arteriogram obtained through guiding catheter after second (distal)
stent placement shows no residual stenosis.
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Discussion
All three patients presented with transplant renal artery stenosis due to
intimal dissection within a week after renal transplantation. To our
knowledge, only one case report of stent angioplasty for transplant renal
artery stenosis in such an early period after transplantation has been
documented [4].
In general, transplant renal artery stenosis becomes apparent in the later
posttransplantation period, presenting with refractory hypertension, renal
dysfunction, or both. The cause of transplant renal artery stenosis is
multifactorial, including long cold ischemia time, type of allograft
[8], surgical technique
[9], immunologic factors
[10], and cytomegalovirus
infection [11]. Theoretically,
transplant renal artery stenosis associated with surgical techniques can also
occur in the early postoperative days. An imperfect suturing technique of the
anastomosis or kinking of the graft artery may cause early stenosis, which
should be corrected by surgery
[3,
12]. On the other hand,
excessive traction of the graft artery during the harvesting, cannulation for
transplant perfusion, or a surgical clamp may cause endothelial injury or
intimal tears, which can eventually lead to vascular dissection.
However, early arterial dissection after transplantation has rarely been
documented in the literature
[4], conceivably because the
timely diagnosis of this entity is challenging. The thin and unstable intimal
flap is not necessarily visualized with color Doppler sonography. Furthermore,
if the timely diagnosis fails, renal artery thrombosis may eventually occur
and almost inevitably lead to graft loss
[1]. Sudden oliguria with
Doppler sonographic findings of decreased graft perfusion is nonspecific for
arterial dissection or even for transplant renal artery stenosis, especially
when graft function is delayed. The differential diagnosis includes acute
rejection, acute tubular necrosis, cyclosporine toxicity, and graft venous
thrombosis [2]. In our series,
one patient developed graft venous thrombosis. Although differentiation among
parenchymal abnormalities is usually made by percutaneous sonographically
guided graft biopsy, the biopsy cannot rule out vascular complications. In
addition, acute rejection rarely develops in the first few days after
transplantation [1]. Therefore
in this period, vascular complications should be much higher on the
differential diagnosis list, and angiographic confirmation, including graft
venography, is indicated before biopsy.
For the assessment of late posttransplantation vascular complications
presenting with hypertension or renal dysfunction, contrast-enhanced MR
angiography has been shown to be a reliable method with almost no nephrotoxic
risks [13]. However, to our
knowledge, research regarding MR angiography in the early posttransplantation
period is limited in the literature. In all our patients, Doppler sonography
revealed global and severe perfusion failure of allografts but failed to
identify the direct signs of vascular damage. Thus, our use of the emergency
catheter angiography is warranted in such challenging cases. Unfortunately,
angiography with iodinated contrast material exposes patients to the potential
risk of nephrotoxicity. Carbon dioxide (CO2) may be used as an
alternative contrast agent. However, CO2 angiography does not
visualize anatomic detail such as an intimal flap as well as angiography and
often requires image postprocessing, such as multiple image summation or
remasking. Furthermore, rapid serial injections should be avoided because of
the risk of vapor lock—induced renal ischemia
[14].
These limitations are usually of little significance for elective
angiography but may be of great concern in an emergency setting. To date, to
our knowledge, there have been no published reports of contrast-induced acute
renal failure in transplantation patients.
For vascular dissection, stent angioplasty has been broadly accepted as the
treatment of choice, whether the lesion is of spontaneous or iatrogenic
origin. Surgical treatment of transplant renal artery stenosis is often
difficult, risking significant injury to renal hilar structures and associated
with a 15% graft loss and 5% mortality
[15]. We encountered no
procedure-related complications. The real benefit of this treatment, however,
should be further proven with a larger prospective study.
Graft venous thrombosis has been relatively well documented
[2]. It usually manifests
within the first 2 weeks after transplantation, clinically presenting sudden
oliguria, hematuria, and graft swelling. Doppler sonography can show the
disappearance of venous signal or the thrombus itself, whereas suggestive
signs such as an increased resistive index or arterial reverse flow are
nonspecific for graft venous thrombosis. Well-recognized risk factors for
graft venous thrombosis include technical surgical problems, donor's right
kidney, left lower quadrant allografts
[1], vessel compression by
hematoma or lymphocele, hypercoagulability, and hypovolemia. In one of our
patients, however, none of the previously mentioned factors nor typical
symptoms could be proven. It could be postulated that the vascular dissection
and graft venous thrombosis in that patient might have had hemodynamically
synergistic effects. Oliguria might occur before thrombophlebitis. The
prognosis of graft venous thrombosis is generally poor. Recently, Rerolle et
al. [2] described the
usefulness of catheter thromboaspiration for graft venous thrombosis. We also
confirmed its effectiveness and safety, although only in one patient.
Unfortunately, the allograft in one patient failed because of extensive
arterial infarction. Although the pathologic exploration failed to show a
source for thromboembolism, in general, arterial dissection itself can lead to
distal thrombosis. Another explanation for such an extensive infarction would
be cholesterol emboli from the recipient's atherosclerotic iliac artery.
In summary, we described three cases of early vascular complications in
renal allografts and their treatment with interventional radiology. Timely use
of interventional radiology should be recognized as a potentially effective
and safe treatment for early vascular complication after renal
transplantation.
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Abstract
Introduction
