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Early Posttransplantation Renal Allograft Perfusion Failure Due to Dissection: Diagnosis and Interventional Treatment

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

Top Abstract Introduction Subjects and Methods Results Discussion References

 
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

Top Abstract Introduction Subjects and Methods Results Discussion References

 
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

Top Abstract Introduction Subjects and Methods Results Discussion References

 
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

Top Abstract Introduction Subjects and Methods Results Discussion References

 
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.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   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.

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.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   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).

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   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.

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.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   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).

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   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).

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   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.

Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
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.

References

Top Abstract Introduction Subjects and Methods Results Discussion References

 

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This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Takahashi, M. Articles by Uder, M. Search for Related Content PubMed PubMed Citation Articles by Takahashi, M. Articles by Uder, M. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?