Editor's Choice - Ex vivo Renal Artery Repair with Kidney Autotransplantation for Renal Artery Branch Aneurysms: Long-term Results of Sixty-seven Procedures.

OBJECTIVE/BACKGROUND: To evaluate the long-term outcome of renal revascularization by ex vivo renal artery reconstruction and autotransplantation for renal artery branch aneurysms (RABAs). METHODS: Between 1991 and 2015, 67 ex vivo renal artery reconstructions with kidney autotransplantation were performed in 55 adults (mean age 47 years) and 10 children to repair 87 RABAs. The main underlying disease was fibromuscular dysplasia in 34 patients. Other etiologies were systemic congenital disease in eight patients, spontaneous dissecting aneurysms in five, iatrogenic aneurysms in three, atheromatous aneurysms in two and unknown etiology in 13. Median RABA diameter was 20.5 mm. Fifty-three patients (82%) were hypertensive, 60 had normal renal function and no patient was on hemodialysis. Seven patients (11%) were operated on after failure of an endovascular procedure. The mean number of renal artery branches repaired per patient was 3.5 and multiple aneurysms were treated in 14 patients (22%). The hypogastric artery was used in 41 patients, the saphenous vein in 18, the superficial femoral artery in five and a combination of different materials in three. RESULTS: No deaths occurred during the first 30 days. Primary patency at 30 days was 90.8% following to six early thromboses. Three patients (5%) were lost to follow up. No other thrombosis occurred. At 8 years, the primary and primary-assisted patency were 88% and 91%, respectively. Survival was 95% at 9 years. Among the 53 hypertensive patients, two were lost to follow up. At 9 years, 22 (43%) were cured and nine (18%) were improved with a significant reduction of antihypertensive medication (p < .05). The pre-operative modification of the diet in renal disease (MDRD) clearance was 93 ± 29 mL/minute, the immediate post-operative MDRD was 94 ± 33 mL/minute, and at the end of follow up it was 86 ± 26 mL/minute (p > .05). CONCLUSION: Ex vivo renal artery reconstruction for complex RABAs eliminates the risk of rupture, confers a benefit to hypertension, and preserves renal function with a satisfactory long-term patency.

Common hepatic artery as inflow in kidney transplantation.

Kidney transplantation originating from the hepatic artery has not previously been reported. Herein, we report a third kidney transplantation with the common hepatic artery as inflow. A 62-year-old male with chronic renal failure due to polycystic kidney disease was proposed to a third kidney transplantation. CT-scan showed diffuse calcification of the aorto-iliac axis and the splenic artery. The common hepatic artery was the only artery suitable for anastomosis and as such was chosen as the inflow for retransplantation. The operation was performed through a right subcostal laparotomy. A saphenous bypass was interposed between the common hepatic artery and the graft, then the renal vein was anastomosed to the suprarenal inferior vena cava. Duration of warm ischemia was 27 min. Postoperative course was complicated with delayed graft function of 17 days and pulmonary infection. Patient was discharged at day 30. With a follow-up of 40 months, serum creatinine level and eGFR are, respectively, 191 µmol/L and 32 mL/min. Hepato-renal bypass technique can be used in kidney retransplantation when patient anatomy is not compatible with other classical options.

Early and late results of ex vivo repair and autotransplantation in solitary kidneys.

INTRODUCTION: Autotransplantation of a solitary kidney provides an excellent opportunity to study the immediate and long-term consequences of intra-operative renal ischaemia. The purpose of this report is to describe a series of nine patients who underwent ex vivo repair and autotransplantation on solitary kidneys. PATIENTS AND METHODS: The series included six females and three males with a mean age of 36 years. Seven of the nine patients were hypertensive (mean number of anti-hypertensive agents: 3). Two patients had chronic renal failure (serum creatinine levels: 192 and 205 µmol l(-1)). All arteries except one with Takayasu disease were affected by dysplastic aneurysm or fibrodysplasia lesion. There was no atherosclerotic lesion. The mean number of renal artery branches repaired was 3.1 per patient. Mean duration of ischaemia was 161 min. RESULTS: Creatinaemia increased in all patients following the procedure. Creatinaemia and clearance returned to preoperative values between the 3rd and 10th postoperative days. One kidney was lost due to renal vein thrombosis. Late findings indicated that renal function was stable and there was no deterioration in the function of the autotransplanted kidneys after a follow-up period of 89 months. Preoperative versus postoperative creatinaemia and clearance levels were respectively 111 vs. 105 µmol l(-1) and 66.9 vs. 62.0 ml min(-1) (ns). During the same time, the mean number of anti-hypertensive agents decreased slightly from 3 to 2.5. CONCLUSION: In this small series of patients who underwent ex vivo repair and autotransplantation on solitary kidneys, intra-operative renal ischaemia had no detrimental effect on renal function.