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Stenoses proximal to transplant renal artery anastomoses are a complication that leads to allograft dysfunction. In this case, a 45-year-old male was transplanted a deceased donor kidney with 2 arteries implanted with an aortic patch. Reperfusion of the organ was complicated by bleeding at the proximal site of the anastomosis. Controlling the bleeding was very difficult given the deep pelvis and the body habitus of the recipient. The iliac artery had to be re-clamped and several 6-0 polypropylene stitches were placed at the proximal end of the donor aortic patch. Post-operatively, the urine output was low, and the lower extremity on the side of the transplant showed a markedly diminished dorsal pedal pulse, decreased sensation, and pitting edema when compared to the contra lateral lower extremity. An arterial duplex showed a high grade stenosis of the external iliac just proximal to the renal artery anastomosis, with increased flow velocity at the transplant arterial anastomosis. Angiography confirmed an iliac artery stenosis (most likely at the location where the stitches had been placed to control the post-reperfusion hemorrhage. No stenosis was observed at the origin of the renal arteries. We performed a common iliac to distal external iliac artery bypass with a polytetrafluoroethylene (PTFE) ringed graft (Figures 112-43 and 112-44). Adequate flow was re-established to the kidney as well as to the lower extremity (Figures 112-45112-50) with immediate resolution of all findings. This approach requires only a brief proximal clamping of the arterial inflow to the kidney. We did not infuse any preservation fluid into the kidney during the brief time of clamping for the anastomosis. Our technique allows for re-vascularization of both the allograft and the lower extremity. Benefits of this approach when compared to re-transplantation or procedures directly involving the transplant renal artery include: minimization of ischemic time, no need to repair the stenosis, anastomoses with vessels of grater diameter, no need to stop the blood flow to the kidney and perfuse it with preservation fluid, no need to take down the transplant renal artery anastomosis, no need to dissect the transplanted kidney, no further lower extremity ischemia.

FIGURE 112-43

Angiogram showing the stenosis (yellow arrow) at the external iliac artery. Note that the stenosis does not involve the origin of either of the two transplant renal arteries (green arrow). The dotted red line represents the site of the soon-to-be constructed ilio-iliac bypass graft.

FIGURE 112-44

Iliac-iliac bypass with ringed polytetrafluoroethylene (PTFE) graft allowing for retrograde flow via the external iliac artery and adequate perfusion of the transplant kidney and the ipsilateral lower extremity.

FIGURE 112-45

Duplex Doppler ultrasound of the external iliac artery proximal to the stenosis before construction of the ilio-iliac bypass. The waveforms do not suggest any flow impediment.

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