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  • Stenoses proximal to transplant renal artery anastomoses are associated with allograft dysfunction. In this specific case, a 70-year-old female presented with worsening creatinine 3 years after a live donor kidney transplant implanted onto the right external iliac artery.

  • Duplex Doppler ultrasound showed elevated flow velocities in the proximal external iliac and transplant renal arteries.

  • Magnetic resonance angiogram revealed a stenosis of the right common iliac artery with diminished perfusion of the transplanted organ (Figure 112-41).

  • A femoro-femoral bypass graft using an 8-mm ring PTFE graft was performed (Figure 112-42).

  • Postoperative imaging studies showed retrograde flow via the distal external iliac artery with adequate perfusion of both the kidney and the ipsilateral lower extremity.

  • This approach prevents any proximal clamping of the arterial inflow to the kidney and allows for re-vascularization of the allograft as well as of the distal extremity. Benefits of this technique 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 renal artery anastomosis, no need to dissect the transplanted kidney, no further lower extremity ischemia.

FIGURE 112-41

Right common iliac artery stenosis (yellow arrow) with compromised perfusion of the distally located transplant kidney. The red line shows the site of the future bypass.

FIGURE 112-42

Femoro-femoral 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.

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