|Year : 2019 | Volume
| Issue : 3 | Page : 216-218
Renal transplantation in bilateral iliac vein thrombosis: A difficult case scenario
Debayan Banerjee, Tarshid Ali Jahangir, Tapas Kumar Saha, Anup Dutta Baruah
Department of Urology and Renal Transplantation, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India
|Date of Submission||28-Jan-2019|
|Date of Decision||05-May-2019|
|Date of Acceptance||06-Jun-2019|
|Date of Web Publication||17-Sep-2019|
Dr. Tarshid Ali Jahangir
124, EM Bypass Kolkata 99, West Bengal
Source of Support: None, Conflict of Interest: None
A case of end-stage renal disease with bilateral iliac vein thrombosis underwent renal transplantation at our institute. Right external iliac vein (EIV) is the common site for anastomosing renal vein during renal transplantation. Patients undergoing repeated venous access for hemodialysis particularly femoral venous cannulation, have iliac vein thrombosis which we encounter during transplant workup. A 51-year-old diabetic, hypertensive female with end-stage renal disease with a history of multiple arteriovenous fistulae and bilateral femoral venous cannulation was planned for renal transplantation. On evaluation, her right common iliac vein and left EIV showed diffuse narrowing in computed tomography angiography. The renal vein was anastomosed to the proximal part of the inferior vena cava and the stump of the renal artery anastomosed to the right common iliac artery. Creatinine showed gradual decline, and the patient was discharged home on the 10th postoperative day with serum creatinine value of 1.76 mg/dl.
Keywords: Iliac vein thrombosis, inferior vena cava, renal transplantation
|How to cite this article:|
Banerjee D, Jahangir TA, Saha TK, Baruah AD. Renal transplantation in bilateral iliac vein thrombosis: A difficult case scenario. Indian J Transplant 2019;13:216-8
|How to cite this URL:|
Banerjee D, Jahangir TA, Saha TK, Baruah AD. Renal transplantation in bilateral iliac vein thrombosis: A difficult case scenario. Indian J Transplant [serial online] 2019 [cited 2019 Dec 11];13:216-8. Available from: http://www.ijtonline.in/text.asp?2019/13/3/216/266943
| Introduction|| |
Renal transplantation has become the therapy of choice for patients with end-stage renal disease. The standard surgical procedure entails positioning the kidney in the retroperitoneal right iliac fossa near the iliac vessels. However, when the iliac veins are thrombosed, anastomosis at this location is difficult and hence conventionally thrombosis of iliac veins has been a contraindication for renal transplantation. Several case reports have, in the recent past, aptly demonstrated ways to circumvent the obstructed veins by utilizing the systemic or portal veins in the area. Renal allografts have successfully been anastomosed to pelvic or presacral venous collaterals draining into the inferior vena cava (IVC),,, right ovarian vein,, and the superior mesenteric vein.
| Case Report|| |
A 51-year-old female patient who is a known patient of diabetes mellitus and hypertension was diagnosed as a case of chronic kidney disease on April 2016. She was on regular oral hypoglycemic therapy (pioglitazone) and antihypertensive medication. Left femoral venous cannulation was done on February 2017, and hemodialysis (HD) was started. Later, the patient had a failed attempt of left radiocephalic fistula; subsequently, a left brachiocephalic fistula (BCF) was constructed which functioned normally till November 2017. A fistuloplasty was done on the BCF, and in this perioperative period, two sessions of HD were given through the right femoral vein cannula. Thereafter, the patient received HD through the left BCF till the admission for renal transplantation. The patient had a history of hysterectomy in 2008 and no history of abortions. Her peripheral pulses were normal.
On investigation, her blood group is B positive, her serologies were nonreactive, and Prothrombin time /International normalised ratio (INR) was normal. A Doppler study of pelvic veins demonstrated lack of flow in the left external iliac vein (EIV). Computed tomography (CT) angiogram of the pelvic vessels showed diffuse narrowing of the right common iliac vein and diffuse narrowing of the left EIV [Figure 1]. Consultation from a vascular surgeon was sought. The absence of painful lower limb swelling and no history of disabling pedal edema suggested that venous outflow was maintained by collaterals, and revascularization procedures were not utilized. The patient underwent HD on the day before surgery, and the serum creatinine on the morning of surgery was 3.61 mg/dl.
|Figure 1: Computed tomography angiogram of the pelvic vessels showing diffuse narrowing of the right common iliac vein and left external iliac vein|
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The donor was a healthy unrelated male of blood Group B negative. CT angiography of the left kidney showed renal artery two in number and a single renal vein.
Description of the procedure
The patient was positioned supine and general anesthesia was administered. An 18 Fr 3-way Foley's catheter was inserted per urethra. A midline vertical incision was given. On entering the peritoneal cavity, the ascending colon, cecum, and terminal part of small bowel were mobilized medially by dividing the retroperitoneum along the line of Toldt. In the retroperitoneum, large dilated collateral veins were observed and preserved. Medial mobilization continued till full exposure of beginning of IVC and right common iliac artery [Figure 2]. In the bench, the two renal arteries were anastomosed side to side to create a single stump, and excess perinephric fat was removed. The vein was anastomosed to exposed part of IVC end to side [Figure 3] and reconstructed single stump of renal artery anastomosed end to side to right common iliac artery. On declamping the vessls, graft reperfusion was immediate. The ureter was implanted into the bladder using Lich–Gregoir technique. Hemostasis was secured and the abdomen was closed with a single drain placed in the pelvic fossa. The total warm ischemia time was 10 min, and cold ischemia time was 30 min.
|Figure 2: Medial mobilization continued up to full exposure of beginning of inferior vena cava and right common iliac artery|
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|Figure 3: Renal vein was anastomosed to exposed part of inferior vena cava end to side|
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Immunosuppression was induced with antithymocyte globulin and methylprednisolone. Maintenance regimen included tacrolimus, mycophenolate, and prednisolone. A Doppler study of graft on postoperative day 1 showed normal flow patterns. Serum creatinine gradually declined, and the patient was discharged on the 10th postoperative day with serum creatinine value of 1.76 mg/dl.
| Discussion|| |
Renal transplantation to the iliac veins remains the standard under ideal conditions. However, thrombosed iliac vein or IVC is not necessarily a contraindication for successful transplantation. Case reports have shown favorable outcomes with anastomosis to other vessels, including portal and systemic veins. Kumar et al. described a successful transplantation, in which his team connected the donor renal vein to the recipient splenic vein (portal system) after an incidental peroperative finding of thrombus in the IVC.
The gonadal veins and inferior mesenteric vein can be good choices for allograft venous drainage if they are determined to be large for adequate perfusion. The relatively early localization coupled with proximity to large arterial supplies (aorta or iliac) reduces warm ischemia time. Further, this venous anatomy is usually preserved among individuals, thereby helping reduce intraoperative time and complications. In our case report, the patient had had a bilateral femoral vein cannulation, for maintenance HD. The ultrasonography of the pelvic vessels picked up the thrombosis iliac vessels, which was confirmed by CT angiography.
| Conclusion|| |
Kidney transplantation on IVC is a safe and viable alternative when bilateral iliac veins are thrombosed. The approach, however, is to be done with caution and needs to have high level of surgical expertise in managing vascular anastomosis. The patient needs to be on close monitoring for any evidence of thrombosis or torsion to the kidney.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]