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Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 358-359

Kidney transplant in the presence of massively calcified vessels: A surgical challenge - A case report

Yashoda Hospitals, Secunderabad, Telangana, India

Date of Submission26-Jun-2020
Date of Acceptance05-Aug-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Dr. Bipin Chandra Pal
Yashoda Hospitals, S.P Road, Secunderabad - 500 003, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_67_20

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Kidney transplant in the presence of calcified vessels becomes a challenging task. There is a possibility of intraoperative complications and occasionally graft loss. Here, we present a case where we performed a kidney transplant in such a patient and discuss the importance of proper imaging and the surgical technique adapted by us to carry out the transplant.

Keywords: Arterial anastomosis, computed tomography abdomen, kidney transplant, vascular calcification

How to cite this article:
Pal BC, Patel G, Anandh U, Kukreja V. Kidney transplant in the presence of massively calcified vessels: A surgical challenge - A case report. Indian J Transplant 2020;14:358-9

How to cite this URL:
Pal BC, Patel G, Anandh U, Kukreja V. Kidney transplant in the presence of massively calcified vessels: A surgical challenge - A case report. Indian J Transplant [serial online] 2020 [cited 2021 Jun 16];14:358-9. Available from: https://www.ijtonline.in/text.asp?2020/14/4/358/305432

  Introduction Top

Kidney transplant in itself is a demanding surgery. Moreover, it has worse outcome in vascular complex recipients than the conventional patients.[1] Here we present a case where we performed transplant in a recipient having extensive arterial calcification and discuss the role of imaging and the surgical technique for carrying out the transplant.

  Case Report Top

A 49-year-old male patient had end-stage renal disease due to prolonged diabetes and hypertension. He was on maintenance hemodialysis for the last 1 year through a left brachiocephalic arterial venous fistula. His clinical examination revealed normally palpable femoral, dorsalis pedis, and posterior tibial artery. Bilateral iliofemoral Doppler study was reported as normal. Coronary angiography revealed 55% and 65% block in left anterior descending and circumflex arteries, respectively. Fundus examination revealed grade 2 diabetic retinopathy. A plain computed tomography (CT) of the abdomen showed extensive calcification of the vasculature [Figure 1].
Figure 1: Calcified iliac arteries

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During the donor surgery, the left kidney was retrieved with a relatively long length of ureter intentionally. During the bed preparation in the right iliac fossa, the external iliac and the internal iliac arteries were found to be hard in consistency circumferentially throughout their length. The common iliac artery (CIA) had a hard plaque in most of its length posteriorly. The common iliac vessels were exposed up to the aorta and inferior vena cava, respectively. Near the bifurcation of the aorta, the CIA was devoid of the plaque. It was doubly looped with a vascular sling near the aorta. The internal and the external iliac arteries were also doubly looped by vascular slings, respectively. The venous anastomosis was performed first in the common iliac vein. For arterial control, the CIA was gently pulled up with the preplaced vascular sling and a clip was applied over the stretched sling. In addition, a bulldog clamp could be placed just proximal to the sling. The doubly looped slings over the external and internal iliac arteries were also gently stretched and hem-o-lok clips were applied over them. The arteriotomy was made with blade rather than a punch. Intimal fixation at the edges of arteriotomy was done at 4 places using 6-0 Prolene with the knots remaining outside. Arterial anastomosis was carried out using 6-0 Prolene with passage of suture from inside lumen of the CIA to the renal artery [Figure 2]. After the release of clamps, the kidney became pink and turgid immediately and brisk urine output was noted. Ureteric reimplant was done with modified Lich-Gregoir technique.
Figure 2: Arterial anastomosis

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He was kept on low-molecular-weight heparin in the perioperative period. Postoperative period was uneventful and he was discharged with a creatinine of 1.2 mg%.

  Discussion Top

The population of the kidney transplant recipient has changed significantly in the last few decades. With increasing number of diabetes and hypertension, the prevalence of arterial disease, especially the arterial calcification, has increased. Chronic kidney disease itself and hemodialysis further add to calcification of vessels due to various factors.[2]

Screening these patients with CT helps in identifying the presence and extent of calcification, opinion on whether the transplant is possible or not, and if any presurgical procedures such as aortofemoral bypass are needed.[3] Our case bolsters the opinion to do a CT abdomen in all such patients, rather than rely solely on clinical examination and iliofemoral Doppler findings.

The options in severe aortoiliac calcification are to do arterial anastomosis in a relatively free area of CIA, use of aortofemoral bypass, or an orthotopic kidney transplant.[4],[5]

The proximal arterial control for vessel occlusion during anastomosis may be difficult because the bulldog clamp may not close over a circumferentially hardened artery, the plaque can fracture during manipulation, and it may not be possible to make an arteriotomy over a hardened artery. To circumvent these problems, we dissected CIA till aorta where we could find an area free of the plaque to sling the vessel and an area over anterior wall of common iliac where we could perform the anastomosis. We used doubly looped vascular sling with a clip over it to occlude the vessel which provides a uniform pressure all around the vessel. Using a blade for arteriotomy is more controlled, rather than using a punch as sometimes punch can destroy the edges of the arteriotomy. Besides fixing, the intima at the edges of the arteriotomy reduces the chance of intimal dissection. Further, more passing suture from the iliac artery to the renal artery during anastomosis fixes the intima, leading to a successful transplant.

  Conclusion Top

Kidney transplantation in a patient having extensive vascular calcification can be performed with proper planning and good surgical expertise and technique. A plain CT abdomen preoperatively, use of doubly looped vascular slings for arterial control, and intimal fixation are desirable during surgery.

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.

  References Top

Hevia V, Gómez V, Hevia M, Lorca J, Santiago M, Dominguez A, et al. Troubleshooting complex vascular cases in the kidney transplant recipient: vascular anomalies, challenging vessel diseases, and procedural disasters. Curr Urol Rep 2020;21:7.  Back to cited text no. 1
Nelson AJ, Raggi P, Wolf M, Gold AM, Chertow GM, Roe MT. Targeting vascular calcification in chronic kidney disease. JACC Basic Transl Sci 2020;5:398-412.  Back to cited text no. 2
Catalá V, Martí T, Diaz JM, Cordeiro E, Samaniego J, Rosales A, et al. Use of multidetector CT in presurgical evaluation of potential kidney transplant recipients. Radiographics 2010;30:517-31.  Back to cited text no. 3
Musquera M, Peri LL, Alvarez-Vijande R, Oppenheimer F, Gil-Vernet JM, Alcaraz A. Orthotopic kidney transplantation: An alternative surgical technique in selected patients. Eur Urol 2010;58:927-33.  Back to cited text no. 4
Davins M, Llagostera S, Jimenez R, Rosales A, Romero JM, Diaz JM. Aortofemoral bypass to bridge end-stage renal disease patients with severe iliac calcification to kidney transplantation. Vascular 2009;17:269-72.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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