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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 66-68

Live-related renal transplant with bench repair of saccular aneurysm of graft renal artery - A case report


1 Department of Urology and Plastic Surgery, Medical Trust Hospital, Kochi, Kerala, India
2 Consultant Nephrologist, Medical Trust Hospital, Kochi, Kerala, India

Date of Submission10-Sep-2020
Date of Acceptance27-Jan-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Amit Hosamani
Department of Urology and Plastic Surgery, Medical Trust Hospital, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_103_20

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  Abstract 


Renal artery aneurysm is a rare entity with an incidence of about 1%. The preoperative evaluation of a voluntary kidney donor incidentally revealed a saccular aneurysm of the right renal artery on a computed tomography angiogram. Laparoscopic right donor nephrectomy was performed with Bench repair of the aneurysm and transplantation of this kidney to the recipient in the right iliac fossa. Transplant kidney had good perfusion on revascularization with normal postoperative graft function. Transplanting kidneys with renal artery aneurysm can be safely performed with a win-win situation for both donor and recipient.

Keywords: Ex vivo aneurysmal repair, laparoscopic donor nephrectomy, renal artery aneurysm


How to cite this article:
Hosamani A, Bhaskara K G, John RP, Iqubal M. Live-related renal transplant with bench repair of saccular aneurysm of graft renal artery - A case report. Indian J Transplant 2021;15:66-8

How to cite this URL:
Hosamani A, Bhaskara K G, John RP, Iqubal M. Live-related renal transplant with bench repair of saccular aneurysm of graft renal artery - A case report. Indian J Transplant [serial online] 2021 [cited 2021 Apr 11];15:66-8. Available from: https://www.ijtonline.in/text.asp?2021/15/1/66/312744




  Introduction Top


Renal transplantation is the optimal treatment for patients of all ages with end-stage renal disease. Transplantation offers advantages related to longevity and quality of life.[1] In India alone, approximately 80,000 such patients are added annually.[2] As the number of patients awaiting renal transplants increases, more living donors may be sought to meet the increasing demand for organs. Limited availability of live donors for renal transplant has resulted in the acceptance of donors with renal vascular anomalies. We report a case of transplanting a kidney with renal artery aneurysm (RAA) from a living-related donor after ex vivo repair on the bench.


  Case Report Top


A 60-year-old female with hypertension, on calcium channel blockers, volunteered to donate kidney. During donor assessment, computed tomography angiogram showed a 12.8 mm × 12 mm sized peripherally calcified almost completely thrombosed saccular aneurysm at the bifurcation of the right renal artery with the neck of aneurysm measuring approximately 7 mm [Figure 1]. She had two left renal arteries which were unremarkable and two renal veins on right side. The isotope renogram showed bilaterally normal functioning kidney (left 46%, right 54%) with no evidence of any obstruction. We decided to use the right kidney as a graft with a plan to carry out the excision and repair of aneurysm on the bench.
Figure 1: Computed tomography angiogram showing saccular aneurysm at the bifurcation of right renal artery. (a) Coronal cut. (b) Three dimentional reconstructed image

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Surgical technique

Laparoscopic right donor nephrectomy was done using standard technique. The procedure was uneventful. Graft retrieved and handed over for perfusion.

Ex vivo reconstruction

During bench dissection, the saccular aneurysm was identified at the bifurcation of the right renal artery measuring about 13-mm diameter with a 7 mm base [Figure 2]a, it was excised at the ostium using fine scissors. The edges of the arterial defect were approximated using 8-0 Nylon with interrupted sutures [Figure 2]b. Patency was checked, no leak was observed.
Figure 1: Computed tomography angiogram showing saccular aneurysm at the bifurcation of right renal artery. (a) Coronal cut. (b) Three dimentional reconstructed image

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Recipient allograft transplantation was done in the right iliac fossa with an end-to-side anastomosis to the external iliac artery [Figure 2]c and venous anastomosis to the external iliac vein. On revascularization, graft color, texture and consistency were good with good diuresis. No anastomotic leak was found. The ureter was anastomosed with Lich-Gregoir extravesical anti-reflux technique.

In the immediate postoperative period, transplant kidney Doppler was unremarkable with good flow in all poles of graft kidney, normal resistive index (0.65), normal appearances of the renal artery, and the anastomoses. Peak systolic velocity in the main renal artery was 160 cm/s. No evidence of leak from the renal artery. On postopertive day nine, patient had acute graft dysfunction. Serum creatinine increased from 1.1 to 1.4 mg/dl, managed with pulse steroid therapy. Subsequently, patient developed graft dysfunction for the second time which was diagnosed to be antibody-mediated rejection and managed with plasmapheresis and intravenous immunoglobulin. After 5 months of post renal transplant patient's serum creatinine was 3 mg/dl.

The donor was discharged 3 days after the right laparoscopic donor nephrectomy. Recovery was uneventful.


  Discussion Top


RAA is a rare pathological entity. Tham et al.,[3] reported its incidence as 1%. About (80%) of them are saccular, and the rest are fusiform or dissecting lesions. Excluding the cases with multiple vessels, anomalies of the renal vasculature can be identified in up to 6% of the live donor preassessment investigations.[4]

Symptoms vary and may include hypertension, pain, hematuria, and renal infarction; however, most patients are asymptomatic and lesions are benign. Complications include thrombosis, rupture, embolic episodes, etc., especially in premenopausal women.

Although some consider RAA calcification to be protective of rupture, no correlation between RAA calcification and risk of rupture was evident in most previous reports.

The management of RAA includes close follow-up, endovascular procedures and surgical excision and repair based on age, gender, symptoms, size, and type of aneurysm.

Fusiform aneurysms are usually repaired using aneurysmal segment excision and vascular bypass technique. The procedure of choice for saccular aneurysm is tangential excision and primary repair or patch angioplasty if the aneurysmal neck is wide.

In our case, it was a 12.8 mm × 12 mm sized peripherally calcified almost completely thrombosed saccular aneurysm at the bifurcation of the right renal artery with the neck of aneurysm measuring approximately 7 mm, which was tangentially excised and repaired primarily. Based on the literature recommendations, we believe that the use of this kidney as a graft after ex vivo repair of the aneurysm was justified.

Jung et al. reported 2 cases with RAA, 2 and 2.4 cm in size. 11 Patients underwent hand-assisted laparoscopic donor nephrectomies and ex vivo reconstruction. The allografts worked well immediate postoperatively, but no long-term outcomes were recorded.[5]

The shortage of organs has resulted in increasing the use of so-called marginal kidneys from living donors with anatomical anomalies and even kidneys with small malignant tumors.

Isolated case reports and small case series[4] showed that the selected use of organs with renovascular pathology is a safe solution for the recipient and at the same time gives definite treatment to the donor. There is, however, the need for close postoperative follow-up of the donor (in addition to the recipient) because of a reported increased risk of aneurysm incidence in the remaining kidney.[4]


  Conclusion Top


To conclude, in cases of renal artery aneurysm, allograft transplants can be safely considered which adds up to the donor pool. Ex vivo repair of the aneurysm in the hands of experienced surgeons is safe with a successful outcome. Furthermore, it is beneficial to the donors who are at higher risk of aneurysmal complications. In living donors, considering the benefits, Laparoscopic donor nephrectomy can be safely considered.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Textor CS, Taler JS, Driscoll N, Larson TS, Gloor J, Griffin M, et al: Blood pressure and renal function after kidney donation from hypertensive living donors. Transplantation 2004;78:276-82.  Back to cited text no. 1
    
2.
Kumar A, Mandhani A, Verma BS, Srivastava A, Gupta A, Sharma RK, et al. Expanding the living related donor pool in renal transplantation: Use of marginal donors. J Urol 2000;163:33-6.  Back to cited text no. 2
    
3.
Tham G, Ekelund L, Herrlin K, Lindstedt EL, Olin T, Bergentz SE. Renal artery aneurysms. Natural history and prognosis. Ann Surg 1983;197:348-52.  Back to cited text no. 3
    
4.
Olakkengil SA, Mohan Rao M. Transplantation of kidneys with renal artery aneurysm. Clin Transplant 2011;25:E516-9.  Back to cited text no. 4
    
5.
Jung CW, Park KT, Kim MG. Experiences of renal transplants from donors with a renal artery aneurysm after a laparoscopic donor nephrectomy and ex vivo reconstruction of the renal artery. Exp Clin Transplant 2013;11:324-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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