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16
II. ХИРУРГИЯ
TRANSPLANTATION OF KIDNEY WITH RENAL ARTERY ANEURYSM WITH EX-VIVO RECONSTRUCTION. CASE REPORT
Baimakhanov B.B., Ibragimov R.P., Issayev D.A., Madadov I.K., Syrymov Zh.M.
National scientific centre of surgery named after A.N. Syzganov, Almaty, Kazakhstan
Abstract
Clinical case of the transplantation of kidney with RAA. 25 years old patient with end-stage renal disease was referred to our hospital for living related kidney transplantation. His donor was his mother. During the preoperative evaluation of donor RAA of the left kidney was revealed. The dimensions of the latter were 2.0x2.0 cm. We preferred to harvest that kidney with aneurysm in order to save donor from further complications due possible rupture and perform reconstruction ex-vivo. All the objectives were achieved: transplantation was performed successfully and donor is now is apart from the risk of rupture.
АВТОРЛАР ТУРАЛЫ
P. П. Ибрагимов - уролог-транспланто-логдэр!гер!, буйрек трансплантациясы, урология жэне нефрология бел!мшес!н!н жетекш!с!, ылы/ми жетекш!
Д.А. Исаев - уролог-трансплантолог дэр!гер!, буйрек трансплантациясы, урология жэне нефрология бел!мшес!
И.К. Мададов - урологдэр!гер!, буйрек трансплантациясы, урология жэне нефрология бел!мшес!, к!ш! рылыми цы/зметкер (dominic89@mail.ru 87478397110)
Ж.М. Сырымов - урологдэр!гер!, буйрек трансплантациясы, урология жэне нефрология бел!мшес!
TYЙiн сездер
apтepия, aнeвpизua, бyйpeк, тpaнcплaнтaция
Трансплантация почки с аневризмой почечной артерии с ех^гоо реконструкцией. Клинический случай
Баймаханов Б.Б., Ибрагимов Р.П., Исаев Д.А., Мададов И.К., Сырымов Ж.М.
Национальный научный центр хирургии им. А.Н. Сызганова, Алматы, Казахстан
Аннотация
Kлиничecкий cлучaй пepecaдки пoчки c aнeвpизuoй пoчeчнoй apтepии. Пaциeнт 25 лeт c диarнoзou тepuи-нaльнaя oraдия бoлeзни пoчeк пocтупил в нaшу клинику для aллoтpaнcплaнтaции пoчки oт живoro poдcтвeннoro дoнopa. Em дoнopou выcтупилa poднaя uan. Пpи пpeдoпepaциoннou oбcлeдoвaнии у дoнopa былa выявлeнa aнeвpизua cerueнтapнoй apтepии лeвoй пoчки. Paçuepbi пocлeднeй cocтaвляли 2,0x2,0. cu. Мы пpeдпoчли ^e-лaть зaбop пoчки c aнeвpизuoй apтepии для пpeдoтвpaщeния cocудиcтыx ocлoжнeний у дoнopa, в œязи c вoз-тжньш paзpывou aнeвpизuы, и пpoвecти peкoнcтpукцию aнeвpизuы ex-vivo. Bce пocтaвлeнныe цeли были дo-cтиrнуты: былa уcпeшнo пpoвeдeнa тpaнcплaнтaция пoчки и уcтpaнeн pиcк paзpывa aнeвpизuы у дoнopa.
MPHTÈ 76.29.51.
ABOUT THE AUTHORS
R.P. Ibragimov - urologist, transplant-surgeon, head of kidney transplantation, urology and nephrology department, scientific manager.
D.A. Issayev - urologist, transplant-surgeon, kidney transplantation, urology and nephrology department.
I.K. Madadov- urologist, kidney transplantation, urology and nephrology department (dominic89@mail.ru 87478397110)
Zh.M. Syrymov - urologist, kidney transplantation, urology and nephrology department
Keywords
artery, aneurysm, kidney, transplantation
Буйрек кантамыры аневризмасыньщ ex-vivo реконструкциясымен жacaлfaн бYЙpeк трансплантациясы. Клиникалык о^а
Баймаханов Б.Б., Ибрагимов Р.П., Исаев Д.А., Мададов И.К., Сырымов Ж.М.
А.Н. Сызганов атында?ы Улттык, fbrnbiMè хирургия орталы^ы, Алматы, Казахстан
Ацдатпа
Apтepия aнeвpизuacы бoлfaн бyйpeк тpaнcплaнтaцияcыныœ клинитлык o^faui. 25 œacap нaукac б!здщ aуpуxaнafa vpÍ туыcкaн дoнopлык бyйpeк тpaнcплaнтaцияcын жacaту uaкcaтыueн ^лп yт!. Оныц дoнopы туfaн aнacы бoлды. Дoнopды oтafa дeйÍнrÍ зepттeу бapыcындa coл бyйperÍндe apтepия aнeвpизuacы aныктaлды. Aнeвpизuaнын eлшeuдepÍ 2,0x2,0. cu бoлды. Aнeвpизuaнын ^eweiae жы^тылу uyuкÍншÍлÍп бoлfандыкrан, дoнopды ж^п aлу т^т^н aнeвpизua бoлfaн бyйpeктÍ aлып ex-vivo peкoнcтpукцияcын жacaу 0e0ÍuÍ кaбылдaдык. Koйылfaн uatcauap opындaлды: бyйpeк тpaнcплaнтaцияcы cení еттÍ жднe дoнopдa aнeвpизuaныц жы^тылу щШ жoйылды.
ОБ АВТОРАХ
P. П. Ибрагимов - уролог-трансплантолог, заведующий отделением трансплантации почек, урологии и нефрологии, руководитель исследования
Д.А. Исаев - уролог-трансплантолог, отделение трансплантации почек, урологии и нефрологии
И.К. Мададов - уролог, отделение трансплантации почек, урологии и нефрологии, младший научный сотрудник (dominic89@ mail.ru 87478397110)
Ж.М. Сырымов - уролог, отделение трансплантации почек, урологии и нефрологии
Ключевые слова
apтepия, aнeвpизua, пoчкa, тpaнcплaнraция
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ВЕСТНИК XИPУPГИИ KA3AXCTAHA № 3-2018
Introduction
According to the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients (OPTN/SRTR) Annual Data Report in 2013, the total number of patients waiting for a kidney transplant is 96 607. Median waiting times for adults increased from three years in 2003 to more than 4.5 years in 2009 [1, 2]. In order to increase organ availability, it is necessary to evaluate the feasibility of kidney transplantation from living donors with RAA. Most commonly, it is asymptomatic and diagnosis is made incidentally during evaluation of different conditions, such as living donor workup [1]
A RAA is a dilated segment of renal artery that is more than twice the diameter of a normal renal artery [3].
Roughly, RAAs are saccular in 62%, fusiform in 24%, and dissecting in 14% [4]. Renal artery aneurysm (RAA) is a rare condition; the incidence of RAA is 0.7% [5]. Symptoms vary and may include hypertension, pain, hematuria, and renal infarction [6]; however, most patients are asymptomatic and lesions are benign. Pregnancy is associated with a higher rate of rupture [7].
Olakkengil in his study reported four living donors with RAA who had a mean follow-up of 3.5 years (range 1.9-8) [8]. The follow-up of donors included annual USD of the remaining kidney and renal function. He recommended following donors to look for an incidence of RAA in the opposite kidney, as Dzsinich reported bilaterality of RAA in 3.1%. The potential risk for rupture lies with increasing size of aneurysms.
The lack of organs for transplantation has resulted in increasing the criteria for selection of potential donors with so-called marginal kidneys with anatomical anomalies and even kidneys with small malignant tumors [9].
The reported series on transplantation from living donors with RAA are small and from a single center. Jung et al reported two cases with RAA that were 2 cm and 2.4 cm in size. Patients underwent hand-assisted laparoscopic donor nephrectomies and ex-vivo reconstruction ensued. The allografts worked well immediately postoperative, but no long-term outcomes were recorded [10]. Autopsy studies indicating the incidence range to be 0.010.09% [11].
Nahas et al reported 11 recipients from donors with vascular abnormalities, including three RAA cases, after open nephrectomy and ex-vivo reconstruction. One patient had arterial thrombosis at 55 months; the other two had a mean follow-up of 133 months with good renal function [12].
Case presentation
30-years old male was referred to our hospital for living related donor kidney transplantation. His donor was his mother. Donor didn't have any complaints, such arterial hypertension or flank pain. During preoperative evaluation aneurysm of left kidney was revealed. The latter was 2.0*2.0 cm. and had a saccular shape [Fig. 1]. Considering the tendency of aneurysm for further enlargement posing a risk for patient, we decided to harvest this kidney with ex-vivo reconstruction on back-table, thus preventing it from rupture in future.
Donor underwent laparoscopic hand-assisted nephrectomy. On back-table the renal tightly denuded and the aneurysm of segmental artery was revealed [Fig. 2]. The latter had a wide neck
Fig. 1.
CT angiogram. RAA is 2.0*2.0 cm and has a saccular shape
Fig. 2.
Kidney graft on back-table. Aneurysm is tightly dissected
BULLETIN OF SURGERY IN KAZAKHSTAN № 3-2018
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Fig. 3.
Aneurysm was clipped with metal clip at the neck
Fig. 4.
Kidney is engrafted in right iliac fossa
and it was preferred to put a metal clip [Fig. 3]. Graft was placed on right iliac fossa and arterial and venous anastomoses were performed in end-to-side fashion with external iliac artery and vein of recipient, respectively [Fig. 4]. Graft function was immediate.
Further ultrasound Doppler investigation revealed no circulatory disturbances. Patient was under the follow-up for only 6 months up to day and graft circulation and function is already good.
Conclusion
In this clinical case we presented an interesting clinical event of transplantation kidney with aneurysm of segmental artery. The aim was to perform successful transplantation and save donor from further risk of rupture of aneurysm and we completely achieved all objectives. Considering the lack of kidney donors it is socially important to expand the criteria for donor selection.
References
1. Lugo-Baruqui JA, Guerra G, Chen L, et al. Living donor renal transplantation with incidental renal cell carcinoma from donor allograft. Transpl Int. 2015;28:1126-30. https://doi.org/10.1111/ tri. 12594.
2. Silver PR, Budin JA. Unusual manifestations of renal artery aneurysms. Urol Radiol. 1990;12:80-3. https://doi.org/10.1007/BF02923973.
3. Bastounis E, Pikoulis E, Georgopoulos S, et al. Surgery for renal artery aneurysms: A combined series of two large centres. Eur Urol. 1998;33:22-7. https:// doi.org/10.1159/000019530.
4. Dulabon LM, Singh A, Vogel F, et al. Intrarenal pseu-doaneurysm presenting with microscopic hematuria and right flank pain. Can J Urol. 2007;14:3588-91.
5. Dzsinich C, Gloviczki P, McKusick MA, et al. Surgical management of renal artery aneurysm. Cardiovasc Surg. 1993;1:243-7.
6. Jung CW, Park KT, Kim MG. Experiences of renal transplants from donors with a renal artery aneu-rysm after a laparoscopic donor nephrectomy and ex vivo reconstruction of the renal artery. Exp Clin Transplant. 2013;11:324-6. https://doi.org/10.6002/ ect.2013.0023.
10,
12,
Matas AJ, Smith JM, Skeans MA, et al. OPTN/SRTR 2013 annual data report: Kidney. Am J Transplant. 2015; 15(Suppl 2):1-34. https://doi.org/10.1111/ ajt.13195.
Nahas WC, Lucon AM, Mazzucchi E, et al. Kidney transplantation: The use of living donors with renal artery lesions. J Urol. 1998;160:1244-7. https://doi. org/10.1016/S0022-5347(01)62508-4. Olakkengil SA, Mohan Rao M. Transplantation of kidneys with renal artery aneurysm. Clin Transplant. 2011 ;25:E516-9. https://doi.org/10.111Vj.1399-0012.2011.01460.x.
Rautio R, Haapanen A. Transcatheter embolization of a renal artery aneurysm using ethylene vinyl alcohol copolymer. Cardiovasc Intervent Radiol. 2007;3:300-3. https://doi.org/10.1007/ s00270-005-0238-2.
Seppala FE, Levey J. Renal artery aneurysm: Case report of a ruptured calcified renal artery aneurysm. American Surg. 1982;48:42-4. Tham G, Ekelund L, Herrlin K, et al. Renal artery aneurysms. Natural history and prognosis. Ann Surg. 1983;197:348-52. https://doi. org/10.1097/00000658-198303000-00016.
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 3-2018
