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• W2045982770 abstract "A 34-year-old man with renal failure secondary to vesicoureteral reflux and protein C deficiency underwent a live-related kidney transplant. The kidney was placed onto the portal system due to thrombosis of his systemic venous circulation. He was on peritoneal dialysis for 1 year; subsequently hemodialysis for 6 years. Before that, he was diagnosed with inferior vena cava (IVC) and bilateral iliac veins obstruction and was on therapeutic anticoagulation. He was deemed untransplantable before being referred to our center. Computed tomography angiogram and pelvic venogram demonstrated an atrophic right iliac venous system, occluded left common iliac vein, patent left external iliac vein, and an occlusive thrombus throughout the infrarenal IVC with multiple retroperitoneal collaterals. The superior mesenteric vein (SMV) and portal vein were normal (Fig. 1).FIGURE 1.: Computed tomography angiogram showing the venous anastomosis to splenic vein and arterial anastomosis to the aorta.The transplant was thus planned to use the portal system for venous drainage. Warfarin was stopped preoperatively, and unfractionated heparin infusion was started. Two doses of Campath (30 mg) were used as induction immunosuppression. Maintenance immunosuppression was based on tacrolimus at the standard dose of 0.05 mg/kg two times per day and mycophenolate 750 mg two times per day. A midline laparotomy was performed. The root of the small bowel mesentery was mobilized to expose the infrarenal aorta and a dilated inferior mesenteric vein (IMV), which was traced until the confluence of SMV and splenic vein (SV). The confluence was dissected and slung. At this point, the left donor nephrectomy was commenced on the patient's mother. Venous anastomosis was fashioned end to side to the confluence SMV-SV with 5/0 Prolene suture. Arterial anastomosis, end to side to infrarenal aorta with 6/0 nylon suture. After clamps were released, the kidney showed slow but good reperfusion. The native left ureter appeared atrophic, and it could not be used: a neoureterocystoanastomosis over a ureteric stent was performed to reconstitute the urinary drainage. A postoperative ultrasound confirmed good graft perfusion. During the following 4 days, the patient remained oliguric, despite a computed tomography angiogram and serial ultrasound showed excellent graft enhancement. He complained of persistent abdominal pain with feature of peritonitis. At exploratory laparotomy, a caecal perforation was found. A right hemicolectomy with ilio- transverse anastomosis was performed. The patient made a good recovery; still dialysis dependent, he was discharged on the 17th postoperative day. Hemodialysis was continued until 19th day postop when serum creatinine stabilized around 240 μmol/L. At a follow-up of 75 days, the creatinine is stable at 160 μmol/L. A review of the literature showed that multiple solutions exist. An orthotopic kidney transplant was first considered in 1976 by Mozes et al. (1). The patient had bilateral iliac system and distal IVC thrombosis. The donor renal vein was anastomosed end to end to recipient renal vein; the renal artery was anastomosed to the aorta. The urinary drainage was reconstituted through a uretero-ureteroanastomosis. More recently, the same approach was utilized by Pirenne et al. (2). Two works, from Patel and Krishnamurthi (3) and Rosenthal and Loo (4), described how venous drainage, in the presence of bilateral iliac vein and IVC thrombosis, could be obtained using a nondilated IMV. This choice is burdened with increased risk of thrombosis because of a thin-walled IMV, which also does not allow the use of donor caval patch. Two cases of the use of the SMV in patients with thrombosis of infrarenal IVC have been described. Aguirrezabalaga et al. (5) used an end-to-side anastomosis to the SMV. For the arterial reconstruction, in one case the common iliac was used directly, while in the second case interposition of a donor arterial segment was necessary. On a different note, the case of 14 simultaneous kidney/pancreas transplants was performed at the University of Toronto (6). They used portal venous drainage of the pancreas graft to overcome the problem of hyperinsulinemia occurring in case of systemic drainage into the IVC. CONCLUSIONS This case adds to the growing literature that complete iliocaval thrombosis is not a contraindication to transplantation. The portal system can be safely used as a conduit for venous drainage. The native left renal vein was not an option for us because it had a thrombus in it. Campath induction was used to avoid steroids in the postoperative setting. This strategy also obviated the need for biopsy in the first week of delayed graft function. The incidence of rejection after Campath induction (7) and adequate tacrolimus levels in addition to mycophenolate mofetil is rare in the first few weeks. Appropriate imaging is essential in the postoperative period to exclude vascular problems. An accurate study of the anatomy is essential to identify a suitable venous site for the anastomosis. Dialysis independence and improved quality of life can thus be achieved. Anna Rizzello Oliver Smyth Nilay Patel Srikanth Reddy Sanjay Sinha Anil Vaidya Transplant Surgery Churchill Hospital, Oxford Oxfordshire, United Kingdom" @default.
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• W2045982770 date "2011-11-27" @default.
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• W2045982770 title "Successful Splenic Venous Drainage for Kidney Transplant in Case of Inferior Vena Cava Thrombosis" @default.
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