Simultaneous aortoiliac reconstruction and renal transplantation: is it safe?

A 54-year-old man with an aortoiliac aneurysm and renal failure due to renal artery thrombosis was placed on a transplantation waiting list. The aneurysm had a 3 cm diameter and, therefore, did not require aortoiliac reconstruction, while its evolution was followed by ultrasound color-doppler every six months. The aneurysm was stable and two years later, when a cadaver kidney became available, a preoperative ultrasound color-doppler showed initial wall dissection. Therefore, an abdominal aneurysmectomy using a standard Dacron bifurcation graft and renal transplantation were successfully carried out. The patient had no associated complications and 24 months after transplantation and aneurysmectomy currently has good renal function and distal pulses. Only 20 cases of simultaneous aortoiliac reconstruction and renal transplantation have been reported in the literature. The excellent results of our case and those reported in the literature prove that patients who have both severe aortoiliac disease and end-stage renal failure can safely undergo simultaneous aortic reconstruction and renal transplantation. However, the atherosclerosis in these patients is a generalized process, so that in the pretransplant protocol special attention should be paid to detecting coronary artery atherosclerosis. In fact, coronary artery disease may have a priority claim to therapy because of the high risk of myocardial infarction. Our own policy is to put the patient back on the waiting list for renal transplantation after treatment for coronary artery disease. Furthermore, considering that the management for aortoiliac disease and kidney failure is safe in both simultaneous and staged cases, we think that the real issue is whether or not these patients with coronary atherosclerosis can be candidates for renal transplantation. We believe that each transplant centre has to develop its own general policy for these critically ill patients on the basis of its own experience.