Bovine Carotid Artery Is a Viable Iliac Artery Conduit During Solid Organ Transplantation

The medical care of patients with end stage renal disease (ESRD) has improved over the last 20 years. Many more patients are living with ESRD and many undergo evaluation and listing for transplantation. However, the comorbidities associated with ESRD have not disappeared. In fact, given their longer survival, the metabolic consequences of ESRD have more time to evolve while on the waitlist. The deranged calcium and mineral metabolism of patients with ESRD is compounded by associated comorbidities of diabetes, hypertension, and tobacco use. As such, it is not surprising to find dense atherosclerosis (ASVD) that commonly results in an aborted transplant effort and limited access to life-saving transplants. We report ten cases of patients with significant vasculopathy whose transplant was salvaged with bovine carotid artery (BCA) biologic graft with good outcomes.

All patients who underwent kidney or simultaneous pancreas and kidney transplant with BCA between 2019 and 2024 were identified. Patient demographics including sex, age, race, indication for transplant, indication for BCA use, complications specific to BCA use (thrombosis/infection), operative details, postoperative course, and outcomes were recorded.

Transplant limiting atherosclerosis was found in 10 (1.5%) of 657 patients transplanted during this 6-year time period. There were eight women and two men with an age range of 31 to 74. The most common etiology of renal disease was hypertension (n = 3), diabetes (n = 2), or a combination of diabetes and hypertension (n = 2). The majority (78%) of our cohort was African American. Six patients developed a dissection. Four others were found to have extensive atherosclerotic disease. One of the four patients with extensive atherosclerotic disease had a prohibitively calcified common iliac artery leading to an occluded external iliac artery and large, patent internal iliac artery providing flow to the lower extremity and a target for end to side BCA. All ten patients were transplanted successfully with a BCA arterial conduit. Two patients died, one clearly of cardiovascular disease 8 months after their transplant and the second of unclear etiology 13.1 months after their transplant. Both died with functioning allografts. One patient developed vascular rejection. All others have done well with no thrombotic events, no peripheral vascular complications, no infections, and all have ongoing allograft function ranging from 403 days to 2253 days (6 years, 2 months).

Patients with ESRD have compounded comorbidities that often culminate in severe atherosclerosis (ASVD). In fact, this cohort of patients is often denied a life-saving transplant due to the presence of ASVD. While still a substantial challenge to a safe renal transplant, severe atherosclerosis may not necessarily represent an absolute contraindication to a life-saving transplant. We herein demonstrate the use of BCA as a viable iliac arterial conduit during solid organ transplantation.