Successful Kidney Transplant Using a Preoperatively Planned Polytetrafluoroethylene Graft in a Patient with Extensive Vascular Calcification

Kidney transplant in itself is a complex surgery. Moreover, it has worse outcomes in recipients with extensive vascular calcifications than the conventional patients.[1] Polytetrafluoroethylene (PTFE) grafts are commonly used in vascular and hemodialysis access surgery, but their application in kidney transplantation is rarely documented, except in emergency settings, such as external iliac artery dissection. Their preplanned use as a primary arterial conduit in kidney transplantation has not been widely reported. The use of PTFE grafts in kidney transplants has been met with skepticism, primarily due to concerns regarding graft thrombosis, long-term patency, and infection risks. However, recent experiences suggest that careful patient selection, meticulous surgical technique, and postoperative anticoagulation therapy can optimize graft patency and minimize complications.[2] A 60-year-old male with diabetes, hypertension, a history of chronic smoking, and post angioplasty had been undergoing hemodialysis for 5 years due to end stage kidney disease. He was evaluated for a live-donor kidney transplant, with his wife serving as the donor, necessitating an ABO-incompatible transplantation. Preoperative Doppler ultrasonography and computed tomography angiography revealed severe circumferential calcification of the aorta, common iliac, external iliac, and internal iliac arteries, rendering them unsuitable for direct anastomosis, although without luminal obstruction. In addition to iliac vessel calcifications, bilateral femoral artery calcifications were noted, with the exception of a 3–4 cm segment in the left femoral artery, which was identified as the only viable site for anastomosis preoperatively [Figure 1].Figure 1: Polytetrafluoroethylene (PTFE) graft tunnelled and the other end of the PTFE graft sutured to the left femoral artery in an end-to-side manner with Prolene 7-0 sutureA preplanned surgical strategy was devised using a 6 mm PTFE graft to bypass the diseased iliac arteries, establish arterial inflow from the left femoral artery, and perform an end-to-end anastomosis between the renal artery and the PTFE graft, whereas the renal vein was anastomosed in the usual end-to-side manner to the external iliac vein. A laparoscopic donor nephrectomy was performed, and the kidney was retrieved with a single renal artery and renal vein. In the recipient, a Gibson incision was made in the left iliac fossa, and extensive dissection was performed. A 7–8 cm longitudinal incision was made over the left femoral artery, where a segment free of calcification was confirmed intraoperatively. The PTFE graft was tunneled beneath the inguinal ligament and anastomosed end-to-side to the femoral artery and end-to-end with the renal artery. Upon declamping, immediate diuresis was observed, confirming successful renal perfusion. The postoperative course was uneventful, with no vascular complications and no signs of thrombosis. Serial Doppler ultrasonography confirmed patent vascular anastomoses and normal perfusion of the transplanted kidney. The patient remained hemodynamically stable, and renal function progressively improved, with a serum creatinine level of 1.1 mg/dL at 2 months postoperatively. Patient exhibited stable graft function without any vascular compromise or rejection. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.