Application of endovascular stent graft in ABO-incompatible living donor kidney transplantation: a case report

Severe iliac arteriosclerosis is a contraindication for kidney transplantation (KT). This report details a case of a 34-year-old female with type 2 diabetes mellitus and severe iliac arteriosclerosis who underwent ABO-incompatible living donor KT in which the renal graft artery was anastomosed to the self-expandable endovascular covered stent placed in the external iliac artery. The initial anti-blood group anti-A antibody titers were 1:4 and 1:32 for IgG and IgM, respectively. Routine pre-transplant therapy including rituximab 200mg, triple immunosuppressants included tacrolimus (7mg/d, tacrolimus concentration was between 3.8 and 9.2 ng/mL), mycophenolate mofetil (1500mg/d), methylprednisolone (16mg/d). Following one session of double filtration plasmapheresis, anti-blood group antibody titers were reduced 1:4 and 1:8 for IgG and IgM. Two days prior to surgery, patient underwent one session of plasma exchange and antibody titers were IgG 1:4 and IgM 1:8 on the day of KT. Basiliximab was administered for immune induction. The initial routine was performed with conventional end-to-side anastomosis between the renal graft artery and the right external iliac artery. However, pulsation of the transplant renal artery disappeared shortly. Upon opening the anastomosis, thrombosis at the anastomotic site was identified due to plaque embolism from the external iliac artery. Consequently, a self-expandable endovascular covered stent was implanted into the external iliac artery via the right femoral artery under intervention. Because part of the external iliac artery wall was defective, the endovascular stent was partially exposed, used the prosthetic graft for coverage and reinforcement. Finally, the renal allograft artery was anastomosed end-to-side to the stent–prosthetic complex. The anti-blood group antibody titers were 1:2 and 1:4 for IgG and IgM and serum creatinine was 124 μmol/L at 1 month. During the 2 years follow-up, graft function remained satisfactory, the serum creatinine levels were 116, 107, and 113 μmol/L at 6 months, 1 year, and 2 years postoperatively, and no signs of right lower limb ischemia were evident. This study demonstrates that renal graft implanted on the endovascular stent is a feasible therapeutic option for recipients with severe iliac arteriosclerosis.