Kidney Transplantation in Children with Thrombosed Inferior Caval Vein – Atypical Vascular Anastomoses

Abstract

BackgroundDiffuse thrombosis of iliac veins and IVC has been considered a significant technical obstacle in pediatric kidney transplantation (KT).Material/MethodsBetween 1984 and 2018, 951 KTs were performed in our institution. In 4 children qualified for KT, diffuse thrombosis of iliac veins or IVC was found. The surgical techniques, complications, patient and graft survival, and long-term renal function were studied retrospectively. The patients’ age at transplantation was 2.5–13 years and body mass was 11–39 kg.ResultsAll children were transplanted with venous anastomoses made to infrahepatic IVC (3 patients) or collateral circulation (1 patient). Early complications developed in 2 patients: significant bleeding from the graft area requiring revision on the second day after transplantation and chyle leak that resolved spontaneously. The follow-up period was 1–12.5 years. Three patients are alive with a follow-up at 7 months, 4.5, and 12 years with serum creatinine 0.7 mg%, 0.6 mg% and 1.4 mg%, respectively. One patient died 1 year after KT, with normal graft function. No late complications related to KT were observed in any patient.ConclusionsRenal transplantation in pediatric patients with thrombotic vascular complications is associated with a number of technical difficulties and problems.

Endovenous Iliocaval Revascularization for Transplant Kidney Salvage

“…The incidence of IVC thrombosis in children after a central venous access through a femoral vein is described to be as high as 10%-15%. [6][7][8] Due to extensive collateral venous flow, most patients remain asymptomatic. 6,7 During pretransplant workup, this patient received a duplex ultrasound of the aorta and pelvic arteries.…”

“…They found 4 cases with a preoperative diagnosis of thrombosis of the iliac vein and vena cava. 6 In 3 cases, they performed the venous anastomosis of the transplant kidney on the infra-hepatic IVC, and in the fourth case, they performed the venous anastomosis on a collateral vein. 6 All arterial anastomoses were made to the aorta.…”

“…6 In 3 patients, an extravesical ureterocystostomy, and in 1 patient, a uretero-ureteric anastomosis was performed. 6 When iliocaval fibrosis is diagnosed during the pretransplant work-out, we suggest an endovascular recanalization as the first treatment option before proceeding to renal transplantation. If this is not possible or not successful, a different transplantation technique should be considered.…”

“…Chronic venous stenosis/fibrosis may only moderately impede venous flow due to extensive collateral vessels and, in this case, the proximity of the kidney representing a physiological arteriovenous shunt. [6][7][8]11 Presence of occlusion or stenosis of the vena cava or iliac veins should be discussed in a multidisciplinary team to determine the best treatment strategy and surgical approach.…”

Bench thrombolysis and “autotransplantation” as a rescue treatment for venous thrombosis after living‐donor kidney transplantation

“…Nevertheless, thrombosis of the ICV did not represent a contraindication for pediatric KT, but several series reported a higher rate of adverse events. 9,10 Taking into account all these reasons, in our case, anticoagulation with LMWH was preventively prescribed at the pretransplant evaluation in order to avoid further extension of thrombosis. Continuous infusion of unfractioned heparin was also started in the immediate posttransplant period.…”