Positional Diuresis, a Curious Manifestation Secondary to a Post-transplant Renal Artery Kinking

Abstract

installation of an aortoeunilateral endograft in the right side, and we performed a femoroefemoral bypass from the right common femoral artery (CFA) to the left CFA using a 6mm e-PTFE standard-wall graft. The left common iliac artery (CIA) was blocked with a plug. Case 2: A 77 years-old male patient arrived at the Emergency Department of our Hospital because of acute abdominal pain, symptoms of left leg ischemia and decreased hemoglobin levels. His past medical history included an asymptomatic 12 cm infrarenal AAA treated with a bifurcated stent graft two years ago. Urgent ultrasound (U/S) and CT revealed a sac growth of approximately 13cm, a double Type IIIa endoleak due to the disconnection of both limbs from the main body with caused left leg thrombosis, and a late Type II endoleak from the IMA. We implanted a bridging limb extension to the right leg using a snare after exposure of the left brachial artery and both femoral arteries. Moreover, we implanted two aortic cuff endografts in the main body to close the ostium of the left leg. We also performed a femoro-femoral bypass from the right to the left common femoral artery to reperfuse the left leg. Both procedures were uneventful. After that, we proceeded in the treatment of type II endoleaks in both patients with endovascular embolization of feeding arteries. Conclusion: Type III endoleaks, although a rare complication after EVAR, may be presented with a late, untreated or undetected Type II endoleak. In these cases, the treatment options are technically demanding, and a combination of endovascular and open surgical procedures needed.

Case report of transplant renal artery stenosis secondary to mechanical renal artery kinking: Balloon angioplasty as a supportive diagnostic tool?

“…Several management techniques have been successfully utilized including conservative management [ 5 ], endovascular repair [ 8 , 10 ], or surgical correction [ 7 , 9 , 11 , 12 ]. In cases where the renal artery kink is near the anastomosis and there is evidence of early graft dysfunction (rising creatinine, decreased urine output, or uncontrolled hypertension), the renal artery kinks are often resistant to endovascular repair and require prompt surgical correction with nephropexy or re-anastomosis [ 3 , 7 , 9 , 10 , 11 , 12 ]. It is likely the kink does not act as a true stenosis and frequently rebounds to its former configuration after percutaneous transluminal angioplasty or is propagated distally during stenting [ 3 ].…”

“…With malposition of the graft the most likely cause of kinking, it can be deduced that surgical re-anastomosis or repositioning of the graft is often required to permanently correct the dysfunction. Based on literature review, only 15% (2/13) of TRAS secondary to mechanical artery kinking were successfully treated with endovascular repair [ 4 , [8] , [9] , [10] , [11] , [12] , [13] ]. While our case was also resistant to endovascular repair, we suggest balloon angioplasty as an important diagnostic clue in the identification of TRAS secondary to mechanical artery kinking.…”

“…These underlying factors are thought to cause malposition of the graft making it prone to kinking but the rarity of this phenomenon leaves much to be determined. Previous case reports identified only thirteen instances of post-transplant renal artery kinking between 1994 and 2019 [ 4 , [7] , [8] , [9] , [10] , [11] , [12] , [13] ]. Due to the rarity of this post-operative complication, a true incidence is unknown.…”