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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2016  |  Volume : 27  |  Issue : 5  |  Page : 1043-1046
Emergency ligation of external iliac artery for control of bleeding following allograft nephrectomy


1 Department of Urology, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Radiology, Tabriz University of Medical Sciences, Tabriz, Iran

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Date of Web Publication22-Sep-2016
 

   Abstract 

Renal transplantation is the best treatment for end-stage renal disease. Vascular complications of renal transplantation can be hazardous. Bleeding from the anastomotic site in external iliac artery is a nightmare for kidney transplant surgeons. Ligation of the external iliac artery might possibly lead to the loss of the lower limbs. We present two cases of postallograft nephrectomy bleeding, in which the external iliac artery was ligated without consequent ischemia.

How to cite this article:
Zomorrodi A, Abolhassan S, Jabbari A, Zomorrodi S, Sheikh MF. Emergency ligation of external iliac artery for control of bleeding following allograft nephrectomy. Saudi J Kidney Dis Transpl 2016;27:1043-6

How to cite this URL:
Zomorrodi A, Abolhassan S, Jabbari A, Zomorrodi S, Sheikh MF. Emergency ligation of external iliac artery for control of bleeding following allograft nephrectomy. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Oct 22];27:1043-6. Available from: https://www.sjkdt.org/text.asp?2016/27/5/1043/190885

   Introduction Top


Kidney transplantation is the optimal modality of treatment for patients with chronic renal failure (CRF). However, the procedure is associated with dangerous complications, one of them being allograft nephrectomy with postsurgery bleeding. This complication is rare, but carries a disastrous outcome. [1] In our kidney transplant unit with more than 20 years of experience, we encountered two cases of postallograft nephrectomy bleeding due to weakness of the Carrel patch caused by infection. For controlling the bleeding, the external iliac artery was ligated without any consequent ischemic complications of the corresponding foot with subsequent reperfusion through collateral artery, especially superficial femoral artery.


   Case Report Top


Two cases with CRF, who were on hemodialysis for more than one year, underwent kidney transplantation.

One of them was a 35-year-old male who underwent kidney transplantation with double kidneys from an 11-year-old deceased donor. The double kidneys were anastomosed with a Carrel patch to the right external iliac artery with end-to-side technique, and after one week, the kidney was rejected. One month later, the patient was subjected to allograft nephrectomy, and the Carrel patch was left at the external iliac artery. Two weeks after the nephrectomy, the patient developed massive wound bleeding and was re-explored; there was bleeding from a weak point at the Carrel patch site on the external iliac artery, which was ligated for controlling the bleeding. Ligation of the external iliac artery was performed below the hypogastric artery (internal iliac artery) and proximal to the symphysis pubis. The patient was followed up for more than one year, and there were no ischemic findings in the patient. The femoral artery pulse was well felt, he could walk comfortably. The postligation color Doppler evaluation of the femoral artery is shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4] and [Figure 5].
Figure 1: Abdominal aorta with normal flow.

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Figure 2: Right common iliac artery with normal flow.

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Figure 3: Right proximal external iliac artery without flow.

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Figure 4: Right distal external iliac artery without flow.

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Figure 5: Right common femoral artery with normal flow.

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The second case was a 55-year-old man who was on dialysis for CRF due to hypertension; he underwent kidney transplantation, the allograft kidney was anastomosed to the external iliac artery. Three weeks after transplantation, he had an irreversible acute rejection. He underwent allograft nephrectomy, and 10 days postnephrectomy, the patient developed bleeding from the wound. Exploration of the operation site was carried out, and there was bleeding from a patch on the donor vessels at the anastomotic site with the external iliac artery, which was left behind after nephrectomy. The external iliac artery was ligated below the internal iliac artery and proximal to the pubis to control the bleeding. After ligation, the patient did not experience any ischemic symptoms in the corresponding foot, and the femoral artery pulse could be palpated well.


   Discussion Top


Kidney transplantation is the preferred treatment option for patients with CRF. Complications of kidney transplantation are numerous including vascular, urological, and immunological. In case of vascular complications, if the vessels of the recipient are involved, it can be hazardous, especially if the external iliac artery is involved because the possibility of loss of the foot may occur. For anastomosing the allograft artery, either the external iliac artery or hypogastric artery of the recipient can be used. If a deceased donor kidney is used for transplantation with a Carrel patch or if the internal iliac artery is severely affected with atherosclerosis, the external iliac artery can be used for anastomosis. Although the internal iliac artery is safer compared to the external iliac artery, end-to-end anastomosis with the internal iliac artery is more predisposed to stenosis than the end-to-side technique. [2]

If the external iliac artery is chosen for anastomosis of the allograft renal artery, it is preferred to perform the anastomosis below the internal iliac artery and before the superficial artery. In this situation, if the external iliac artery is ligated proximal and distal to the hemorrhage, it will be associated with less complications. [3]

Eng et al reported an incidence of 10.4% of post-transplant nephrectomies, 5.6% of whom had significant vascular complications. They reported that 78% of the vascular complications of renal allograft nephrectomy required ligation of the external iliac artery. [1] However, a 50% limb amputation rate has been reported by Ball et al, following ligation of the external iliac artery. [4]

The pelvis has many collateral arteries that can help to restore blood supply if one artery is compromised. [5] There are some reports that the common or external iliac artery may be ligated safely without limb loss. [6]

The first report of ligation of the common iliac artery for the treatment of ilio-femoral aneurysm has been reported on 100 patients over 100 years by Halsted; he reported a limb loss rate at 3.3-6.6% in all series he reviewed. [7] Debakey reported a limb loss rate following ligation of the common iliac and external iliac arteries to be, respectively, 53.8 and 46.7% in injured soldiers during the Second World War. [8] He described that the cause of this high rate of limb loss was related to their young age and multiple injuries and greater blood loss in comparison to the report of Halsted; he suggested that atherosclerotic vessels in old patients resulted in the development of more collateral arteries, resulting in lower limb loss rate in the study of Halsted.

Fotopoulou et al reported two cases of external iliac artery rupture after radical bulky lymph node removal. Both cases were successfully managed by ligation of the external iliac artery without crossover bypass. They mentioned that this complication can be managed safely by unilateral external iliac artery ligation. [9]

In the two patients in this report, there was no limb loss following ligation of the external iliac artery. Considering all the above-mentioned factors, it can be concluded that if ligation of the external iliac artery is indicated, it will be associated with less ischemia, if performed between the internal iliac artery and superficial femoral artery.

Conflict of interest: None declared.

 
   References Top

1.
Eng MM, Power RE, Hickey DP, Little DM. Vascular complications of allograft nephrectomy. Eur J Vasc Endovasc Surg 2006;32:2126.  Back to cited text no. 1
    
2.
Sutherland RS, Spees EK, Jones JW, Fink DW. Renal artery stenosis after renal transplantation: the impact of the hypogastric artery anastomosis. J Urol 1993;149:980-5.  Back to cited text no. 2
[PUBMED]    
3.
Owens ML, Wilson SE, Maxwell JG, Bordner A, Smith R, Ehrlich R. Major arterial hemorrhage after renal transplantation. Transplantation 1979;27:285-7.  Back to cited text no. 3
[PUBMED]    
4.
Ball CG, Feliciano DV. Damage control techniques for common and external iliac artery injuries: have temporary intravascular shunts replaced the need for ligation? J Trauma 2010;68:1117-20.  Back to cited text no. 4
[PUBMED]    
5.
Reich WJ, Nechtow MJ, Keith L. Supplementary report on hypogastric artery ligation in the prophylactic and active treatment of hemorrhage in pelvic surgery. J Int Coll Surg 1965;44:1-8.  Back to cited text no. 5
[PUBMED]    
6.
Blohmé I, Brynger H. Emergency ligation of the external iliac artery. Ann Surg 1985;201: 505-10.  Back to cited text no. 6
    
7.
Halsted WS. The effect of ligation of the common iliac artery on the circulation and function of the lower extremity. Bull Johns Hopkins Hosp 1912;23:191.  Back to cited text no. 7
    
8.
Debakey ME, Simeone FA. Battle injuries of the arteries in World War II; an analysis of 2,471 cases. Ann Surg 1946;123:534-79.  Back to cited text no. 8
[PUBMED]    
9.
Fotopoulou C, Neumann U, Kraetschell R, Lichtenegger W, Sehouli J. External iliac artery ligation due to late postoperative rupture after radical lymphadenectomy for advanced ovarian cancer - two case reports. Eur J Gynaecol Oncol 2010;31:198-200.  Back to cited text no. 9
[PUBMED]    

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Correspondence Address:
Afshar Zomorrodi
Department of Urology, Tabriz University of Medical Sciences, Tabriz
Iran
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DOI: 10.4103/1319-2442.190885

PMID: 27752019

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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    Abstract
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