Endovascular Reconstruction Rescues a Kidney Transplant in Severe Iliac Arteriosclerosis
Severe iliac arteriosclerosis can turn kidney transplantation into a surgical dead end. In this case, a 34-year-old woman with type 2 diabetes mellitus, coronary atherosclerotic heart disease, and 7 years of hemodialysis underwent ABO-incompatible living donor kidney transplantation despite nearly occluded pelvic inflow vessels. The operation did not proceed in a straight line. After conventional end-to-side anastomosis, the graft quickly lost pulsation and turned dark red, and thrombosis was traced to plaque embolism from the diseased external iliac artery.
The rescue strategy was as unusual as the vascular anatomy was hostile: a self-expandable endovascular covered stent was deployed in the right external iliac artery, then reinforced with a prosthetic graft before the renal artery was sewn to the resulting stent–prosthetic complex. Two years later, the graft was still functioning, serum creatinine remained stable, and no right lower limb ischemia had emerged.
A High-Risk Recipient With a Narrow Margin for Success
The recipient was Rh-positive with blood type O and had a negative PRA result by single antigen bead assay, with a 1–1–1 HLA mismatch. Complement-dependent cytotoxicity was negative. Before transplantation, anti-A antibody titers measured 1:4 for IgG and 1:32 for IgM by tube agglutination. The desensitization plan included rituximab, tacrolimus, mycophenolate mofetil, and methylprednisolone, followed by one session of double filtration plasmapheresis and one session of plasma exchange. By the day of transplantation, titers had fallen to 1:4 for IgG and 1:8 for IgM. Basiliximab was used for immune induction.
The vascular problem was just as serious as the immunologic one. Computed tomography and CT angiography showed nearly complete occlusion of both internal iliac arteries and extensive sclerosis of both external iliac arteries. Her ankle-brachial index was 0.75, and she had intermittent claudication without rest pain. The preoperative calculus was clear: standard arterial anastomosis might fail, but excluding her from transplantation would leave her on dialysis with a small reserve of options. The team prepared three possible paths, ranging from direct anastomosis to prosthetic bypass or endovascular stent placement if the arterial wall could not support conventional reconstruction.
Conventional Anastomosis Failed Within Minutes
The donor was the patient’s father, a 58-year-old man with blood type A, who underwent laparoscopic left nephrectomy without complication. The graft contained a single artery and a single vein. Venous anastomosis proceeded in standard fashion, and the renal artery was first connected end-to-side to the right external iliac artery. Urine output appeared immediately after reperfusion, but the graft soon softened and became dark red as arterial pulsation disappeared.
Opening the anastomosis revealed thrombosis, and the culprit was mechanical as much as thrombotic: plaque embolism from the severely diseased iliac artery. The arterial wall had become so compromised that parts of the anastomotic site could not be reused. The graft was cooled again, reperfused with hypertonic citrate-adenine solution, and the surgical plan shifted in real time from standard transplant technique to vascular salvage.
This is where the case becomes clinically instructive. In a calcified iliac artery, clamp trauma and plaque fragmentation can convert a technically sound anastomosis into acute inflow failure within minutes. The failure mechanism here was not rejection, not donor quality, and not a problem with the renal vein. It was hostile recipient inflow.
Stent-Driven Inflow Reconstruction Created a New Anastomotic Bed
A vascular surgery team then performed retrograde right common femoral artery access and advanced a guidewire across the previous anastomosis region. An 8 × 100 mm self-expandable endovascular covered stent was deployed in the external iliac artery, and angiography confirmed good placement, intact morphology, and unobstructed iliofemoral flow. Because part of the arterial wall was defective and the stent was partially exposed, a prosthetic graft was trimmed to 8 × 120 mm with a central elliptical fenestration, wrapped around the stent-external iliac segment, and secured with sutures for reinforcement. The stent was then longitudinally incised along the external iliac defect, and the donor renal artery was anastomosed end-to-side to the stent–prosthetic complex.
Warm ischemia time was 30 minutes and cold ischemia time was 6 hours. The graft perfused well after the revised reconstruction.
The biological logic is straightforward. A covered stent stabilizes diseased arterial segments, limits exposure of friable plaque, and creates a more reliable conduit for inflow when the native artery is too rigid or damaged for safe clamping. The prosthetic wrap adds structural support where the native wall has failed, converting an unusable artery into a workable anastomotic platform.
Early Delayed Graft Function Did Not End the Story
Postoperatively, delayed graft function developed on day 1. Hemodialysis began on day 2 and continued for 2 weeks. Continuous intravenous heparin was used to prevent thrombosis, and the regimen later shifted to aspirin and clopidogrel on postoperative day 11. In an ABO-incompatible transplant with a fresh vascular reconstruction, the need to balance thrombosis prevention against bleeding risk is immediate and unforgiving.
One month after transplantation, serum creatinine had decreased to 124 μmol/L. Anti-blood group titers were 1:2 for IgG and 1:4 for IgM at that point. Over the next 2 years, graft function remained stable, with serum creatinine of 116 μmol/L at 6 months, 107 μmol/L at 1 year, and 113 μmol/L at 2 years. Estimated glomerular filtration rate was 56 mL/min by CKD-EPI equations. No clinical rejection occurred, the stent remained in place without displacement, and imaging showed good graft blood flow. No signs of right lower limb ischemia were observed.
What This Case Adds to Transplant Surgery
Severe aortoiliac disease is often viewed as a barrier to kidney transplantation, especially when calcification is diffuse and the arterial wall cannot tolerate routine clamping or suturing. This case shows that an endovascular covered stent, reinforced with a prosthetic graft, can serve as a surgical platform for renal artery implantation when no conventional bed is usable. The patient also had ABO incompatibility, which added another layer of complexity and required desensitization, rituximab, plasmapheresis, plasma exchange, and induction immunosuppression before the vascular problem even entered the operating room.
Prior approaches for calcified iliac arteries have included endarterectomy, bypass grafting, angioplasty, and stent placement. Endarterectomy works best for localized lesions, bypass depends on adequate inflow and outflow tracts, and angioplasty performs poorly in heavily calcified stenosis. In contrast, the covered stent used here offered a minimally invasive way to reconstruct a long diseased segment and protect against rupture or plaque instability.
The report supports a practical conclusion: when iliac arteries are too diseased for standard kidney transplant anastomosis, endovascular stent-assisted reconstruction may preserve access to transplantation. The case also exposes the limits of certainty. This is a single patient, and the technique was used in the setting of meticulous multidisciplinary care, prolonged antithrombotic management, and close follow-up. Broader use will depend on whether similar vascular reconstruction can be reproduced safely in recipients with comparable anatomy and whether long-term patency remains durable beyond 2 years.