Deepesh B. Kenwar

Ultrasound-guided angioplasty for treatment of peripheral stenosis of arteriovenous fistula – a single-center experience

Purpose In patients with end-stage renal disease, arteriovenous fistulas (AVFs) are the access of choice for hemodialysis but are often complicated by stenosis. We present single-center experience of 78 ultrasound-guided angioplasty procedures for treating peripheral stenoses of AVFs. Methods Between January 2013 and November 2015, 78 angioplasties were performed under ultrasound guidance in 53 patients with end-stage renal disease who were referred from dialysis centers with low flow rate, difficult cannulation, increased cannulation site bleeding, immature or thrombosed AVF. Angioplasties were carried out in the presence of a structural lesion in the AVF resulting in at least 50% reduction in vein diameter with a blood flow of <250 mL/min or a peak systolic velocity >300 cm/s. Clinical success, anatomical success and post-intervention primary and secondary patency rates at 6, 12, 18 and 24 months were studied. Results In 49/53 patients (92.4%), 74 angioplasty procedures were successfully performed, whereas 4/53 patients (7.6%) had primary failure. A total of 35/49 patients (71.4%) underwent single angioplasty procedure whereas 14/49 patients (28.6%) underwent multiple angioplasty procedures. Post-intervention primary patency rates at 6, 12, 18 and 24 months were 78.6%, 60.2%, 53.8% and 48.9%, respectively. Post-intervention secondary patency rates at 6, 12, 18 and 24 months were 100%, 100%, 95.4% and 89%, respectively. Clinical success and anatomical success was 94.8% and 89.7%, respectively. Conclusions Ultrasound-guided angioplasty is an effective method with good long-term outcomes in selected dialysis patients with peripheral stenosis of AVF.

Retroperitoneal Single Port Versus Transperitoneal Multiport Donor Nephrectomy: A Prospective Randomised Control Trial

Background Laparoscopic donor nephrectomy(LDN) converted a retroperitoneal procedure into a transperitoneal operation with reports of bowel and solid organ injuries leading to mortality in occasional cases. Laparoscopic retroperitoneal donor nephrectomy can reduce these risks but never became popular due to the muscle cutting approach. Lumbotomy incision can be used to approach retroperitoneum by incising fascial planes eliminating disadvantages of retroperitoneal approach. This report compares the outcomes of standard multiport transperitoneal LDN with translumbar Laparoendoscopic Single Site Donor Nephrectomy (LESS-DN). Methods Between January 2016 to June 2017, 50 voluntary kidney donors out of 267 donors were randomised to undergo LESS DN vs LDN. Donors with BMI ≥30, multiple renal arteries and right sided nephrectomy those were excluded from the study. Postoperative pain, duration of surgery, length of graft vessels and ureter, warm ischaemia time, intraoperative blood loss, incision length, convalescence period, duration of hospital stay and recipients’ creatinine at discharge were compared amongst both the groups. Pain assessment was done using Visual analogue Score. Surgical Technique - Kidney was approached through 6cm lumbotomy incision parallel to sacrospinalis muscle. Lumbar fascia was incised and ureter along with gonadal vein was lifted off the retroperitoneal tissues with the open approach. Alexis® port with rubber glove was used as a single port and further dissection was carried out laparoscopically. Gonadal vein was dissected till its drainage into renal vein. Renal vein was dissected and its tributaries ligated. Renal artery could be seen after ligation of lumbar vein. At this stage, lower pole of the kidney was separated from the peritoneum which allowed the dissection on the anterior surface of kidney till renal vein was seen anteriorly. Kidney was separated from adrenal and remaining fat. Ureter, renal artery and vein were ligated with two Hemolok clips each and kidney retrieved into the Alexis wound retractor, and taken out. Figure. No caption available. Figure. No caption available. Figure. No caption available. Figure. No caption available. Results Retroperitoneal group experienced lesser pain (VAS score 0.3±0.3 vs 1.1±0.0,p 0.000), lesser analgesic requirement (186±51.07 vs 254±62.7 p0.000), faster convalescence (7.0±3.0 vs 10.7±3.3 days, p 0.00) related to smaller cumulative incision (7.8±0.8vs12.4±2.0,p0.00) and had reduced operative time (142±26.2 vs170.8±34.75 p 0.001) and blood loss. Other recorded parameters were similar in both the groups. Conclusion Single port retroperitoneal approach significantly reduced postoperative pain and hastened recovery when compared to a transperitoneal approach. Converting to a retroperitoneal approach presents an opportunity for surgeons to further reduce morbidity associated with the donor nephrectomy.

Esophageal tuberculosis with coexisting opportunistic infections in a renal allograft transplant recipient

We report a renal allograft transplant recipient with esophageal tuberculosis (TB) coinfected with herpes simplex virus (HSV) and Candida. The patient presented with oropharyngeal candidiasis and was started on fluconazole. Upper gastrointestinal endoscopy showed whitish patches with mucosal ulcers in the esophagus. Histopathological examination confirmed TB and HSV infection. The patient recovered after antiviral, antifungal, and anti‐tubercular therapy with reduction in immunosuppression. In a TB‐endemic zone, TB can coexist with opportunistic infections in an immunocompromised host.

Salvage of renal allograft in mycotic pseudoaneurysm of the transplant renal artery

Mycotic pseudoaneurysm of transplant renal artery is a rare complication and warrants allograft nephrectomy. We report a 54-year-old renal allograft recipient who presented with 9.2 cm × 5.9 cm × 5.7 cm sized pseudoaneurysm of transplant renal artery. Blood culture grew Pseudomonas aeruginosa. The allograft was explanted, aneurysm was excised, and the allograft was reimplanted to right internal iliac artery with interposition of autogenous arterial graft. Microbiological examination of the aneurysm wall did not reveal active infection. The patient did well and at four years maintains normal renal function. Salvage of renal allograft is possible in selected patients with mycotic pseudoaneurysm of transplant renal artery.