Gabriele Soldini

Initial experience with the Gore® Acuseal graft for prosthetic vascular access

Purpose The purpose of this study is to report the short-term results of the Gore® Acuseal graft for prosthetic vascular access (pVA) in patients with end-stage renal disease on hemodialysis. Methods Between October 2011 and October 2013, all the consecutive patients who underwent implantation of a new expanded Polytetrafluoroethylene (ePTFE) tri-layer graft were included in the study. Primary and secondary patency rate, time to first cannulation, and complications were recorded. Follow-up was performed at 1, 3, 6, and 12 months after the intervention. Results Thirty ePTFE tri-layer heparin bonded grafts were implanted in 18 males and 12 females. The graft configuration was radial-basilic (n=12, 40%), brachial-basilic (n=10, 33.3%), femoro-femoral (n=3, 10.0%), radial-cephalic (n=2, 6.7%), radial-antecubital forearm (n=2, 6.7%), and brachial-axillary (n=1, 3.3%). No patient was lost during a mean follow-up time of 6.3±5.9 months (range, 1-24; median, 5). Mean time to first cannulation was 2.4±1.2 days (range, 1-15). Primary functional patency rate was 68.0% ± 10 at 6 and 12 months. Secondary patency rate was 93.3% ± 6 at 6 and 12 months. Pseudoaneurysm, bleeding, seroma, or graft infection was never observed. Conclusions In our experience, the Gore® Acuseal graft was useful and safe. Early cannulation was always performed, and structural complications did not occur. Primary functional and secondary patency rate are satisfactory in the short term.

Impact of static cold storage VS hypothermic machine preservation on ischemic kidney graft: inflammatory cytokines and adhesion molecules as markers of ischemia/reperfusion tissue damage. Our preliminary results

At the present time, deceased heart-beating donor kidney allografts are usually stored cold. Extended-criteria donor (ECD) grafts show higher sensitivity to ischemia-reperfusion damage than standard kidneys. The increasing use of marginal organs in clinical transplantation urgently requires a more effective preservation system. Pulsatile hypothermic machine perfusion has shown major advantages over static cold storage in terms of reduced organ injury during preservation and improved early graft function. This preliminary study aims to compare pulsatile hypothermic machine perfusion and static cold storage of kidney allografts, outlining differences in the levels of early inflammatory cytokines (TNF-α, IL-2 and IL-1β) and soluble intracellular adhesion molecule (sICAM-1) in perfusion and preservation liquid.

Vascular Fluorescence Imaging Control for Complex Renal Artery Aneurysm Repair Using Laparoscopic Nephrectomy and Autotransplantation

Intraoperative fluorescent imaging using indocyanine green enables vascular surgeons to confirm the location and states of the reconstructed vessels during surgery. Complex renal artery aneurysm repair involving second order branch vessels has been performed with different techniques. We present a case of ex vivo repair and autotransplantation combining the advantages of minimally invasive surgery and indocyanine green enhanced fluorescence imaging to facilitate vascular anatomy recognition and visualization of organ reperfusion.

Treatment of aortoiliac occlusive or dilatative disease concomitant with kidney transplantation: how and when?

BACKGROUND AND PURPOSE Aortoiliac (AI) lesions (both dilatative and occlusive) can occur in kidney allograft recipients. The correct timing of vascular imaging and treatment is controversial. Aim of the present paper is to report our experience. METHODS between January 2010 and December 2012, 106 patients included in our waiting list for kidney transplant underwent computed tomography (CT) angiogram to study AI axis. In 21 cases an AI lesion was identified before transplant. In 3 cases surgery was mandatory before kidney transplant, and in 18 cases lesions were treated simultaneously with kidney transplantation. MAIN FINDINGS AI pathology distribution was as follows: 15 iliac stenoses treated with thromboendarterectomy (TEA), 2 Leriche syndrome and 1 aortic aneurism treated with an aortobisiliac bypass (AI-BP), and 3 aneurysms treated with endovascular aortic repair (EVAR). In two cases a postoperative hematoma occurred. In one case occlusion of a stent-graft branch was treated with a femoro-femoral crossover bypass and transplant was then performed on the contralateral iliac axis. Perioperative mortality was 0%, and graft survival rate was 100% at 1 year in all cases. CONCLUSIONS A CT angiogram is useful in order to detect AI lesions and to be able to evaluate the best treatment option for the kidney transplantation and the correct timing for additional vascular surgery. The EVAR procedure should be safe, and does not compromise anastomosis success and graft survival, with less postoperative complications than open surgery.

Inferior Epigastric Artery Pseudoaneurysm in a Kidney Transplant Recipient

Pseudoaneurysm of inferior epigastric artery (IEA) is a very rare clinical entity. We reported a case of combined kidney transplant and pseudoaneurysmectomy in a young HBV-HCV-HIV recipient. This case emphasizes the possibility of planning a safe and correct surgical treatment and the best timing to treat IEA pseudoaneurysm. An exhaustive preoperative radiological study in all patients candidate to kidney transplant could identify the possible aortoiliac disease both stenotic or dilatative even if it is rare and helps to define the best treatment options.

Pretransplant Nephrectomy for Large Polycystic Kidneys in ADPKD (Autosomal Dominant Polycystic Kidney Disease) Patients: Is Possible Peritoneal Dialysis Recovery After Surgery?

Introduction and Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is characterized by relentless development and growth of cysts causing progressive kidney enlargement and progressive renal failure. Diuresis and fluid volume control is often preserved also during the dialytic period. Some recent studies have proposed peritoneal dialysis (PD) as a valid alternative even for ADPKD, which was once considered a relative contraindication because of the possible limited intraperitoneal space and the risk of hernia. Native kidneys are not routinely removed before transplantation in consideration of the significant morbidity and mortality associated to the procedure. Indications for nephrectomy include recurrent or severe infection, symptomatic nephrolithiasis, recurrent or severe bleeding, intractable pain, suspicion of renal cancer and space restrictions prior to transplantation. Considering that after a trans-peritoneal nephrectomy the peritoneum often results damaged and unsuitable for PD, the aim of this study is to assess if and how long after nephrectomy PD may be effectively resumed. Materials and Method A retrospective analysis of ADPKD patients in waiting list for kidney transplant which underwent nephrectomy in our trasplant surgery department between December 2012 and October 2017 was carried out. All patients were included, male and female, and the indications for nephrectomy were symptoms (pain, urinary tract infections or hematuria) or steric hindrance. In all cases the surgical procedure was performed with meticoulus technique by laparotomic access with subcostal incision with recostruction of the posterior peritoneal flap in order to preserve peritoneal cavity avoiding visceral adhesions and for future peritoneal dialysis recovery. Results and Discussion From December 2012 to October 2017 30 ADPKD patients underwent nephrectomy in our transplant surgery department. The patients were 18 (63%) males and 12 (37%) females, with a mean age of 54±8. 9 patients were in peritoneal dialysis, 19 in hemodialysis and 2 were affected by stage 5 chronic renal failure. 4 patients underwent nephrectomy after trasplantation. The indication for nephrectomy was steric hindrance in 43,3% of cases, while 56,6% of patients had symptoms (52,9% UTI, 35,3% haematuria and 11,7% pain). No complications were reported after surgery. Among patients treated with peritoneal dialysis before nephrectomy 3 underwent nephrectomy after trasplantation, 3 started hemodialysis and 3 resumed peritoneal dialysis 30 days after surgery. Conclusions Monolateral nephrectomy with a laparotomic approach seems to be a safe and feasible procedure also for very large kidneys. A meticulous technique with accurate peritoneal preservation avoids commons postsurgical complications and may allow a rapid peritoneal dialysis resume.

Intraoperative Retrograde Intrarenal Surgery (RIRS) as a Good Management Option for Large Ureteropelvic Impacted Stone of Transplanted Kidney

Introduction Urolithiasis is a rare complication following kidney transplantation. Many of the clinical features of urinary stones after transplantation differ from those of non- transplant patients, but the course is essentially similar to that in non-transplant patients with lithiasis. The management of kidney stones has evolved radically over the years and involved extracorporeal shock wave lithotripsy (ESWL), flexible ureteroscopy and in situ lithotripsy, percutaneous nephrolithotomy (PCNL), open pyelolithotomy and open cystolitholapaxy. Retrograde URS with laser lithotripsy and/or basket extraction is a reasonable option for treating small and large stones also in transplanted kidney. In order to overcome the difficulty of complex anatomy typical of non-native ureter, ureteroscope can be introduced through a small surgical ureterotomy allowing quite complete stones clear. Matherials and Methods We present surgical treatment and outcome in a 69-year-old male patient with a large ureteropelvic impacted stone of transplanted kidney one year and three months after transplantation. The transplated ureter and the ureteroneocystotomy was identified at the right anterior bladder wall. Ureterotomy was performend on the third part of transplated urether, the double J stent was removed and the ureter was eventually cannulated. Retrograde pyelography revealed an angulation of the mid-ureter toward the renal pelvis seen medially. Access was established with both a standard teflon wire and a superstiff teflon guidewire. A flexible ureteroscope was advanced beyond the midureter through ureterotomy into the transplanted kidney. Laser lithotripsy was then effectively performed in the standard manner by means of 200/273&mgr;m Holmium laser fibers. A tipless nitinol basket was used to extract the fragments. Discussion Native anatomy makes ureteroscopy simple. The orthotopic location of the ureteral orifices allow the urologist to take advantage of the bladder trigone as a backbone to advance wires and ureteroscopes. This is lost in cases as in that one described previously, where the non-native ureter is in a more anterior location. The last attempt to remove pelvic stones in trasplanted kidneys is to introduce the ureteroscope through surgical ureterotomy. In this way is possible to avoid surgical incision of renal pelvis itself which is very difficult to isolate considering its proximity to vascular structures. Conclusion Upper urinary tract endoscopy has long been established as a safe and efficient means of managing urolithiasis with great success. With technological advances, ureteroscopy has evolved into a powerful tool in the armamentarium of the urologist. Management of patients with complex anatomy is now possible while avoiding more invasive interventions such as percutaneous nephrostolithotomy or surgical pyelotomie. Figure. No caption available.

Real-time Intraoperative Fluorescent Lymphography: A New Technique for Lymphatic Sparing Surgery

BACKGROUND Many surgical procedures can produce persistent lymphorrhea, lymphoceles, and lymphedema after lymph node and lymph vessel damage. Appropriate visualization of the lymphatic system is challenging. Indocyanine green (ICG) is a well-known nontoxic dye for lymphatic flow evaluation. ICG fluorescence-guided lymphography has emerged as a promising technique for intraoperative lymphatic mapping. OBJECTIVE Our goal was to develop a high spatial resolution, real-time intraoperative imaging technique to avoid or recognize early deep lymphatic vessel damage. METHODS We intraoperatively performed ICG fluorescence-guided lymphography during a kidney transplant. ICG was injected in the subcutaneous tissue of the patients groin in the Scarpas triangle. A dedicated laparoscopic high-definition camera system was used. RESULTS Soon after ICG injection, the lymphatic vessels were identified in the abdominal retroperitoneal compartment as fluorescent linear structures running side by side to the iliac vessels. Surgical dissection was therefore performed, avoiding iatrogenic damage to major lymphatic structures. Another ICG injection at the end of the procedure confirmed that the lymphatic vessels were intact without lymph spread. CONCLUSIONS Intraoperative lymphatic mapping with an ICG fluorescence-sensitive camera system is a safe and feasible procedure. ICG real-time fluorescence lymphography can be used to avoid or recognize early deep lymphatic vessel damage and reduce postoperative complications related to the lymphatic system.

A Case of Continuous Negative Pressure Wound Therapy for Abdominal Infected Lymphocele after Kidney Transplantation

Lymphocele is a common complication after kidney transplantation. Although superinfection is a rare event, it generates a difficult management problem; generally, open surgical drainage is the preferred method of treatment but it may lead to complicated postoperative course and prolonged healing time. Negative pressure wound therapy showed promising outcomes in various surgical disciplines and settings. We present a case of an abdominal infected lymphocele after kidney transplantation managed with open surgery and negative pressure wound therapy.