OBJECTIVES: Despite the increasing frequency of renal transplantation and high prevalence of peripheral artery disease in the U.S., little is known about endovascular interventions for iliac occlusive disease proximal to renal allografts. We reviewed the outcomes of renal transplant patients who underwent endovascular iliac artery interventions for delayed graft function, hypertension, and/or worsening chronic kidney disease at our institution.
METHODS: A retrospective review was performed at a single institution to identify patients with history of kidney transplant who underwent iliac artery endovascular intervention between Jan 1 2011 - Sept 1, 2023. Demographics, outcomes, and peri-operative data were evaluated.
RESULTS: 13 patients underwent 15 endovascular interventions for acute delayed graft function (n=4), worsening CKD (n=1), uncontrolled hypertension (n=2), and combined CKD with uncontrolled hypertension (n=8) due to iliac artery stenosis. Two patients with CKD had clinically improved renal function at the time of their intervention but underwent intervention for hypertension with previous fluctuations in renal function. Mean age of the patients at the time of intervention was 59.2 years (Range 29.9-75.2). Mean time from transplant to intervention was 5.13 years (range 0-19 yrs). Pre-operative duplex ultrasound suggested iliac artery stenosis in 92% of patients. Primary stenting was performed in 87% of cases. One patient had drug-coated balloon angioplasty for in-stent re-stenosis. Technical success was 100%. Mean contrast volume was 21.8ml (range 0-72ml), with 40% of cases utilizing CO2. Median follow up after intervention was 24 months (Mean 2.9 yr). Primary patency was 85% with two patients undergoing secondary procedures due to recurrent/residual stenosis. Primary assisted patency was 100%. Patients with uncontrolled hypertension as an indication for index intervention had improved blood pressure control with mean decrease of 1.2 antihypertensive medications (p<0.05; CI 0.39-2.01). Patients with existing CKD at the time of their procedure (n=9) had significant improvement in estimated GFR with mean increase by 14.5ml/min (P <0.005; CI 25.9-3.1).
CONCLUSIONS: Endovascular interventions for iliac artery occlusive disease can be performed safely in patients with prior renal transplants and provide meaningful improvement in allograft function as well as hypertension. Novel and recurrent hemodynamically significant iliac stenosis is usually detectable by ultrasound. Renal transplant patients with delayed graft function, HTN, or worsening CKD should have routine ultrasound surveillance to detect iliac artery stenosis.
