DOI: 10.1148/rg.274065135
Interventional Radiologic Management of Renal Transplant Dysfunction: Indications, Limitations, and Technical Considerations1
Katsuhiro Kobayashi, MD,
Michael L. Censullo, MD, MA,
Lucho L. Rossman, MD,
Polina N. Kyriakides, MD,
Barry D. Kahan, MD, and
Alan M. Cohen, MD
1 From the Department of Diagnostic and Interventional Imaging (K.K., M.L.C., L.L.R., P.N.K., A.M.C.), and the Division of Immunology and Organ Transplantation, Department of Surgery (B.D.K.), University of Texas Medical School at Houston, 6431 Fannin St, Houston, TX 77030. Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received July 13, 2006; revision requested September 1 and received October 17; accepted October 19. All authors have no financial relationships to disclose.
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Figure 1a. Drawings illustrate arterial anastomosis of a renal transplant with one renal artery. The renal artery is anastomosed either end-to-side to the external iliac artery (a) or end-to-end to the internal iliac artery (b). Note that a portion of the aorta (Carrel patch) is harvested with the renal artery in the end-to-side procedure (arrow). Renal veins are anastomosed end-to-side to the external iliac vein.
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Figure 1b. Drawings illustrate arterial anastomosis of a renal transplant with one renal artery. The renal artery is anastomosed either end-to-side to the external iliac artery (a) or end-to-end to the internal iliac artery (b). Note that a portion of the aorta (Carrel patch) is harvested with the renal artery in the end-to-side procedure (arrow). Renal veins are anastomosed end-to-side to the external iliac vein.
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Figure 2. Drawings illustrate alternate methods of anastomosing multiple renal arteries: excision of two aortic segments and anastomosis as a neo-Carrel patch (2), or side-to-side anastomosis of same-sized renal arteries (3).
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Figure 3. Drawings illustrate alternate methods of anastomosing multiple renal arteries: excision of two aortic segments and anastomosis as a neo-Carrel patch (2), or side-to-side anastomosis of same-sized renal arteries (3).
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Figure 4. Drawing illustrates the Politano-Leadbetter technique of ureteroneocystostomy. This technique involves making an incision into the serosal surface of the urinary bladder and creating a submucosal tunnel within the bladder wall. The ureteral anastomosis is created from inside the bladder.
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Figure 5. Drawing illustrates the Lich-Gregoir technique. After myotomy incision and the creation of a mucosal nick, the ureter is anastomosed to the bladder mucosa with continuous sutures from outside the bladder. A submucosal tunnel is created by reapproximation of the seromuscular layer.
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Figure 6. Drawing illustrates renal transplantation from a pediatric donor. A segment of the abdominal aorta (A.A.) is anastomosed to the transected external iliac artery (E.I.A.), and the vena cava (V.C.) to the transected external iliac vein (E.I.V.) using an in continuity interposition technique.
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Figure 7. Diagram illustrates an algorithm for the diagnostic work-up and management of transplant RAS. MRA = magnetic resonance angiography, PTA = percutaneous transluminal angioplasty.
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Figure 8a. Proximal right common iliac artery stenosis in a 51-year-old man with persistent hypertension and a rising serum creatinine level with a renal transplant in the right iliac fossa. (a) Digital subtraction angiogram of the distal aorta and common iliac arteries shows proximal right common iliac artery stenosis with a systolic pressure gradient of 50 mm Hg. PTA was performed with a 10-mm balloon catheter. (b) Angiogram obtained after PTA shows restoration of the normal luminal diameter of the right common iliac artery without a pressure gradient.
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Figure 8b. Proximal right common iliac artery stenosis in a 51-year-old man with persistent hypertension and a rising serum creatinine level with a renal transplant in the right iliac fossa. (a) Digital subtraction angiogram of the distal aorta and common iliac arteries shows proximal right common iliac artery stenosis with a systolic pressure gradient of 50 mm Hg. PTA was performed with a 10-mm balloon catheter. (b) Angiogram obtained after PTA shows restoration of the normal luminal diameter of the right common iliac artery without a pressure gradient.
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Figure 9a. PTA of RAS in a 12-year-old girl with a rising serum creatinine level and hypertension. (a) Digital subtraction angiogram shows stenosis of the proximal main renal artery (arrow). Note the superior pole artery anastomosed end-to-side to the external iliac artery. PTA was performed with a 6-mm balloon. (b) Spot view of the anastomosis obtained during PTA shows a guide wire that was passed across the stenosis using an ipsilateral approach. Note the "waist" at the stenosis (arrow). (c) Postangioplasty angiogram shows a patent renal artery without residual stenosis.
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Figure 9b. PTA of RAS in a 12-year-old girl with a rising serum creatinine level and hypertension. (a) Digital subtraction angiogram shows stenosis of the proximal main renal artery (arrow). Note the superior pole artery anastomosed end-to-side to the external iliac artery. PTA was performed with a 6-mm balloon. (b) Spot view of the anastomosis obtained during PTA shows a guide wire that was passed across the stenosis using an ipsilateral approach. Note the "waist" at the stenosis (arrow). (c) Postangioplasty angiogram shows a patent renal artery without residual stenosis.
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Figure 9c. PTA of RAS in a 12-year-old girl with a rising serum creatinine level and hypertension. (a) Digital subtraction angiogram shows stenosis of the proximal main renal artery (arrow). Note the superior pole artery anastomosed end-to-side to the external iliac artery. PTA was performed with a 6-mm balloon. (b) Spot view of the anastomosis obtained during PTA shows a guide wire that was passed across the stenosis using an ipsilateral approach. Note the "waist" at the stenosis (arrow). (c) Postangioplasty angiogram shows a patent renal artery without residual stenosis.
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Figure 10a. Stent placement for the management of recurrent proximal transplant RAS in a 46-year-old man. The patient had already undergone PTA three times. (a) Selective angiogram of the renal artery demonstrates recurrent proximal RAS (arrow). The pressure gradient measured 60 mm Hg. Following angioplasty with a 5-mm balloon, the pressure gradient decreased to 30 mm Hg but remained at that level. A 5 x 17-mm premounted balloon-expandable stent (Express SD; Boston Scientific, Natick, Mass) was deployed across the stenosis. (b) Angiogram obtained after further expansion of the stent with a 6-mm balloon shows good results. The pressure gradient decreased to 15 mm Hg.
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Figure 10b. Stent placement for the management of recurrent proximal transplant RAS in a 46-year-old man. The patient had already undergone PTA three times. (a) Selective angiogram of the renal artery demonstrates recurrent proximal RAS (arrow). The pressure gradient measured 60 mm Hg. Following angioplasty with a 5-mm balloon, the pressure gradient decreased to 30 mm Hg but remained at that level. A 5 x 17-mm premounted balloon-expandable stent (Express SD; Boston Scientific, Natick, Mass) was deployed across the stenosis. (b) Angiogram obtained after further expansion of the stent with a 6-mm balloon shows good results. The pressure gradient decreased to 15 mm Hg.
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Figure 11. Biopsy of a renal transplant under real-time US guidance in a 46-year-old man with decreasing renal function. An 18-gauge core biopsy needle (arrowheads) was advanced into the allograft cortex at the lower pole using a tangential approach.
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Figure 13a. Transcatheter embolization of pseudoaneurysms and an AVF in a 33-year-old man with renal transplant dysfunction. (a) Angiogram of the transplant renal artery shows pseudoaneurysms and an AVF supplied by an enlarged lower segmental artery. (b) Selective angiogram of the segmental artery obtained after proximal embolization of the artery with coils shows successful exclusion of the pseudoaneurysms and AVF. Note the preservation of flow in the upper and middle segmental branches.
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Figure 13b. Transcatheter embolization of pseudoaneurysms and an AVF in a 33-year-old man with renal transplant dysfunction. (a) Angiogram of the transplant renal artery shows pseudoaneurysms and an AVF supplied by an enlarged lower segmental artery. (b) Selective angiogram of the segmental artery obtained after proximal embolization of the artery with coils shows successful exclusion of the pseudoaneurysms and AVF. Note the preservation of flow in the upper and middle segmental branches.
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Figure 14a. Pseudoaneurysm following renal transplant biopsy in a 31-year-old woman. (a) Digital subtraction angiogram demonstrates a pseudoaneurysm at the lower pole of the renal transplant. Following superselective catheterization of the feeding artery with a micro-catheter, the pseudoaneurysm was packed with detachable coils. (b) Selective angiogram of the lobular artery shows successful exclusion of the aneurysm.
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Figure 14b. Pseudoaneurysm following renal transplant biopsy in a 31-year-old woman. (a) Digital subtraction angiogram demonstrates a pseudoaneurysm at the lower pole of the renal transplant. Following superselective catheterization of the feeding artery with a micro-catheter, the pseudoaneurysm was packed with detachable coils. (b) Selective angiogram of the lobular artery shows successful exclusion of the aneurysm.
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Figure 15a. Dissection of the renal artery salvaged with stent placement in a 61-year-old man. The patient had experienced persistent renal dysfunction after undergoing cadaveric transplantation 1 month earlier. (a) Digital subtraction angiogram of the right external iliac artery (ipsilateral femoral approach) shows dissection of the renal artery, a potential precursor to thrombosis. A 5 x 18-mm stent was placed across the stenosis and further expanded to 6 mm with a balloon. (b) Angiogram obtained after stent placement shows improvement of distal flow to the renal transplant.
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Figure 15b. Dissection of the renal artery salvaged with stent placement in a 61-year-old man. The patient had experienced persistent renal dysfunction after undergoing cadaveric transplantation 1 month earlier. (a) Digital subtraction angiogram of the right external iliac artery (ipsilateral femoral approach) shows dissection of the renal artery, a potential precursor to thrombosis. A 5 x 18-mm stent was placed across the stenosis and further expanded to 6 mm with a balloon. (b) Angiogram obtained after stent placement shows improvement of distal flow to the renal transplant.
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Figure 17. Ureteral obstruction in a 37-year-old woman with a rising serum creatinine level. Antegrade pyelogram (right anterior oblique projection) reveals a distal ureteral stricture (arrow) associated with severe hydronephrosis. Note the 22-gauge needle that was placed in a superior and lateral calix to avoid taking a peritoneal approach.
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Figure 18a. Emphysematous pyelitis treated with percutaneous nephrostomy in a 67-year-old diabetic woman who had undergone living-related renal transplantation 10 years earlier. (a) CT scan demonstrates air-fluid levels within the renal collecting system. Note the presence of pyelocaliectasis, a finding that suggests ureteral obstruction. Percutaneous nephrostomy was performed for external drainage, and the patient was started on intravenous antibiotic treatment. Urine culture grew Pseudomonas aeruginosa. (b) Antegrade pyelogram obtained after the patient had recovered clinically shows a proximal ureteral stricture (arrow). Note the decompressed renal collecting system. Adhesion of the proximal ureter to the surrounding scar tissue was found at surgery, and ureterolysis was performed to free up the ureter.
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Figure 18b. Emphysematous pyelitis treated with percutaneous nephrostomy in a 67-year-old diabetic woman who had undergone living-related renal transplantation 10 years earlier. (a) CT scan demonstrates air-fluid levels within the renal collecting system. Note the presence of pyelocaliectasis, a finding that suggests ureteral obstruction. Percutaneous nephrostomy was performed for external drainage, and the patient was started on intravenous antibiotic treatment. Urine culture grew Pseudomonas aeruginosa. (b) Antegrade pyelogram obtained after the patient had recovered clinically shows a proximal ureteral stricture (arrow). Note the decompressed renal collecting system. Adhesion of the proximal ureter to the surrounding scar tissue was found at surgery, and ureterolysis was performed to free up the ureter.
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Figure 19a. Balloon dilation of a ureteral stenosis followed by double-J stent placement in a 27-year-old woman with a rising serum creatinine level. (a) US image of the renal transplant shows moderate hydronephrosis. (b) Antegrade nephrostogram demonstrates a distal ureteral stenosis (arrow) and ureteral dilatation. (c, d) Fluoroscopic images show balloon dilation of the stenosis (c) and a double-J stent that was subsequently placed across the stenosis (d).
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Figure 19b. Balloon dilation of a ureteral stenosis followed by double-J stent placement in a 27-year-old woman with a rising serum creatinine level. (a) US image of the renal transplant shows moderate hydronephrosis. (b) Antegrade nephrostogram demonstrates a distal ureteral stenosis (arrow) and ureteral dilatation. (c, d) Fluoroscopic images show balloon dilation of the stenosis (c) and a double-J stent that was subsequently placed across the stenosis (d).
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Figure 19c. Balloon dilation of a ureteral stenosis followed by double-J stent placement in a 27-year-old woman with a rising serum creatinine level. (a) US image of the renal transplant shows moderate hydronephrosis. (b) Antegrade nephrostogram demonstrates a distal ureteral stenosis (arrow) and ureteral dilatation. (c, d) Fluoroscopic images show balloon dilation of the stenosis (c) and a double-J stent that was subsequently placed across the stenosis (d).
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Figure 19d. Balloon dilation of a ureteral stenosis followed by double-J stent placement in a 27-year-old woman with a rising serum creatinine level. (a) US image of the renal transplant shows moderate hydronephrosis. (b) Antegrade nephrostogram demonstrates a distal ureteral stenosis (arrow) and ureteral dilatation. (c, d) Fluoroscopic images show balloon dilation of the stenosis (c) and a double-J stent that was subsequently placed across the stenosis (d).
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Figure 20a. Urine leak from the distal ureter in a 44-year-old man who had undergone renal transplantation and presented with hematuria and decreased renal function. (a) CT scan shows a large fluid collection surrounding the renal transplant. Note the deformity of the transplant, which is compressed by the collection. (b) Three-hour-delayed radionuclide image obtained with technetium-99m diethylenetriaminepentaacetic acid demonstrates abnormal uptake around the allograft, a finding that was not seen on a 20-minute-delayed image (not shown). Note the dilated pelvicaliceal system. US-guided aspiration of the perigraft fluid collection helped confirm a urinoma. A drainage catheter was placed within the urinoma. (c, d) Antegrade nephrostograms demonstrate a leak from the distal ureter (c) and an 8-F nephrostomy catheter that was placed for urinary diversion (d). Arrowhead indicates the drainage catheter within the urinoma.
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Figure 20b. Urine leak from the distal ureter in a 44-year-old man who had undergone renal transplantation and presented with hematuria and decreased renal function. (a) CT scan shows a large fluid collection surrounding the renal transplant. Note the deformity of the transplant, which is compressed by the collection. (b) Three-hour-delayed radionuclide image obtained with technetium-99m diethylenetriaminepentaacetic acid demonstrates abnormal uptake around the allograft, a finding that was not seen on a 20-minute-delayed image (not shown). Note the dilated pelvicaliceal system. US-guided aspiration of the perigraft fluid collection helped confirm a urinoma. A drainage catheter was placed within the urinoma. (c, d) Antegrade nephrostograms demonstrate a leak from the distal ureter (c) and an 8-F nephrostomy catheter that was placed for urinary diversion (d). Arrowhead indicates the drainage catheter within the urinoma.
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Figure 20c. Urine leak from the distal ureter in a 44-year-old man who had undergone renal transplantation and presented with hematuria and decreased renal function. (a) CT scan shows a large fluid collection surrounding the renal transplant. Note the deformity of the transplant, which is compressed by the collection. (b) Three-hour-delayed radionuclide image obtained with technetium-99m diethylenetriaminepentaacetic acid demonstrates abnormal uptake around the allograft, a finding that was not seen on a 20-minute-delayed image (not shown). Note the dilated pelvicaliceal system. US-guided aspiration of the perigraft fluid collection helped confirm a urinoma. A drainage catheter was placed within the urinoma. (c, d) Antegrade nephrostograms demonstrate a leak from the distal ureter (c) and an 8-F nephrostomy catheter that was placed for urinary diversion (d). Arrowhead indicates the drainage catheter within the urinoma.
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Figure 20d. Urine leak from the distal ureter in a 44-year-old man who had undergone renal transplantation and presented with hematuria and decreased renal function. (a) CT scan shows a large fluid collection surrounding the renal transplant. Note the deformity of the transplant, which is compressed by the collection. (b) Three-hour-delayed radionuclide image obtained with technetium-99m diethylenetriaminepentaacetic acid demonstrates abnormal uptake around the allograft, a finding that was not seen on a 20-minute-delayed image (not shown). Note the dilated pelvicaliceal system. US-guided aspiration of the perigraft fluid collection helped confirm a urinoma. A drainage catheter was placed within the urinoma. (c, d) Antegrade nephrostograms demonstrate a leak from the distal ureter (c) and an 8-F nephrostomy catheter that was placed for urinary diversion (d). Arrowhead indicates the drainage catheter within the urinoma.
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Figure 21a. Urine leak at the proximal ureter in a 58-year-old man with a cadaveric transplant. The patient had undergone ureteroureteral anastomosis for necrosis of the distal transplant ureter 2 months earlier. (a) Antegrade nephrostogram shows marked extravasation of contrast material into the perigraft fluid collection with a drainage catheter in place. (b) Antegrade nephrostogram shows a nephroureteral stent that was placed to achieve leak closure. (c) Antegrade nephrostogram obtained 4 months after stent placement shows complete leak closure at the proximal ureter.
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Figure 21b. Urine leak at the proximal ureter in a 58-year-old man with a cadaveric transplant. The patient had undergone ureteroureteral anastomosis for necrosis of the distal transplant ureter 2 months earlier. (a) Antegrade nephrostogram shows marked extravasation of contrast material into the perigraft fluid collection with a drainage catheter in place. (b) Antegrade nephrostogram shows a nephroureteral stent that was placed to achieve leak closure. (c) Antegrade nephrostogram obtained 4 months after stent placement shows complete leak closure at the proximal ureter.
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Figure 21c. Urine leak at the proximal ureter in a 58-year-old man with a cadaveric transplant. The patient had undergone ureteroureteral anastomosis for necrosis of the distal transplant ureter 2 months earlier. (a) Antegrade nephrostogram shows marked extravasation of contrast material into the perigraft fluid collection with a drainage catheter in place. (b) Antegrade nephrostogram shows a nephroureteral stent that was placed to achieve leak closure. (c) Antegrade nephrostogram obtained 4 months after stent placement shows complete leak closure at the proximal ureter.
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Figure 22. Lymphocele in a 62-year-old woman who had undergone renal transplantation and presented with a rising serum creatinine level. US image shows a periallograft fluid collection with a septum. Note the compressed renal transplant. US-guided aspiration of the fluid helped confirm a lymphocele.
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Figure 23a. Percutaneous drainage of a lymphocele in a 26-year-old woman with persistent discharge from the incision site for a cadaveric renal transplant. (a) Fluoroscopic image of the pelvis shows an 18-gauge needle that was placed in the lymphocele under US guidance. A guide wire was then inserted through the needle and coiled within the lymphocele. An 8-F pigtail drainage catheter was subsequently placed within the lymphocele over the guide wire. (b) Sinogram obtained through the drainage catheter prior to sclerotherapy shows no fistulous communication between the lymphocele and adjacent organs.
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Figure 23b. Percutaneous drainage of a lymphocele in a 26-year-old woman with persistent discharge from the incision site for a cadaveric renal transplant. (a) Fluoroscopic image of the pelvis shows an 18-gauge needle that was placed in the lymphocele under US guidance. A guide wire was then inserted through the needle and coiled within the lymphocele. An 8-F pigtail drainage catheter was subsequently placed within the lymphocele over the guide wire. (b) Sinogram obtained through the drainage catheter prior to sclerotherapy shows no fistulous communication between the lymphocele and adjacent organs.
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Figure 24a. Percutaneous drainage of a perigraft abscess in a 58-year-old man with fever. (a) CT scan shows a perigraft fluid collection extending to the skin surface. CT-guided aspiration of the fluid was performed using an 18-gauge needle and yielded purulent material, which was sent for culture. (b) CT scan shows successful placement of an 8-F drainage catheter within the fluid collection. The collection was confirmed to be a bacterial abscess.
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Figure 24b. Percutaneous drainage of a perigraft abscess in a 58-year-old man with fever. (a) CT scan shows a perigraft fluid collection extending to the skin surface. CT-guided aspiration of the fluid was performed using an 18-gauge needle and yielded purulent material, which was sent for culture. (b) CT scan shows successful placement of an 8-F drainage catheter within the fluid collection. The collection was confirmed to be a bacterial abscess.
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