Salvage of renal allograft using venous thrombectomy in the setting of iliofemoral venous thrombosis.

A 49-year-old Caucasian female underwent a second kidney–pancreas transplant in May 2002 for end-stage diabetic nephropathy. Her postoperative course was complicated by intra-abdominal sepsis and the development of bilateral deep venous thrombosis (DVT). The patient was treated conservatively, with a 6-month course of oral anticoagulation. One month after discontinuation of oral anticoagulation, the patient noted a 7-day history of a painful and swollen left lower extremity. Three days prior to admission she noted paresthesia, pain and pallor of her left lower extremity. The next day she noticed left lower quadrant abdominal pain over her renal allograft associated with anuria. On the day of admission, initial creatinine at her referring physician’s office was 1.7mg/dl. Seven hours later, her creatinine had climbed to 4.7mg/dl with persistent anuria. On examination, her left leg was oedematous and swollen. Her renal allograft was tender to palpation in the left lower quadrant. Duplex examination revealed venous thrombosis arising in the post-tibial veins and extending to the iliac veins, an enlarged renal allograft (>1 cm in increase in length compared with previous ultrasound) and a patent renal artery with absence of diastolic flow consistent with venous outflow obstruction. The patient was systemically anticoagulated with unfractionated heparin. A decisionwasmade to attempt graft salvage by performing a venous thrombectomy. Via local cut down to the femoral vein, venography of the vena cava and the left common iliac veins was completed using <30 cc of half strength Visipaque contrast. This confirmed the extension of thrombus distal to the renal allograft venovenostomy and the absence of flow within the left iliac vein. A standard venous thrombectomy was performed via a common femoral vein venotomy. A Fogarty thromboembolectomy catheter (Edwards Lifesciences, Irvine, CA) and Esmarch compression were used proximally and distally, respectively, for thrombus removal. Repeat venography (30 cc of half strength Visipaque) demonstrated a widely patent left iliac vein with dye washout at the level of the renal allograft venostomy. Repeat duplex of the renal allograft on postoperative day 1 demonstrated normal arterial and venous flow to the transplanted kidney with appropriate diastolic flow. Her creatinine steadily declined to baseline (1.0mg/dl) postoperatively and she was discharged on postoperative day 5 with lifelong anticoagulation. At 6 months postoperative, her creatinine is normal (0.8 mg/dl) with venous duplex examination demonstrating absence of residual thrombus.