Advancements in Renal Transplantation Methodology

End-stage renal disease (ESRD) is a severe and irreversible condition of kidney failure in which the kidneys have lost their ability to function. Also known as stage 5 chronic kidney disease, ESRD can result in premature death. According to the Centers for Disease Control and Prevention, Medicare fee-for-service expenditures for ESRD totaled $37.3 billion in 2019.

The decline in kidney function is accompanied by symptoms including fatigue, swelling, changes in urination, nausea, vomiting, loss of appetite, muscle cramps, itching, mental confusion and drowsiness. ESRD patients require either a kidney transplant or dialysis to sustain life, the former being the gold standard. Diabetes and hypertension are two of the most common causes of ESRD.

However, a significant challenge of renal transplantation is atherosclerosis in the common and iliac arteries , which can lead to complications such as inadequate vascular control, clamp injury and vessel dissection or occlusion. Maham Rahimi, MD, PhD, RPVI, Associate Professor of Cardiovascular Surgery, presented a novel, one-stage intravascular occlusion method in a 54-year-old ESRD patient with prolific calcification listed for dual cardiac-renal transplant. This method offers lesser surgical complexity compared to the currently available vascular reconstruction techniques. The details of this case are published in the Journal of Vascular Surgery Cases, Innovations and Techniques. Located in the pelvic region, the iliac arteries provide blood to the legs, pelvis, reproductive organs and other organs. Iliac arteries are crucial for establishing blood flow to the transplanted kidney. The external iliac artery is a common site for anastomosis in renal transplants, which surgically connects the donor’s renal artery to those in the recipient.

Maham Rahimi, MD, PhD, RPVI

The 54-year-old male ESRD patient in this case report also had type 2 diabetes mellitus, ischemic myopathy and pulmonary hypertension. Conventional cardiovascular risk factors such as diabetes, hypertension and dyslipidemia are known drivers of atherosclerosis. The buildup of plaques and lesions in the arteries leads to narrow and hardened vessels. Extensive atherosclerotic lesions in this patient’s common and external iliac arteries presented a challenge for renal transplantation. ESRD patients with comorbidities have accelerated atherosclerosis. In many cases, calcium deposits accumulate in atherosclerotic lesions (calcification), a process strongly correlated with the risk of cardiovascular events. Typically, atherosclerosis is accelerated in ESRD patients requiring transplantation.

A successful heart transplant was conducted in this patient a day before the renal transplantation. The patient had extensive calcification in the external iliac, common iliac and abdominal aorta. Only a 1.5 cm area of the external iliac artery was free of atherosclerotic lesions, which was used as the site for anastomosis by Rahimi. Typically, in renal transplantation, the donor's renal artery is connected to the recipient's external or internal iliac artery, and the donor's renal vein is connected to the recipient's external iliac vein. Blood flow in these vessels is usually controlled by temporarily applying vascular clamps proximal and distal to the anastomosis site. In this case, using vascular clamps was not an option owing to the extensive calcification. Hence, Rahimi used balloons to control the complex vascular systems in this patient.

“Intravascular occlusion remained the only viable option for distal vascular control in this patient,” commented Rahimi. The patient was discharged on dialysis and was no longer on dialysis at the time of Rahimi’s publication.

Rahimi’s innovative methodology widens the scope for successful renal transplantation in the vast majority of ESRD cases.

Extensive atherosclerosis presents a challenge to renal transplantation owing to the risk for inadequate vascular control or vessel injury. We present a novel single-stage method by which intravascular balloon occlusion was used to obtain proximal and distal control of the external iliac artery in a patient with prolific calcification. This approach reduces surgical complexity and reduces ischemia time when compared to previously described methods of reconstruction.

Maham Rahimi, MD, PhD, RPVI

Associate Professor, Cardiovascular Surgery

Daanish Sheikh, Shri Timbalia, Mahnoor Zia, Yusuf Mufti, Maham Rahimi. A novel technique for external iliac artery reconstruction in renal transplant patients with extensively atherosclerotic lower limb vasculature. J Vasc Surg Cases Innov Tech. 2024 Nov 30;11(2):101698. doi: 10.1016/j.jvscit.2024.101698.

Abanti Chattopadhyay, PhD

October 2025

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