血流再開直後に移植腎動脈解離を認め動脈形成術を行った1例

Abstract

58歳女.慢性糸球体腎炎の治療を受けていたが, 徐々に腎機能が増悪し, 血液透析療法を受けていた.今回, 夫をドナーとする生体腎移植目的に入院となった.レシピエントの骨盤部CTで右内腸骨動脈に著明な石灰化を認め, ドナーの腹部CTで腹部大動脈に石灰化を認めた.ドナーの血管造影では, 左腎動脈は腹部大動脈から分岐した約1cm末梢部で3本に分岐していた.生体腎移植術を施行し, ドナー腎摘は後腹膜腔鏡下ハンドアシスト法を行った.冷却灌流後に径3mmの吻合口を腎動脈本幹に形成し, 6-0プロリン糸で端側吻合を施行した.血流再開後, 腎後面を主とする2/3以上の領域の色調と緊張が不良で, 初尿も認められなかった.移植腎動脈を詳細に観察したところ, 動脈内膜の解離による偽性動脈瘤を発見し, 血流障害の原因となっていると診断した.レシピエントから移植腎を摘出し再冷却灌流の後, 内膜解離によって生じた偽腔に対して動脈形成術を行い, 再び右外腸骨動静脈の同じ部位に端側吻合した.血清クレアチニン値は術後1日目急速に低下し, 以後, 腎機能の悪化を認めなかった

A 58-year-old woman, who had been suffering from chronic renal failure on hemodialysis since 1999, underwent living renal transplantation on January 14, 2003. The donor was her husband, and his left kidney was resected by a hand-assisted retroperitoneoscopic technique. Vascular clamps were removed after vascular anastomoses, but the color of two-thirds of the graft back side was dark, and urine excretion was not observed for 1 hour. The intimal dissection of the graft artery developed false lumen that occluded the blood flow to the transplanted kidney. The graft was resected from the recipient, and an angioplasty was performed for the false lumen of the graft artery after the second cold preservation. The graft with repaired artery was re-transplanted, and urine excretion was observed immediately after operation. Total ischemia time was 5 hours. Clinicopathological acute rejection episode and stenosis of graft artery did not occur for 6 months after operation. The intimal dissection of graft artery might occur at the time of catheterization on the perfusion for cold preservation and/or vascular anastomosis.